Court Opinion

ID: 9562131
Source: CourtListenerOpinion
Date Created: 2023-08-21 18:22:12.43784+00
Date Added: 2024-06-11T09:17:13.242588
License: Public Domain

Finley, C. J.
This is a suit for damages for personal injuries brought against a doctor who performed an operation to repair a stomach ulcer of the plaintiff-wife, and against the drug company which supplied a portion of the anesthetic used in the operation. The plaintiff-wife will be referred to hereafter as though she were the sole plaintiff.
The results of the operation mentioned above were partly beneficial and partly disastrous to the patient. Her gastric symptoms were alleviated, but when the plaintiff recovered consciousness, her lower trunk had lost feeling or sense of touch, and she could not move her legs. The source of this disability centers around the spinal block administered to plaintiff to anesthetize her during the operation.
At the time of trial, although there had been some slight improvement in her condition, her right foot, bowels, and bladder were still in a state close to paralysis.
The jury returned a verdict in favor of both defendants, and plaintiff has appealed. We believe that plaintiff is entitled to a new trial as to defendant-Dr. Bussabarger because of certain errors which occurred at trial.
There is no substantial basis for appeal as to defendant-drug company. No question is raised regarding the correctness or purity of the substance which the company delivered to the hospital. The only question raised by plaintiff is whether the company should have labeled the drug’s container so 'as to warn of possible dangers of use of the drug. *478However, even if we assume such labeling should have taken place, defendant-Dr. Bussabarger testified that he relied on his own knowledge of anesthetics and, in fact, did not read the labeling which was on the container. Thus, if defendant-drug company was negligent in not labeling its container so as to warn of dangers, this negligence was not a proximate cause of plaintiff’s disability. We therefore will devote the remainder of this opinion exclusively to issues relating to Dr. Bussabarger.
The author of a recent article prefaced his remarks by saying:
[A]s the following consideration of medical professional liability in Washington indicates, no single group occupies a more favorable position at law than members of the medical profession. J. Steincipher, Survey of Medical Professional Liability in Washington, 39 Wash. L. Rev. 704, 710 (1964).
If we were to affirm the judgment of the trial court, not only would we perpetuate the advantageous position of the medical profession, but we would exaggerate and extend it unnecessarily. Three assigned errors in particular were highly prejudicial to plaintiff’s case, and unnecessarily beneficial to defendant-Bussabarger.
The first of plaintiff’s three assignments of error which we will consider relates to the trial court’s instruction No. 11. This instruction reads as follows:
In this case the plaintiffs claim that the defendant Bus-sabarger was guilty of negligence in the professional services he performed for them; you are instructed that such matters involve technical professional questions and can only be proven by physicians and surgeons trained in their profession, and in ascertaining in this case whether the defendant Bussabarger was guilty of malpractice, you are limited exclusively to the testimony of doctors, (italics ours.)
In the absence of negligence so obvious that a layman can recognize it, some medical testimony is necessary to support a finding that the doctor departed from the standard of reasonable care. Often this requirement becomes a difficult, almost insurmountable obstacle for plain*479tiffs in malpractice suits when they encounter what has been termed the “conspiracy of silence.”1 But none of the cases go so far as to require that malpractice be established exclusively by the testimony of doctors. If the rule is to have any rational justification at all, it should be limited to the requirement that, in those cases in which negligence is not apparent, some medical testimony is necessary to establish the proper standard of care. See Note, Malpractice and Medical Testimony, 77 Harv. L. Rev. 333, 334-36 (1963). This would satisfy the avowed rationale of the rule in that it would prevent laymen from speculating as to what is the standard of reasonable care in a highly technical profession. But certainly it is putting a heavy burden or impediment upon the victim of medical negligence to require him to show the specific acts of negligence (as well as all the other elements of his cause of action if the trial court’s words are to be taken literally) exclusively by the testimony of doctors when, frequently, as here, the only doctor who witnessed the allegedly negligent acts was the defendant.
In the instant case, defendant-Dr. Bussabarger testified that when a patient is undergoing a stomach operation, injection of spinal anesthesia above the second lumbar vertebra is not proper procedure. Plaintiff produced further expert testimony to show that if the needle insertion were too high, particularly if it hit the spinal cord, there likely would be a spasm or some immediate reaction from the patient. Plaintiff testified that she felt a sharp pain low in her back on the entry of the spinal needle, and complained of the hurt before losing consciousness. In addition, one of *480plaintiff’s witnesses, Dr. Durkin, testified that he found some evidence of damage to her spinal cord. The trial court’s instruction No. 11 did allow the jury to consider this evidence. However, it apparently was not enough, standing alone, to persuade the jury of defendant-Bussabarger’s negligence.
Plaintiff attempted to provide additional evidence of negligence. Various hospital records admitted into evidence at trial showed the diagnosis of plaintiff’s post-operative condition to be cord damage, which could well indicate improperly high injection of the spinal anesthetic. Other evidence was introduced by plaintiff which indicated that the amount of anesthetic injected was excessive. However, under the trial court’s instruction No. 11, none of this additional evidence could be considered by the jury since it was not the testimony of doctors.
In our judgment, it was error for the trial court to give instruction No. 11 to the jury and thereby exclude from their consideration the additional evidence of negligence which plaintiff attempted to provide. Testimony of doctors is not the only type of evidence which may be considered by juries when deciding whether or not physicians are guilty of malpractice.
Defendant-Bussabarger cites Teig v. St. John’s Hosp., 63 Wn.2d 369, 387 P.2d 527 (1963), to support his contention that negligence can be shown only by the testimony of doctors. In Teig, a doctor testified for the plaintiff as to what would be the reasonable standard of care in that particular situation and what would constitute a violation of that standard; but nurses’ notes, X-rays, and hospital records were used to show the fact of the departure from the established standard of care. This court reversed a judgment for the defendant doctor and reinstated a verdict for the plaintiff.
It seems to us that the proper approach toward any evi-dentiary requirement of expert testimony was expressed in Byrom v. Eastern Dispensary & Cas. Hosp., 136 F.2d 278 (D.C. Cir. 1943), in which the court had before it a jury instruction possibly less objectionable than the one before *481us. The instruction in Byrom read: “ ‘. . . If you find from the testimony of the experts in this case that the treatment and conduct of defendant, Dr. Young, was in keeping with good and approved practice among physicians of like qualifications and experience . . . then your verdict must be for the defendant.’ ” In reversing a judgment for the defendants, the court said, 136 F.2d at 279:
We think this instruction went a little too far. It in effect told the jury to ignore all of the evidence in the case save that of the doctors who testified as experts ....
Unquestionably only experts are qualified to express an intelligent opinion as to what constitutes the proper method of treatment of a serious bone injury. But that their evidence should be accepted in exclusion of other evidence of conditions and results is contrary to the applicable rule, both in this jurisdiction and elsewhere. As was said in Cornwell v. Sleicher, 119 Wash. 573, 205 P. 1059, 1061, the proposition that experts alone are qualified to testify as to the manner of treatment of a patient is “sound only when soundly applied,” ....
We adopt the view indicated by the Byrom opinion. The jury should have been instructed that the need for expert medical testimony is limited to establishing the proper standard of care that defendant-Dr. Bussabarger should have followed. Furthermore, the jury should have been instructed to consider all the evidence in determining whether the defendant failed to meet that standard of care.
As has been observed, “Except for malpractice cases (against a doctor, dentist, etc.) there is no general rule or policy requiring expert testimony as to the standard of care, and this is true even in the increasingly broad area wherein expert opinion will be received.” 2 F. Harper & F. James, The Law of Torts § 17.1, at 966 (1956). It has also been observed that, “[n]evertheless, the possible distinction [between malpractice actions and other tort actions] has not seemed to most courts sufficient to warrant a unique requirement of expert testimony for the purpose of providing general background facts . . . .” Note, Malpractice and Medical Testimony, 77 Harv. L. Rev. 333, 335 (1963). It *482therefore seems clear that the type of instruction suggested above would meet the requirements and suggestions of the authorities, protect the legitimate interests of physicians and surgeons, and be much fairer to laymen-plaintiffs in malpractice actions.
Defendant-Bussabarger contends, however, that, even if it was error for the trial judge to give instruction No. 11, it was harmless error since the evidence discussed above is insufficient to establish his negligence as the cause of plaintiff’s injuries. We find no merit in this contention. The doctrine of res ipsa loquitur was available to plaintiff to get her case to the jury.
In the recent case of Pederson v. Dumouchel, 72 Wn.2d 73, 81, 431 P.2d 973, 979 (1967), we described cases in which res ipsa loquitur is available as follows:
A case in which the doctrine of res ipsa loquitur applies is a circumstantial-evidence case. In it, the jury is permitted to infer negligence from a result which ordinarily would not have been reached unless someone was negligent. The jury may make the inference of negligence or it may refuse to do so.
We believe the instant case falls within this rule. Plaintiff submitted to surgery for the purpose of having a stomach ulcer repaired. After surgery she was paralyzed from the waist down. It is clear to us that this typifies those cases in which res ipsa loquitur applies because mankind’s general experience and observation teaches that the harmful result probably would not occur in the absence of someone’s negligence. See Horner v. Northern Pac. Beneficial Ass’n Hosps., Inc., 62 Wn.2d 351, 382 P.2d 518 (1963).
In Pederson v. Dumouchel, supra, at 81, 431 P.2d at 979, we made the following statement:
Not to awaken from a general anesthetic for almost a month, and then with apparent brain damage is so extraordinary an occurrence within the general observations of mankind as to raise an inference of negligence.
In our judgment, paralysis after an operation to repair a stomach ulcer raises the same inference.
*483Assuming that plaintiff’s disability does not fall clearly and unmistakably within the category of those res ipsa cases described above, nevertheless we believe the medical testimony in the instant case, under what we regard as the unique circumstances of medical malpractice cases, was enough in this case to create an inference of negligence and justify application of the principles of res ipsa loquitur.
Dr. Malden, a physician who testified for plaintiff, set forth seven possible causes of the type of condition suffered by the plaintiff after the operation by the defendant-Bussa-barger. They are: (1) that the needle was introduced at the wrong place; (2) that there was a contaminant on the needle; (3) that the needle carried damaging bacteria or other organisms; (4) that the wrong substance was injected; (5) that there were contaminants in the substance injected; (6) that the correct substance was injected in the proper quantity and in the proper way, but produced an abnormal result; and (7) that the quantity of the substance injected was incorrect.
Dr. Malden effectively eliminated the second possibility, a contaminant on the needle, by saying that, “long before the needle enters the spinal canal, it has to squeeze through the skin, through the muscle, through the ligaments, and this simply, by physical action of squeezing, will cleanse the needle.” He also ruled out the third possibility, that the needle carried damaging bacteria or other organisms, since no infection was introduced into plaintiff’s spinal cord or subarachnoid space. This means that five of Dr. Malden’s original seven possible causes survived closer scrutiny. They are: (1) that the needle was introduced at the wrong place (although he later concluded in his testimony that it was unlikely the needle hit the spinal cord since, unlike Dr. Durkin, another physician who testified in the matter, he was unable to find cord damage); (2) that the wrong substance was injected; (3) that there were contaminants in the substance injected; (4) that the quantity of the substance injected was incorrect; and (5) that the correct sub*484stance was injected in the proper quantity and in the proper way, but produced an abnormal result.
An oft-quoted statement of the doctrine of res ipsa loquitur is that of Chief Justice Erie in Scott v. London & St. Katherine Docks Co., 3 H. & C. 596, 601, 159 Eng. Rep. 665, 667 (1865):
There must be reasonable evidence of negligence.
But where the thing is shewn to be under the management of the defendant or his servants, and the accident is such as in the ordinary course of things does not happen if those who have the management use proper care, it affords reasonable evidence, in the absence of explanation by the defendants, that the accident arose from want of care.
The usual conditions precedent to application of res ipsa loquitur are: (1) An event which ordinarily does not occur unless someone is negligent, (2) the agency or instrumentality causing the event within the exclusive control of the defendant (s), and (3) no voluntary action or contribution to the event on the part of the plaintiff. Emerick v. Mayr, 39 Wn.2d 23, 234 P.2d 1079 (1951); W. Prosser, Torts 218 (3d ed. 1964).
It is apparent that the first condition is not met unless all possible causes of an injury are such as would not ordinarily occur in the absence of someone’s negligence. It is contended by defendant that an abnormal reaction to the anesthetic given plaintiff does not fulfill this condition. Although it may appear initially that she was not entitled to the benefits of res ipsa loquitur, it is our judgment that a different conclusion must be reached upon further examination of the nature of the particular reaction which plaintiff may have had.
Dr. Malden testified that plaintiff’s abnormal reaction might have taken one of two forms: idiosyncratic or hyper-ergic. An idiosyncratic reaction, according to Dr. Malden, belongs in the family of allergic reactions. It differs from a normal reaction in type, rather than in degree. A hyperer-gic reaction, on the other hand, is evidently a term used by medical theorists to describe what can only be called an *485unexpected and unexplainable reaction to an injection of the correct substance in the proper quantity and in the proper way. It differs from a normal reaction in degree, rather than in type — the opposite of an idiosyncratic reaction. Dr. Malden distinguished idiosyncratic and hyperergic reactions as follows:
An idiosyncratic reaction is an entirely different reaction [from a hyperergic reaction], not only in quantity, but in quality. If I give an aspirin to somebody, I expect them —let’s take a patient who has a temperature. I give them aspirin to lower the temperature. If I give aspirin to a normal patient, I expect the temperature to come down for four hours, and again, go up again. Now, let’s take another patient. I give him a tablet of aspirin, and this patient drops dead. That is an idiosyncratic reaction. It did not affect his temperature at all, but he just dropped dead, or he had a bronchial spasm. Now, take the same aspirin; I give a normal dose to the patient, and the patient’s temperature, instead of dropping down five degrees and five-tenths of a degree and staying down for four hours, drops down precipitously and stays down for three days. That is an abnormal reaction to a normal dose; but the actual quality of the response is normal. The temperature dropped and stayed down. It dropped too much, it stayed down too long. This is called hyper-ergy.
Dr. Malden eliminated an idiosyncratic reaction as one of the possible causes of plaintiff’s disability because of subsequent tests which he ran. Presumably, however, he was unable to determine by testing whether or not plaintiff had had a hyperergic reaction because such reactions are evidently unpredictable and not subject to diagnosis except through a process of eliminating other possible causes. In other words, “hyperergy” is a term used to label abnormal reactions for which theoretically there is no explanation.
We are thus confronted with a situation in which there are four possible causes of plaintiff’s disability which would be the result of negligence and one possible cause of the disability which would be the result of some indefinite and amorphic abnormality. Under the circumstances, we do not believe plaintiff should have been denied the aid of the *486doctrine of res ipsa loquitur. Were we to hold otherwise, patients who suffer injury or disability while being operated upon will be unable to recover damages if the doctor merely alleges that a mysterious, unexpected, and unexplainable reaction by the patient to treatment took place on a single, isolated occasion, even though there is other medical testimony from which a jury could reasonably conclude that the doctor was in fact negligent. Such a result seems particularly unjustifiable and undesirable in light of the conclusion reached in one major study of the effects of spinal anesthetics that if there is such a thing as hyperergy (resulting in what is termed the cauda equina syndrome), and there is serious doubt that there is, it may be avoided by proper medical precautions. R. Dripps and L. Vandam, Long-term Follow-up of Patients Who Received 10,098 Spinal Anesthetics, 2 Foundations of Anesthesiology 888 (1965). We thus believe the instant case may be fairly said to come within the following rule set forth by Dean Pros-ser, W. Prosser, supra, at 222:
The plaintiff is not required to eliminate with certainty all other possible causes or inferences [in order to have res ipsa loquitur apply], which would mean that he must prove a civil case beyond a reasonable doubt. All that is needed is evidence from which reasonable men can say that on the whole it is more likely that there was negligence associated with the cause of the event than that there was not.
Defendant-Bussabarger contends that even if res ipsa lo-quitur would otherwise apply, it is inapplicable in the instant case because the drug company was also a defendant at trial. The general rule is, as defendant-Bussabarger points out, that a plaintiff does not make out the requisite preponderant case by showing only that he has been injured by the negligence of one or the other of two defendants. W. Prosser, supra, at 225.
Because we have already determined that the drug company’s negligence, if any, was not a proximate cause of plaintiff’s disability, Dr. Bussabarger will be the only defendant on retrial. Assuming, however, for purposes of *487argument, that evidence exists which might suggest negligence on the part of the drug company proximately causing plaintiff’s disability, plaintiff may still get her case against Dr. Bussabarger to the jury. A case against one defendant which is supported by specific circumstantial evidence of negligence and which would otherwise go to the jury under the res ipsa loquitur doctrine is not prevented from doing so by the existence of evidence of negligence on the part of another defendant. McCarty v. Hosang, 154 F. Supp. 852 (W.D. Mo. 1957); W. Prosser, supra, at 255 n.70.
We thus hold that the doctrine of res ipsa loquitur was available to plaintiff to get her case to the jury.
It is important to emphasize that the effect of our decision is not to make doctors “insurers,” nor to make it impossible for them to defend themselves in malpractice cases. On the contrary, the function of the doctrine of res ipsa loquitur is only to prevent a nonsuit, not to decide the case. Doctors still have an opportunity if they so choose to come forward with evidence as to exactly what did take place in the operating room and thereby seek to avoid liability.
Plaintiff’s second assignment of error relates to the trial court’s failure to give her requested instruction No. 13, which explains the application of the doctrine of res ipsa loquitur. The requested instruction is substantially the same as that approved by this court in Pederson v. Dumouchel 72 Wn.2d 73, 431 P.2d 973 (1967), and in Horner v. Northern Pac. Beneficial Ass’n Hosps., Inc., 62 Wn.2d 351, 382 P.2d 518 (1963).
We have in this jurisdiction two lines of cases concerning the res ipsa loquitur doctrine, one of which is represented by Ball v. Mudge, 64 Wn.2d 247, 391 P.2d 201 (1964), which states that res ipsa loquitur is not a rule of law but a rule of evidence and that it never requires a jury instruction, but serves only to get a plaintiff past a nonsuit. (Although the plaintiff failed to present direct evidence of causation in this case, her evidence was properly held sufficient to take her case to the jury.)
*488The other line of cases is exemplified by Horner v. Northern Pac. Beneficial Ass’n Hosps., Inc., supra, which approved an instruction on circumstantial evidence which, inter alia, advised the jury of its right to infer negligence when the plaintiff’s evidence showed that the injury was one which ordinarily would not have occurred without negligence.
In the instant matter, Dr. Malden’s testimony established that four of the five possible causes of plaintiff’s injuries required the negligence of defendant-Bussabarger. Because of the nature of the fifth possible cause, this evidence supports the finding that the result was one which does not ordinarily occur in the absence of negligence. Therefore, since the line of cases exemplified by Horner, supra, is applicable, the requested instruction No. 13 should have been given.
Plaintiff’s third principal assignment of error relates to instruction No. 7. This instruction reads as follows:
You are instructed that the defendant, Dr. R. A. Bussa-barger, should be held only to the standard of practice of the ordinary prudent general practitioner performing general surgery in the Raymond, Washington or a similar community during the time involved, that is, August of 1961.
Dr. Bussabarger conceded in his testimony that the standard of care for the operation he performed on the plaintiff would be the same for general practitioners in Olympia, Tacoma, or Seattle. Plaintiff excepted to the instruction given and proposed an instruction which would have allowed the jury to determine the standard of care based on testimony as to what it was in a broader geographical area. It would seem that the defendant-Bussabarger’s admissions would be sufficient grounds to establish that it was error to allow the jury to believe he was to be held to a less stringent standard. A defendant should not be judged by a lower standard of care than he himself requests. But, apart from Dr. Bussabarger’s admissions, we are convinced the instruction was erroneous because it led the jury to believe that less stringent standards should be allowed for general *489practitioners in Raymond, Washington, than those allowed for physicians elsewhere in more populous areas.
Admittedly, there probably was considerable justification for the local standard rule in frontier days. Dean Pros-ser points out that the original rationale for this rule was that in early America a country doctor did not have the facilities, contacts, or opportunities for learning and experience afforded by large cities. W. Prosser, Torts § 32, at 166 (3d ed. 1964). But times have changed. Modern means of transportation permit country doctors to attend up-to-date medical seminars; the general circulation of medical journals makes new developments readily available to them, and they can easily and quickly communicate with the most modern and up-to-date medical centers in cities throughout the United States. As has been pointed out, today’s rural practitioner can and does give and receive advice transmitted thousands of miles over the telephone, and he is expected to keep himself apprised of recent developments as they are regularly published in medical journals. F. Spies, Arkansas Model Jury Instructions: Malpractice, 20 Ark. L. Rev. 86 (1966).
The editorial board of the Stanford Law Review conducted a survey to determine to what extent the practice of medicine within each of the nineteen recognized specialties of the American Medical Association is similar throughout the country. Letters and questionnaires were sent to each of the American Specialty Boards, the American Medical Association and American Hospital Association, publishers of medical specialty journals, and medical specialty societies. The letters and questionnaires were written with the aid of the Stanford University School of Medicine and several practicing physicians. The conclusion reached was as follows:
On the basis of the existence of standardized requirements for certification, subscriptions to medical specialty journals, medical specialty societies, and statements from American Specialty Boards, it is concluded that the practice of medicine by certified specialists within most medical specialties is similar throughout the country. Note, *490Medical Specialties and the Locality Rule, 14 Stan. L. Rev. 884, 887-88 (1962).
The results of this survey, although cautiously worded, confirm what was fairly obvious; viz. that there is no longer any basis in fact for the “locality rule.” •
Rural and small-town doctors should not enjoy advantages not given by the law to any other class of rural and small-town tort defendants. When patients considering operations approach doctors in Raymond, the doctors do not admit that they can be a little more careless and act with less responsibility than can doctors in Olympia, who can be a little more negligent than doctors in Tacoma, who can be a little more negligent' than doctors in Seattle, who can be considerably more negligent than the doctors in New York City. Certainly, if doctors should freely indicate such discrepancies in medical practice, it would not be surprising that there would be a decrease in the number of operations in Tacoma and Olympia — and a greater decrease still in the Raymond area.
Many courts have already recognized this situation. Dean Prosser notes the following in regard to the “locality rule,” W. Prosser, supra, at 166-67:
The older decisions sometimes stated this as a standard of the “same locality;” but this is now quite generally recognized as too narrow. Later cases expanded it to speak of “the same or similar localities,” thus including other towns of the same general type. The present tendency is to abandon any such formula, and treat the size and character of the community, in instructing the jury, as merely one factor to be taken into account in applying the general professional standard.
Dean Prosser cites cases from California, Pennsylvania, North Dakota, Iowa, Idaho, New Jersey and Florida in support of his statement. The decision in Pederson v. Du-mouchel, 72 Wn.2d 73, 431 P.2d 973 (1967) aligns Washington with these states, and updates Washington law with regard to the realities of the contemporary medical practice.
*491We affirm this case as to defendant-drug company. As to defendant-Bussabarger, we remand the case for a new trial in keeping with the views expressed in this opinion.
Weaver, Hunter, Hamilton, and Hale, JJ., concur.

 See J. Steincipher, supra, at 705; M. Belli, An Ancient Therapy Still Applied: The Silent Medical Treatment, 1 Vill. L. Rev. 250 (1956). Dean Prosser, commenting on “[t]he well known reluctance of doctors to testify against one another,” says in a footnote: “A survey made by the Boston University Law-Medicine Research Institute, and reported in Medical Economics, Aug. 28, 1961, found that out of 214 doctors, only 31% of the specialists and 27% of the general practitioners said they would be willing to appear for the plaintiff if a surgeon, operating on a diseased kidney, removed the wrong one. In Agnew v. Parks, 1959, 172 Cal. App.2d 756, 343 P.2d 118, a suit was actually brought against a group of doctors for ‘conspiracy to obstruct the ends of justice’ by refusal to testify.” W. Prosser, Torts § 32, at 167 n.45 (3d ed. 1964).