Court Opinion

ID: 4670527
Source: CourtListenerOpinion
Date Created: 2021-03-23 16:13:56.947964+00
Date Added: 2024-06-11T08:02:01.342333
License: Public Domain

J-A28033-20

NON-PRECEDENTIAL DECISION - SEE SUPERIOR COURT I.O.P. 65.37

 MADELINE KERI, PERSONAL         :            IN THE SUPERIOR COURT OF
 REPRESENTATIVE OF THE ESTATE OF :                 PENNSYLVANIA
 VELMA KERI                      :
                                 :
                Appellant        :
                                 :
                                 :
           v.                    :
                                 :            No. 1774 WDA 2019
                                 :
 CONEMAUGH VALLEY MEMORIAL       :
 HOSPITAL, LAUREL GROUP          :
 ANESTHESIA, P.C., AND MOHAN K.  :
 NAMA, M.D.                      :

           Appeal from the Judgment Entered November 4, 2019
  In the Court of Common Pleas of Cambria County Civil Division at No(s):
                               2013-2389

BEFORE: OLSON, J., MURRAY, J., and McCAFFERY, J.

MEMORANDUM BY McCAFFERY, J.:                    DATE: March 23, 2021

      Madeline Keri (Appellant), personal representative of the Estate of

Velma Keri (Decedent), appeals from the judgment entered in the Cambria

County Court of Common Pleas, following a jury verdict in favor of Conemaugh

Valley Memorial Hospital (Hospital), Laurel Group Anesthesia, P.C. (Laurel

Group), and Mohan K. Nama, M.D. (Dr. Nama) (collectively Appellees), in this

medical malpractice action.    Appellant contends the trial court abused its

discretion when it limited and/or excluded her use of two learned treatises for

cross-examination purposes, and excluded the testimony of a proposed

witness. For the reasons below, we affirm.
J-A28033-20

       The facts underlying this appeal are as follows.    On July 19, 2011,

Decedent fell in her home and broke her right hip. N.T., 7/11/19, at 186. At

the time, she was 83 years old and weighed approximately 110 pounds. N.T.,

7/15/19, at 116. The next day, July 20th, Decedent underwent successful

surgery at Hospital to repair her hip. N.T., 7/11/19, at 30, 187. Dr. Nama

was Decedent’s anesthesiologist. N.T., 7/12/19, at 43.1 Following surgery,

Decedent was moved to a recovery unit. N.T., 7/15/19, at 123-24. Later,

recovery unit Nurse Lisa Kozuch noted that Decedent was “crying complaining

of pain to right hip.” N.T., 7/12/19, at 63. Nurse Kozuch called Dr. Nama for

permission to administer pain medication to Decedent.        Id. at 60; N.T.,

7/15/19, at 124-25. Dr. Nama approved giving Decedent up to two milligrams

of Dilaudid, a hydromorphone, in two doses. N.T., 7/15/19, at 126. The first

dose of one milligram of Dilaudid was administered at 7:25 PM, and the second

one milligram dose was administered twenty minutes later. N.T., 7/12/19, at

59. Shortly thereafter, Decedent went into cardiac arrest. N.T., 7/15/19, at

136, 139. She was eventually resuscitated and transferred to an Intensive

Care Unit, where she remained on a ventilator. Id. at 152. She underwent a

____________________________________________

1 The certified record includes two volumes of testimony dated July 12, 2019,
memorializing different parts of the trial proceedings that day. The cover page
of one volume bears the description, “Excerpt of Proceedings: Testimony of
Pamela Vranich,” whereas the cover page of the other has no corresponding
description. Our citations to the July 12, 2019, transcript are to the volume
lacking a cover page-description. For ease of review, we further describe this
volume as including the testimony of Julianne Keri, Dr. Nama (called by
Appellant as if on cross-examination), Madeline Keri, and Lisa Kozuch. See
N.T., 7/12/19, at 2.

                                           -2-
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tracheostomy on July 29th.            Appellant’s Complaint, 10/25/13, at ¶ 31.

Decedent was hospitalized until November 7, 2011, when she was transferred

to a skilled nursing care center where she remained until she returned home

on January 2, 2012. Id. at ¶ 34; N.T., 7/11/19, at 48.

        Decedent initiated this medical malpractice action by writ of summons

issued on July 24, 2013. She subsequently passed away on September 12,

2013.     Appellant filed a suggestion of death on October 23, 2013, and a

complaint on October 25th, asserting claims for wrongful death and survival

on behalf of the estate. The case proceeded to a jury trial commencing on

July 10, 2019. During the course of trial, Appellant sought to cross-examine

Appellees’ witness with information contained in two “learned treatises.” The

court precluded reference to one publication, and restricted Appellant’s use of

the other. In addition, the court limited the testimony of one of Appellant’s

fact witnesses.

        On July 17, 2019, the jury returned a verdict for Appellees, concluding

they were not negligent in their care and treatment of Decedent. Verdict Slip,

7/17/19, at 1. Appellant filed a timely post-trial motion for a new trial, which

the trial court denied on October 3, 2019.          Thereafter, Appellant filed a

praecipe for the entry of judgment on November 4th, followed by this timely

appeal on November 27th.2

____________________________________________

2Appellant complied with the trial court’s order to file a concise statement of
errors complained of on appeal pursuant to Pa.R.A.P. 1925(b).

                                           -3-
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        Appellant raises the following issues on appeal:3

        [1] Did the trial court abuse its discretion when it disallowed
        [Appellant’s] use of the “Up[T]o[D]ate” publication to impeach
        [the defense] expert[’s] opinion on causation, on the basis that it
        was neither a “learned treatise” nor contained information that
        antedated [Decedent’s] surgery?

        [2] Did the trial court unfairly restrict [Appellant’s] use of the
        [Pennsylvania Patient Safety Authority (PPSA)] article to impeach
        Dr. Nama, when Dr. Nama implied during the examination that he
        agreed with some of the dosage information in the article?

        [3] Should the trial court have offered a limiting instruction to the
        jury rather than restrict [Appellant’s] use of the “PPSA” article to
        impeach [the defense] expert[’s] opinion on causation, where the
        article expressly contradicts [the expert’s] opinion that
        [Decedent] received an “appropriate” dose of Dilaudid?

        [4] Did the trial court abuse its discretion to exclude the
        testimony of respiratory therapist Carl Kenyon on the basis of a
        pre-trial order dated May 9, 2019 when such statement was
        otherwise admissible under Pa.R.E. 803(4)?

Appellant’s Brief at 3.

        Appellant’s claims challenge the trial court’s denial of her motion for a

new trial. “Our standard of review in denying a motion for a new trial is to

decide whether the trial court committed an error of law which controlled the

outcome of the case or committed an abuse of discretion.”             Pledger by

Pledger v. Janssen Pharm., Inc., 198 A.3d 1126, 1138 (Pa. Super. 2018)

(citation and footnote omitted), appeal denied, 217 A.3d 179 (Pa. 2019).

        “An abuse of discretion exists when the trial court has rendered a
        judgment that is manifestly unreasonable, arbitrary, or capricious,
____________________________________________

3   We have reordered Appellant’s claims for purposes of disposition.

                                           -4-
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      has failed to apply the law, or was motivated by partiality,
      prejudice, bias or ill-will.”

Burton-Lister v. Siegel, Sivitz & Lebed Assocs., 798 A.2d 231, 238 (Pa.

Super. 2002) (citation omitted). Moreover, rulings concerning the admission

or exclusion of evidence, as well as the scope of cross-examination, lie within

the sound discretion of the trial court. See Crespo v. Hughes, 167 A.3d 168,

181 (Pa. Super. 2017) (citation omitted); Jacobs v. Chatwani, 922 A.2d 950,

965 (Pa. Super. 2007) (citation omitted).

      Thus[,] our standard of review is very narrow; we may only
      reverse upon a showing that the trial court clearly abused its
      discretion or committed an error of law. To constitute reversible
      error, an evidentiary ruling must not only be erroneous, but also
      harmful or prejudicial to the complaining party.

Crespo, 167 A.3d at 181 (citation omitted).

      Appellant’s first three issues concern the trial court’s restriction of her

use of two “learned treatises,” which, she contends, were relevant to impeach

the credibility of both Dr. Nama and his expert anesthesiologist, Dr. Richard

Stypula.

      A “learned treatise” is any textbook, published work, or periodical
      that has been accepted as authoritative or as reliable authority by
      members of a specific professional community.                Under
      Pennsylvania law, the contents of a learned treatise offered at
      trial to establish principles or theories is inadmissible hearsay,
      an extrajudicial declaration offered to prove the truth of the
      matter asserted. Experts may rely on authoritative publications
      in formulating their opinions, and, to a limited extent, our courts
      permit experts to briefly reference materials to explain the
      reasons underlying their opinions. While such materials are
      not admissible, an expert may be impeached with
      statements contained in a text or publication deemed
      authoritative or reliable by him or other experts in the
      same field.

                                      -5-
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Charlton v. Troy, 236 A.3d 22, 38–39 (Pa. Super. 2020) (emphases supplied

and citations omitted). This Court has held that when a “learned treatise” is

used in such a manner, it is “not admitted for the truth of the matter asserted,

but only to challenge the credibility of the witness’ opinion and the weight to

be accorded thereto.” Majdic v. Cincinnati Mach. Co., 537 A.2d 334, 339

(Pa. Super. 1988) (en banc) (citation omitted).         See also Aldridge v.

Edmunds, 750 A.2d 292, 296-97 (Pa. 2000) (noting that Pennsylvania has

not followed other jurisdictions, including the federal courts, which permit “the

admission of treatise materials as substantive evidence on a limited basis”).

      In her first issue, Appellant argues the trial court abused its discretion

when it precluded her from impeaching Drs. Nama and Stypula with the online

publication “UpToDate.”      Appellant’s Brief at 15.      Dr. Martin Dauber,

Appellant’s expert anesthesiologist, explained that UpToDate is an “online

medical resource available to physicians which contains . . . relevant, mostly

overwhelmingly clinical information” and is a “frequent site for practitioners to

visit[.]” N.T., 7/10/19, at 106.

      By way of background, we note that during Dr. Dauber’s testimony,

Appellant presented to him for authentication three articles from UpToDate.

Appellant simply stated the titles of the articles and noted each included

“literature review current through June 2019.” See N.T., 7/10/19, at 106-07.

Without discussing the contents of those articles, Dr. Dauber testified that

they were “authoritative.” Id. at 107. Pertinently, Appellant did not ask Dr.

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Dauber if the information contained in the articles was relevant at the time of

the alleged malpractice, eight years earlier, in the present case.

      Appellant then intended to cross-examine both Appellee Dr. Nama, and

Appellees’ expert witness, Dr. Stypula, with information contained in those

articles.   Before trial on the morning of July 15, 2019, the court ruled in

chambers that it would not permit Appellant to use the UpToDate articles.

See N.T., 7/15/19, at 3.      Although the discussion was not transcribed,

Appellant’s counsel explained the court’s ruling on the record prior to the start

of the testimony:

      In chambers before we came into court, the Court indicated that
      it would prohibit the use of the articles that Dr. Dauber described
      as authoritative from the UpToDate source because Your Honor
      indicated you felt that they were not in the category of
      authoritative treatises or articles.       Counsel for [Appellees]
      objected because they indicated that they were current through
      June of 2019. These articles are premised on literature surveys,
      and each and every cite in the article has a date and none of the
      matters set forth in the articles are related to — that I intend to
      cross-examine the experts with — are related to articles or
      standards that post-dated the treatment in this case. There are
      three of those. . . .

Id.

      Appellant’s challenge to the court’s ruling is two-fold. She contends the

trial court abused its discretion when it determined (1) the UpToDate

publication did not qualify as a “learned treatise” and (2) the articles post-

dated Decedent’s care. Appellant’s Brief at 15-18. First, Appellant maintains

Dr. Dauber’s testimony was sufficient to establish the UpToDate online

resource qualified as a learned treatise. She notes Dr. Dauber testified the

                                      -7-
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site, which is frequently visited by practitioners, contains clinical information,

and the specific articles Appellant intended to rely upon were “authoritative.”

Id. at 16. Appellant insists this testimony was “sufficient to lay the proper

foundation for the Up[T]oDate publication to quality as a ‘learned treatise.’”

Id. Second, Appellant argues that, while the publication was current through

June of 2019, the sources the articles relied upon “antedated [Decedent’s]

surgery.” Id. at 18. Indeed, Appellant maintains the publication is “akin to

an anthology of medical articles that a practitioner may consult on a variety

of issues.” Id. Because the opioid subsection upon which Appellant intended

to rely included references that antedated Decedent’s surgery, Appellant

asserts the court’s “broad refusal to allow [her] to cross[-]examine defense

witnesses with this publication was an abuse of discretion[.]” Id.

        Initially, our review of this issue was somewhat hampered because the

discussion of Appellant’s potential use of the UpToDate articles, as well as the

court’s ruling, occurred off the record. See N.T., 7/15/19, at 3. Moreover,

although Appellant challenged the court’s ruling in her post-trial motion, the

court did not address that claim in its opinion. See Trial Ct. Op., 10/3/19, at

1-6.4    Consequently, on January 4, 2021, we remanded this appeal and

directed the trial court to file a supplemental opinion addressing “Appellant’s

claim that the court abused its discretion when it precluded her from cross-
____________________________________________

4 We note the trial court did not file a Pa.R.A.P. 1925(a) opinion, but rather,
relied upon its October 3, 2019, opinion denying Appellant’s post-trial motion.
See Order, 1/6/20.

                                           -8-
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examining Appellees’ witnesses regarding the online publication, ‘UpToDate’

[and] Appellant’s proposed use of the publication.” Order, 1/4/21, at 1. The

trial court complied with our directive and filed a supplemental opinion on

February 3, 2021.

      Preliminarily, we note that in its supplemental opinion, the trial court

did not discuss whether the UpToDate publication qualified as a learned

treatise.   Rather, the opinion focused on the relevance of the recent

publication with regard to the questions presented at trial. See Trial Ct. Op.,

2/3/21, at 5-6. Upon our review, we agree with Appellant that Dr. Dauber’s

testimony — that the UpToDate articles were “authoritative” — was sufficient

to establish the online periodical as a learned treatise. See Charlton, 236

A.3d at 38 (“A ‘learned treatise’ is any textbook, published work, or periodical

that has been accepted as authoritative or as reliable authority by members

of a specific professional community.”).

      Nonetheless, we conclude Appellant is entitled to no relief because the

publication date of the articles is the critical issue. As the court explained in

its supplemental opinion, “the articles were exactly what [they] say they are,

‘up to date’ from June 2019.” Trial Ct. Op., 2/3/21, at 5. See N.T., 7/10/19,

at 106-07 (Dr. Dauber testifying the UpToDate articles were “current through

June 2019”). However, the medical care at issue in the present case occurred

in July 2011, nearly eight years before the publication. Therefore, the trial

court concluded “the articles were not relevant to the trial discussing the

standard of care as it was in 2011.” Trial Ct. Op., 2/3/21, at 5.

                                      -9-
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       Appellant insists, however, the section on opioids that she intended to

use for cross-examination referenced “medical publications that antedated

[Decedent’s] surgery.”        Appellant’s Brief at 18.   Therefore, because the

sources upon which the article relied were dated prior to Decedent’s surgery,

Appellant contends the trial court abused its discretion when it precluded her

use of the publication for impeachment purposes. See id.

       We disagree. The trial court explained that it precluded Appellant from

cross-examining Drs. Nama and Stypula with the UpToDate articles,5

       because no specific showing of record was made concerning the
       date of the material Appellant proposed to us. The [c]ourt
       deemed that a specific showing was necessary because the
       content Appellant proposed to use consisted of articles current
       through June 2019 and referring to standards of care in place in
       July 2019, the time of the trial, when [D]ecedent’s treatment in
       this case occurred eight years prior in 2011. The [c]ourt found
       that it would be improper for . . . Appellant to utilize the UpToDate
       articles to represent the standard of care during the 2011 time
       period with an article from June 2019 to impeach the witness’s
       credibility.

Trial Ct. Op., 2/3/21, at 5-6. Here, Appellant simply failed to demonstrate the

relevance of the 2019 publication with regard to the standard of care in 2011.

____________________________________________

5  We note that in its supplemental opinion, the trial court indicates it
“permitted Appellant’s counsel to ask five specific questions on cross-
examination which . . . effectively allow[ed] for impeachment of the
witness[es] without publishing the article[s] to the jury.” Trial Ct. Op., 2/3/21,
at 5. However, the record reveals the court permitted this limited examination
only with respect to the other learned treatise Appellant introduced – a
publication by the Pennsylvania Patient Safety Authority. See N.T., 7/12/19,
at 23-25. The court prohibited all references to the UpToDate articles. See
N.T., 7/15/19, at 3.

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As Dr. Nama explains in his brief, “the dates of the studies are irrelevant to

the consideration of whether the article post-dated the treatment.”          Dr.

Nama/Laurel Group Brief at 15 (emphasis added).            He emphasizes that

because “Appellant provided only the June 2019 UpToDate article to counsel

and the [c]ourt, there is no way to know how the article was updated in 2019

or whether the article was originally published prior to the treatment at issue.”

Id. Indeed, Appellant sought to cross-examine Drs. Nama and Stypula with

the 2019 article, not the studies referenced in the article.

      Thus, we conclude the trial court did not abuse its discretion when it

precluded Appellant from using the UpToDate publication to impeach Drs.

Nama and Stypula.      Indeed, Dr. Dauber testified only that the UpToDate

articles, current through June of 2019, were “authoritative.”         See N.T.,

7/10/19, at 106-07. He did not offer any opinion as to whether the articles

contained information that was authoritative at the time of the incident in

question. Accordingly, Appellant is entitled to no relief on this claim.

      Appellant’s next two issues concern the court’s restriction of her use of

another learned treatise — a publication by the Pennsylvania Patient Safety

Authority (PPSA) entitled “Adverse Drug Events with Hydromorphone: How

Preventable Are They?”      See Appellant’s Brief at 6 n.2.      Similar to the

UpToDate publication, the trial court permitted Appellant to present the PPSA

article to Dr. Dauber for authentication. N.T., 7/10/19, at 106. Dr. Dauber

testified that the article, dated September 2010, was “authoritative.”       Id.

Appellant intended to use the article to cross-examine Dr. Nama and his

                                     - 11 -
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expert witness, Dr. Stypula. Id. at 9-10. At that time, the court did not

determine how the article could be used during Appellant’s examination of

Appellees’ witnesses. See id. at 92-93.

       The trial court revisited the issue on the morning of July 12, 2019, when

Appellant indicated she intended to call Dr. Nama as an adverse witness during

her case-in-chief.      N.T., 7/12/19, at 3.       Upon inquiry by the trial court,

Appellant stated she intended to impeach Dr. Nama with the PPSA article

which, she averred, directly contradicted Dr. Nama’s assertion that the dosage

of Dilaudid he approved for Decedent was appropriate. See id. at 5. Appellant

asserted the article stated a single dose of “one milligram, half of what this

doctor ordered, or greater for an elderly patient who was opioid-naive” was

“an inappropriate dose.” Id. After hearing argument from both sides, the

court ruled that Appellant could ask Dr. Nama the following questions

concerning the PPSA article:6

              Are you familiar with the article, citing the name of the
       article; the date of the article, which was in 2010; which predated
       the operation[?]
                                     *    *    *

             [D]id you take any of the contents of this article into
       consideration when you treated [Decedent]?

____________________________________________

6 The trial court indicated that it derived the questions from Philadelphia
County Court of Common Pleas Judge Mark I. Bernstein’s treatise on the
Pennsylvania Rules of Evidence, 2018 edition. See N.T., 7/12/19, at 25. The
relevant text is appended to Appellant’s brief as Addendum IV.

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            Did you rely upon the contents of the article when you
       authorized the dosage for her?

              Do you agree with the content of the article?

             And do you agree that your authorized dosage is at
       variance, the word at variance, with the recommended dosage in
       the article?

Id. at 23-24. The court later sustained Appellees’ objection to use of the

phrase “recommended dosage” in the final question, and Appellant rephrased

the question to inquire whether Dr. Nama agreed that the dosage he

prescribed to Decedent varied from the dosage “described” in the article.7 Id.

at 40-41, 45. The trial court also specifically prohibited Appellant from reading

the article to the jury during the examination. Id. at 20-21.

       Appellant subsequently called Dr. Nama as an adverse witness, and

asked him the above-stated questions.              See N.T., 7/12/19, at 43-45.   In

response, Dr. Nama acknowledged: (1) he was aware of the article before he

treated Decedent; (2) he took the contents of the article into consideration

when he treated her; and (3) the dosage of hydromorphone he authorized for

Decedent was “at variance with the dosage described in the article.” Id. at

44-45. Dr. Nama further indicated he did not rely upon the article when he

authorized Decedent’s dosage, and, when asked if he agreed with the “content

____________________________________________

7 Appellant also complains that the trial court did not permit her to substitute
the phrase “appropriate dosage” for “recommended dosage.” Appellant’s Brief
at 28. However, she did not identify this purported erroneous ruling in her
post-trial motion. Thus, any allegation of error is now waived. See Bd. of
Supervisors of Willistown Twp v. Main Line Gardens, Inc., 155 A.3d 39,
44 (Pa. 2017).

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of the article as it relates to dosages of hydromorphone[,]” he responded, “Not

completely.” Id. at 45 (some capitalization omitted).

      With this background in mind, we address Appellant’s claim that the trial

court abused its discretion when it restricted her cross-examination of Dr.

Nama to the specific questions listed above. See Appellant’s Brief at 29. First,

Appellant insists the court “highjacked” her cross-examination of Dr. Nama by

requiring her to ask “each and every one of the . . . questions it had

formulated[.]” Id. at 30. Appellant cites to the transcript where she asked

the court if she had to ask Dr. Nama the fourth question — if he agreed with

the content of the article — and the court replied, “Yes, I already did this.”

See id. at 30, citing N.T., 7/12/19, at 42 (emphasis omitted). Moreover, she

argues that she was then required to end her cross-examination after asking

the court-formulated questions, despite the fact that Dr. Nama’s final answer

“implied that he agreed with some of the dosage information in the PPSA

article.”   Id. at 32 (emphasis added).       Appellant maintains:   “Dr. Nama’s

response on an issue of substantive importance should have triggered an

opportunity for [her] to explore with some adversarial depth the extent to

which Dr. Nama did agree with the article.” Id. Indeed, Appellant contends

the court abused its discretion when it required her to ask Dr. Nama the court-

formulated questions — and only those questions — regardless of the

witness’s responses. See id. at 30.

      Here, the trial court explained that it limited Appellant’s use of the PPSA

article for impeachment purposes to “ensure this inadmissible hearsay was

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not presented as substantive evidence to the jury.” Trial Ct. Op., 10/3/19, at

3. We detect no abuse of discretion.

      As noted above, a learned treatise, which is deemed authoritative by

experts in the field, may be used to impeach an expert witness. Charlton,

236 A.3d at 39.    This Court has also extended this limited use of learned

treatises to the cross-examination of fact witnesses. See Crespo, 167 A.3d

at 186 (noting the trial court correctly permitted cross-examination of doctor

defendant with learned treatise). However, the law is well-settled that the

contents of such publications are hearsay, and not admissible for the truth of

the matter asserted therein. Majdic, 537 A.2d at 339. Thus, when a trial

court has failed to place appropriate limitations on the use of learned treatises,

and the information contained therein has been read to the jury, the appellate

courts have not hesitated to find error. See Aldridge, 750 A.2d at 298 (trial

court abused its discretion when it failed to “impose appropriate constraints”

on appellee’s use of learned treatise that supported expert’s opinion on direct

examination); Burton-Lister, 798 A.2d at 239 (trial court abused its

discretion when it permitted appellee to “read into the record” parts of learned

treatise while cross-examining appellant doctor).

      Upon our review of the record, we conclude the trial court’s formulation

of specific questions, aimed at limiting Appellant’s use of the PPSA article for

impeachment purposes only, did not constitute an abuse of discretion.

Indeed, through her questioning, Appellant was able to show the jury that the

dosage of Dilaudid Dr. Nama approved for Decedent was “at variance with the

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dosage described in the article[.]” N.T., 7/12/19, at 45. Further, Dr. Nama

conceded that he was aware of the article at the time of treatment, and took

some of the contents of the article into consideration when treating Decedent.

Id. at 44-45. This, coupled with Dr. Dauber’s testimony that the article was

authoritative, constituted a permissible, limited use of a learned treatise.

      To the extent Appellant now complains that the trial court “highjacked”

her cross-examination — by forcing her to ask questions she did not want to,

and then precluding her from asking any follow-up questions — we conclude

these arguments are waived. First, the record does not support her claim that

she was “force[d]” to ask Dr. Nama questions she did not believe should have

been “advanced in the first place.” See Appellant’s Brief at 30. Indeed, just

prior to calling Dr. Nama as an adverse witness, Appellant asked the court,

“Do I have to ask the one [question], do you agree with the content of the

article?” N.T., 7/12/19 at 42. The court responded, “Yes, I already did this.”

Id. At that point, Appellant responded, “Okay. Fair enough. Okay.” Id.

That was the extent of Appellant’s “objection.” Appellant did not inform the

court that she felt it was highjacking her examination, nor did she provide any

explanation as to why she believed the final question was inappropriate.

Accordingly, no relief is warranted. See Pa.R.A.P. 302(a) (“Issues not raised

in the trial court are waived and cannot be raised for the first time on

appeal.”).

      Similarly, after Appellant asked Dr. Nama the court-approved questions,

she stated, “Thank you, Dr. Nama, that is all I have.” N.T., 7/12/19, at 45.

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Appellant now insists that Dr. Nama’s response that he did not completely

agree with the contents of the PPSA article “implied that he agreed with some

of the dosage information” in the article, and warranted further questioning.

Appellant’s Brief at 32 (emphasis added). However, because Appellant did

not ask the court to reconsider its ruling in light of Dr. Nama’s response, her

claim is now waived.8 See Pa.R.A.P. 302(a).

       Appellant also contends the trial court abused its discretion when it

restricted her cross-examination of Appellees’ expert, Dr. Stypula, with regard

to the same PPSA article. She argues the trial court erred when it limited her

examination of Dr. Stypula to the same questions formulated for her

examination of fact witness (and opposing party) Dr. Nama. Appellant’s Brief

at 24-25.     Indeed, she maintains the court should have permitted her to

impeach Dr. Stypula with the statement in the PPSA that “any dosage of one

milligram or greater for a woman of [Decedent’s] physical profile is

‘inappropriate.’” Id. at 26.9

____________________________________________

8Appellant’s assertion that she “risked nothing less than the wrath of the trial
court” had she requested to continue questioning does not overcome her
waiver of this claim. See Appellant’s Brief at 32 n.12.

9 We note Appellant also claims that, rather than restricting her use of the
article on cross-examination, the trial court should have issued a limiting
instruction to the jury, explaining that the text was used “solely to impeach”
the expert’s testimony. Appellant’s Brief at 28-29. This claim was not raised
in Appellant’s post-trial motion, and is, thus, waived on appeal. See Bd. of
Supervisors of Willistown Twp., 155 A.3d at 44.

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        Again, we conclude Appellant is entitled to no relief. As noted supra,

while an expert may be cross-examined with a learned treatise that is

recognized as authoritative in the relevant field, the document may not be

“admitted for the truth of the matter asserted, but only to challenge the

credibility of the witness’ opinion and the weight to be accorded thereto.”

Majdic, 537 A.2d at 339.        The questions formulated by the trial court

appropriately limited the use of the PPSA article to impeachment purposes

only.

        To the extent Appellant insists the questions were drafted to be used

only during the cross-examination of a fact witness, we disagree.           See

Appellant’s Brief at 22-23. As noted above, the questions were derived from

a treatise on evidence, authored by Philadelphia Court of Common Pleas Judge

Bernstein, discussing Pennsylvania Rule of Evidence 803(18). See Appellant’s

Brief, Addendum IV, Bernstein Treatise. The Comment to Rule 803(18) states

that “Pennsylvania does not recognize an exception to the hearsay rule for

learned treatises.”     Pa.R.E. 803(18), comment.          Under the heading

“Impeachment of Expert Witness[,]” Judge Bernstein explains that,

pursuant to the Rule, “[a] learned treatise may be used to cross-examine

an expert as to his . . . qualifications, knowledge, opinions or biases.”

Appellant’s Brief, Addendum IV, Bernstein Treatise at 859 (emphases added).

Under the same subsection, Judge Bernstein provides a list of “proper

questions” that may be asked during cross-examination of an expert to ensure

the text is not admitted for the truth of the matter asserted in violation of the

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rule. See id. at 861. The questions crafted by the trial court in the present

case parrot those listed in the Bernstein text.      Furthermore, Appellant’s

attempt to differentiate the use of a learned treatise when it is used to cross-

examine a witness, as opposed to a party, also fails. See Appellant’s Brief at

24-25.   Indeed, in whatever manner a learned treatise is used, “[u]nder

Pennsylvania law, the contents of a learned treatise offered at trial to

establish principles or theories is inadmissible hearsay[.]” Charlton, 236

A.3d at 38 (emphases added).

      Appellant also maintains the trial court’s ruling precluded her from

attacking Dr. Stypula’s opinion that “the two milligrams of Dilaudid that

[Decedent] received was not too much[.]” Appellant’s Brief at 25. She insists:

      A medical malpractice trial that allows the opinion of an expert to
      go unchecked when medical authority to the contrary expressly
      contradicts not only the opinion of the expert, but even the very
      words the expert has used to communicate an opinion to the jury,
      makes for not merely an imperfect trial, but a trial that is
      manifestly unfair.

Id. at 26.

      However, the limitations the trial court placed on Appellant’s use of the

PPSA article did not permit Dr. Stypula’s opinion to go “unchecked.”        See

Appellant’s Brief at 26.    Rather, as evident in the following exchange,

Appellant was able to demonstrate to the jury that Dr. Stypula’s opinion

regarding the appropriate dosage of Dilaudid for Decedent differed from the

appropriate dosage set forth in the article:

      [Appellant’s counsel:] Doctor, I want to show you an article
      entitled Adverse Drug Events with HYDROmorphone:       How

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      Preventable Are They, from the [PPSA] that was issued to advise
      medical facilities of immediate changes that could be instituted to
      reduce serious events and incidents. . . .
                                  *    *   *

      [Appellant’s lawyers gave you the article a]nd asked you to read
      it?

      [Dr. Stypula:] Yes.

      [Appellant’s counsel:]   Do you agree with the contents of that
      article, sir?

      [Dr. Stypula:] No.

      [Appellant’s counsel:] Did you take into account in looking at the
      Dilaudid dose in this case the information in the publication?

      [Dr. Stypula:] No, I didn’t have it. I had not — I’m not familiar
      with that publication. And when I formed my opinion, I didn’t use
      it.

      [Appellant’s counsel:] The opinion expressed in this publication
      in respect to Dilaudid is different than what you have told the
      jurors, isn’t it?

      [Dr. Stypula:] Yes.

N.T., 7/16/19, at 173-74. Accordingly, we detect no abuse of discretion in

the trial court’s ruling. See Crespo, 167 A.3d at 181.

      Moreover, we note that even if we were to conclude the trial court

abused its discretion when it limited Appellant’s use of the PPSA article on

cross-examination, “[t]o constitute reversible error, an evidentiary ruling

must not only be erroneous, but also harmful or prejudicial to the complaining

party.”   See Crespo, 167 A.3d at 181 (citation omitted).      First, as noted

supra, Appellant was able to establish, through the cross-examination of Drs.

Nama and Stypula, that the dosage of Dilaudid Decedent received, which both

doctors opined was appropriate, varied from the dosage described in the PPSA

                                    - 20 -
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article. See N.T., 7/12/19, at 45; 7/16/19, at 174. Second, Appellant was

able to establish, through the testimony of her expert witnesses, that a dosage

of more than one milligram of Dilaudid was an inappropriate, and potentially

harmful, dosage for Decedent.          See N.T., 7/10/19, at 138-40 (Appellant’s

expert anesthesiologist, Dr. Dauber, testifying that “[i]t was below the

standard of care to give” Decedent 2 milligrams of Dilaudid; noting, “[i]f 1

milligram was indeed necessary to be given, it could have been given in more

typical increments, like 0.2 milligrams every five to ten minutes monitoring

vital signs, including pain”); N.T., 7/11/19, at 93, 95-96 (Appellant’s expert

registered nurse, Debra Ebersole, testifying that the administration of “[t]he

first dose of Dilaudid was not within the standard of care for [Decedent]

because of her comorbidities[;]” explaining “[i]f this were my patient . . . I

would have started at 0.2 milligrams . . . and see how she reacts to it”). Thus,

no relief is warranted on Appellant’s second claim.

       Lastly, Appellant argues the trial court abused its discretion when it

excluded certain testimony by Decedent’s respiratory therapist based upon a

pretrial stipulation. Appellant’s Brief at 33. By way of background, we note

Appellees filed a motion in limine to preclude Appellant from offering any

hearsay testimony that Decedent’s death was the result of an overdose.10 See
____________________________________________

10 The motion indicated that during his deposition, Dr. Nama was asked if he
“recalled other physicians at [Hospital] telling him that Decedent’s arrest was
caused by an overdose of Dilaudid.” Appellees’ Motion in Limine to Preclude
Hearsay Evidence Regarding the Cause of Decedent’s Arrest and/or Overdose
(Motion in Limine), 3/27/19, at 1.

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Appellees’ Motion in Limine at 1-2.     Appellant did not oppose the motion.

Thus, on May 8, 2019, the trial court entered an order directing that

“[Appellant] shall not be permitted to introduce any hearsay evidence at the

time of trial, related to comments made by other physicians regarding the

cause of Decedent’s arrest and/or an overdose.” Order, 5/8/19.

      Three weeks before trial, Appellant filed a Fourth Supplemental Pretrial

Statement, which listed one additional fact witness, Carl Kenyon.           See

Appellant’s   Fourth   Supplemental     Pretrial   Statement,   6/17/19,   at   1

(unpaginated). No further information about Kenyon’s proposed testimony

was provided. After Kenyon was called to testify on July 11, 2019, the trial

court asked Appellant the purpose of Kenyon’s testimony. N.T., 7/11/19, at

4. Appellant responded that Kenyon was Decedent’s respiratory therapist at

Hospital. Id. She further stated Kenyon became friendly with Decedent and

her family, and later visited Decedent in her home. Id. Appellant asserted:

“[H]e is mostly going to talk about her condition and the medical events in

the ICU that he was aware of so he is really a fact witness.” Id. After further

discussion, Appellant acknowledged she intended to elicit testimony from

Kenyon that he was told by another doctor that Decedent “was overdosed[.]”

Id. at 8. Appellant argued such a statement was not hearsay because it was

made “in the course of medical treatment.” Id. The trial court precluded that

testimony based upon its May 8, 2019, pretrial order.

      On appeal, Appellant contends the pretrial order precluded only

“hearsay statements for which there are no applicable exceptions.”

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Appellant’s Brief at 34 (emphasis added).          She maintains that is the only

reason she did not oppose the motion. See id. (“[Appellant’s] counsel would

never in a million years have acquiesced to the motion outright had he

believed it encompassed statements for which a recognized hearsay exception

applied.”).    Rather, Appellant insists Kenyon’s proposed testimony was

admissible as a statement made for medical treatment and diagnosis pursuant

to Pennsylvania Rule of Evidence 803(4).11 She explains:

              [The] excluded statement to Mr. Kenyon . . . addressed both
       the “cause” of [Decedent’s] need for respiratory therapy and
       “how” she sustained the need for it. Cardiac arrest may have
       multiple etiologies, each of which may require a different subset
       of treatments. It was therefore necessary for Mr. Kenyon to know
       the cause of [Decedent’s] cardiac arrest if he was to administer
       respiratory therapy to her in a safe and medically efficacious
       manner talked to her etiology.

              . . . A statement from an ICU physician to a patient’s
       respiratory therapist that the patient overdosed . . . is obviously
       one that addresses the “nature and type of injury” because it
       serves to educate the therapist on a particular etiology that could
       direct the course of the patient’s respiratory therapy. . . .

Id. at 36 (citations omitted).
____________________________________________

11 Rule 803(4) provides an exception to the rule against hearsay when an out
of court statement:

       (A) is made for — and is reasonably pertinent to — medical
       treatment or diagnosis in contemplation of treatment; and

       (B) describes medical history, past or present symptoms, pain, or
       sensations, or the inception or general character of the cause or
       external source thereof, insofar as reasonably pertinent to
       treatment, or diagnosis in contemplation of treatment.

Pa.R.E. 803(4)(A)-(B).

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         The trial court found Kenyon’s proposed testimony fell squarely within

its pretrial order precluding “any hearsay evidence . . . related to comments

made by other physicians regarding the cause of Decedent’s arrest and/or

overdose.”     Trial Ct. Op., 10/3/19, at 4, citing Order, 5/8/19.   We agree.

Appellant stipulated to the broad language in the pretrial order, and, despite

her present complaints, did not request an exception for hearsay statements

made during the course of medical treatment. Thus, her claim fails.

         Furthermore, we note that even if we agreed that the pretrial order may

not have included statements made for the purposes of medical treatment,

we conclude Appellant has failed to establish the statement at issue would

have been admissible pursuant to Rule 803(4).              “The following two

requirements must be satisfied in order for a statement to qualify as a medical

treatment exception: (1) the statement must be made for the purpose of

receiving medical treatment; and (2) the statement must be necessary and

proper for diagnosis and treatment.” Commonwealth v. Belknap, 105 A.3d

7, 11 (Pa. Super. 2014).

         In her brief, Appellant baldly asserts Kenyon may have needed to know

the underlying cause of Decedent’s cardiac arrest to “direct the course of

[Decedent’s] respiratory therapy.” See Appellant’s Brief at 36. However, she

provides no explanation — save for generalized statements that different

“etiologies . . . may require a different subset of treatments” — why this is so.

See id. Moreover, Appellant made a similarly conclusory argument in the trial

court.     In fact, in asserting the statement was admissible, counsel for

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Appellant commented only: “And these are statements made in the course of

medical treatment, Your Honor, so they are not hearsay.” N.T., 7/11/19, at

8.   Thus, Appellant has failed to demonstrate the purported statement of

another physician — that an overdose caused Decedent’s cardiac arrest — was

“necessary for proper diagnosis and treatment.” See Belknap, 105 A.3d at

11. Accordingly, Appellant’s claim would fail even if we agreed the statement

was not precluded by the court’s pretrial order.    See Commonwealth v.

D.J.A., 800 A.2d 965, 977 (Pa. Super. 2002) (en banc) (affirming preclusion

of statement made by child sex abuse victim to doctor implicating father as

abuser because it was not necessary for diagnosis or treatment; “[w]hile

sexual abuse carries with it the danger of contracting a sexually transmitted

disease, a child’s statement identifying the perpetrator cannot obviate that

danger, nor can such a statement, standing alone, determine whether the

child should be tested and/or treated for a sexually transmitted disease”).

      Because we conclude Appellant is entitled to no relief on any of the

claims raised on appeal, we affirm the judgment in favor of Appellees.

      Judgment affirmed.

Judgment Entered.

Joseph D. Seletyn, Esq.
Prothonotary

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Date: 3/23/2021

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