Court Opinion

ID: 9919477
Source: CourtListenerOpinion
Date Created: 2024-01-18 16:06:26.865274+00
Date Added: 2024-06-11T08:06:56.352493
License: Public Domain

RENDERED: JANUARY 18, 2024
                                                         TO BE PUBLISHED

               Supreme Court of Kentucky
                               2022-SC-0302-DG

SAINT ELIZABETH MEDICAL CENTER,                                          APPELLANT
INC., D/B/A
ST. ELIZABETH FLORENCE

                    ON REVIEW FROM COURT OF APPEALS
V.                          NO. 2021-CA-0115
                   BOONE CIRCUIT COURT NO. 16-CI-01672

RONALD N. ARNSPERGER, JR.                                                 APPELLEE

               OPINION OF THE COURT BY JUSTICE CONLEY

                                  REVERSING

      This case is before the Court upon discretionary review sought by the

Appellant, Saint Elizabeth Medical Center, Inc. (St. Elizabeth), after the Court

of Appeals reversed the summary judgment granted by the Boone Circuit

Court. The Court of Appeals’ decision rested on the conclusion that this case

was a simple negligence case and that “no expert medical testimony is

necessary to determine the duty of a hospital staffer driving a wheelchair or to

gauge whether that duty was breached.” Upon review, we reverse the Court of

Appeals. The question of this case turns not upon the duty or breach thereof of

a hospital staffer navigating a wheelchair-bound patient. Instead, the question

is whether the injuries Arnsperger claims to have suffered were caused by the

allegedly negligent actions of the hospital staffer. Given the medical
background of Arnsperger, the question of causation is not one within the

common knowledge of the jury. As such, expert medical testimony was

necessary and the lack of expert testimony on behalf of Arnsperger as to the

element of causation merited summary judgment. The Court of Appeals is

reversed, and we reinstate the summary judgment of the trial court.

                         I.    Facts and Procedural Posture
      Arnsperger is a baseball umpire with an extensive medical history

involving his left ankle. In May 2015 he was diagnosed with Complex Regional

Pain Syndrome (CRPS) in the left ankle. CRPS causes the sufferer to feel

exaggerated pain responses to soft or light touches that in a normal person

would not elicit the same pain response. In August of 2015, he injured his left

ankle while umpiring. He went to Dr. Bilal Shamsi for treatment. Dr. Shamsi

and Arnsperger agreed a surgical repair was necessary.

      On December 14, 2015, Arnsperger went in for surgery. The goal, as Dr.

Shamsi testified in deposition, was to create an osteotomy and then align and

fix the osteotomy with two screws. In layman terms, Dr. Shamsi intentionally

fractured the ankle by sawing into the medial malleolus—the prominent bone

on the inside of the ankle—in order to fix the underlying condition, then to

realign and fix the fracture with two screws. The surgery did not go as planned.

As Dr. Shamsi was drilling a hole in the bone for one of the screws, the drill bit

broke and shards were scattered in the ankle. Most were removed except two. A

further result of this complication was that there was not enough bone to

create another hole for the second screw. Nonetheless, Dr. Shamsi was able to

                                        2
place one screw in and there was some hope that would suffice to heal

Arnsperger. Notes from Dr. Shamsi after the operation stated that Arnsperger

was made aware of the possibility for additional surgery, but no x-rays were

taken that day. Dr. Shamsi told Arnsperger he needed to get x-rays to confirm

the proper alignment of the bone.

      On December 17, 2015, a follow-up visit was conducted. Dr. Shamsi

performed a naked eye examination of the exterior of the ankle and believed all

looked well. But he once again told Arnsperger he needed to get x-rays of the

ankle, which Dr. Shamsi’s office was unable to perform. The following day,

Arnsperger was again informed via voicemail that he needed to get x-rays.

Arnsperger called Dr. Shamsi’s office complaining of intense pain in the ankle.

Dr. Shamsi via his assistant, reminded him to get the x-rays and arranged for a

pain medication prescription. Arnsperger went to St. Elizabeth’s for x-rays on

December 18.

      When he arrived, a hospital staffer greeted Arnsperger with a wheelchair.

While navigating the hospital an incident occurred in which Arnsperger’s

extended left ankle made contact with a desk. There is a factual dispute about

the severity of the collision. Arnsperger describes it as his ankle being rammed

into the desk, while St. Elizabeth contends it was nothing more than a slight

bump. The video of the incident is not clear. Despite this incident, x-rays were

taken. The x-rays showed a lateral displacement in the osteotomy; i.e., the

fracture was not correctly aligned. Dr. Shamsi reviewed the x-rays and

                                        3
concluded another surgery was necessary. That surgery was conducted on

December 24, 2015.

      On December 15, 2016, Arnsperger filed suit against St. Elizabeth. In the

facts giving rise to the complaint, Arnsperger alleged that the impact his left

ankle had with the desk “directly and proximately caused by the negligence of

the unknown female St. Elizabeth Florence employee had caused a displaced

fracture of the left ankle and had dislodged the surgical screw that was placed

during the December 14, 2015 surgery.” In the First Claim for Relief for

negligence and vicarious liability, Arnsperger alleged

      The unknown female St. Elizabeth Florence employee’s negligent,
      grossly negligent, and careless transportation of the Plaintiff
      caused the Plaintiff’s surgically repaired ankle to be forcefully
      impacted into a registration desk, displacing the surgical hardware
      recently inserted into the bone in his ankle, necessitating a second,
      more invasive surgical procedure that permanently restricts
      Plaintiff’s range of motion in his left ankle.
      Arnsperger alleged two other counts, negligent failure to train and

supervise and an independent negligence count against St. Elizabeth. For both

counts, he reaffirmed the above-quoted allegation.

      In August 2018, Arnsperger identified two experts: Dr. Shamsi and Dr.

Robert Klickovich. The latter was Arnsperger’s treating physician prior to the

surgeries at issue and had diagnosed Arnsperger with CRPS. The expert

disclosure stated that Dr. Shamsi was

      expected to provide expert medical opinions regarding the recovery
      he expected Plaintiff to be able to make after the December 14,
      2015 surgery, and state his opinion whether Plaintiff would be able
      to return to his work as a baseball umpire, and/or other similar

                                        4
      physically demanding work but for the injury he suffered on
      December 18, 2015.
It was also stated Dr. Shamsi would testify “about the adverse effect that the

injury Plaintiff suffered as a result of being rammed into the St. Elizabeth

registration desk . . . has had and will continue to have on his ability to

perform work . . . .” It is obvious that none of these disclosures relate to the

causation of the injury but rather presumes causation. Dr. Klickovich was

“expected to provide expert opinions regarding Plaintiff’s future treatment

options and prognosis, as well as the adverse effect that Plaintiff’s injury

suffered . . . and will continue to have on his ability to perform work . . . .”

Again, this is not an expert opinion on causation.

      Dr. Shamsi was deposed on January 28, 2019. He testified to first being

aware he was identified as an expert that same day. Dr. Shamsi did testify that

on his follow-up examination of December 17, 2015, he saw nothing wrong and

did not believe a second surgery would be necessary. But Arnsperger overlooks

the fact that Dr. Shamsi told him that same day, and had his office call him the

next morning, to get x-rays. Dr. Shamsi also conceded that some incident

occurred on the morning of December 18 prior to the x-rays taking place. Once

again, however, Arnsperger overlooks the fact that Dr. Shamsi refused to, in

his words, “speculate” as to what the nature of the incident was or its effects

on Arnsperger’s ankle. Dr. Shamsi testified he had not even seen the video

surveillance video of the incident. When asked directly if “it is safe to conclude

that the traumatic injury that Ron suffered on December 18th to the surgical

site is what caused the second surgery to be required?” Dr. Shamsi disclaimed

                                          5
any opinion. Dr. Shamsi instead referred to Arnsperger’s ankle displacement as

“hardware failure” and affirmed he would not be offering any testimony as to

causation.

      After this deposition, a motion for summary judgment was filed by St.

Elizabeth for failure to provide expert testimony as to causation. Arnsperger

opposed, arguing expert testimony was unnecessary but that he had identified

both Dr. Shamsi and Dr. Klickovich. The trial court denied summary judgment

because Dr. Klickovich had yet to be deposed but did affirm that expert medical

testimony as to causation would be required.

      Dr. Klickovich was deposed on August 20, 2020. Dr. Klickovich also

testified he was unaware he had been disclosed as an expert witness. He

testified he had not even been contacted about giving testimony in the case

until August 3, 2020. He testified he was unaware of the details of Dr. Shamsi’s

surgery on December 14, 2015, including that an osteotomy had been created.

He had not reviewed the x-rays taken on December 18, 2015. When asked, “do

you know to a reasonable degree of medical probability whether or not the

contact with the wall did, in fact, shift Mr. Arnsperger’s hardware?” he replied

“No.” He disclaimed any intention of testifying on the causal link between the

December 18 collision to the ankle displacement; to testifying about the cause

at all; and why the second surgery was required.

       Dr. Mihir Patel, whom Arnsperger did not depose, filed his affidavit on

May 31, 2019. In that affidavit, he identified himself as an expert to offer

testimony as to the causal nature of Arnsperger’s displaced ankle. He stated he

                                         6
had reviewed his medical history and the video surveillance footage. Dr. Patel

stated the displaced osteotomy identified in the December 18 x-rays “most

likely emerged from his first surgery” and that “[i]n light of the surgical

complications and Plaintiff’s pre-existing conditions, a slightly displaced

osteotomy was likely the best fixation the surgeon could accomplish.” He also

stated that even assuming the ankle had been “optimally fixated” after the first

surgery, the collision seen on the surveillance video could not have caused the

displacement, but “a much more violent impact would have been required to

generate a displacement, particularly while Plaintiff was wearing a splint.”

Finally, he concluded the second surgery was necessary to correct the

“suboptimal fixation” resulting from the first surgery.

      Based upon the depositions and consistent with its own ruling that

expert medical testimony was required on causation, the trial court granted

summary judgment on December 21, 2020. Arnsperger appealed. The Court of

Appeals reversed. It did so based on its agreement with Arnsperger that the

“injuries do not require a medical expert to relay to a layperson the cause-and-

effect relationship between the [hospital staffer] employee's conduct and

Arnsperger's injury.”

                               II.   Standard of Review
      Summary judgment is appropriate only when “there is no genuine issue

as to any material fact and that the moving party is entitled to a judgment as a

                                         7
matter of law.” CR 1 56.03. “[T]he proper function of summary judgment is to

terminate litigation when, as a matter of law, it appears that it would be

impossible for the respondent to produce evidence at the trial warranting a

judgment in his favor.” Steelvest, Inc. v. Scansteel Serv. Ctr., Inc., 807 S.W.2d

476, 480 (Ky. 1991). “The record must be viewed in a light most favorable to

the party opposing the motion for summary judgment and all doubts are to be

resolved in his favor.” Id. A grant of summary judgment is reviewed de novo.

Ashland Hosp. Corp. v. Lewis, 581 S.W.3d 572, 577 (Ky. 2019).

      It is elementary for all tort cases that the plaintiff must establish a duty,

breach thereof, causation, and injury. “In medical malpractice cases the

plaintiff must prove that the treatment given was below the degree of care and

skill expected of a reasonably competent practitioner and that the negligence

proximately caused injury or death.” Reams v. Stutler, 642 S.W.2d 586, 588

(Ky. 1982). “The burden of proof in a malpractice case is, of course, on the

party charging negligence or wrong. That must be established by medical or

expert testimony unless the negligence and injurious results are so apparent

that laymen with a general knowledge would have no difficulty in recognizing

it.” Johnson v. Vaughn, 370 S.W.2d 591, 596 (Ky. 1963). The failure to provide

expert medical testimony when necessary is “truly a failure of proof” and merits

summary judgment. Adams v. Sietsema, 533 S.W.3d 172, 177 (Ky. 2017)

(quoting Blankenship v. Collier, 302 S.W.3d 665, 668 (Ky. 2010)).

      1 Kentucky Civil Rules of Procedure.

                                         8
                    III.   Necessity of Expert Medical Testimony
      That a medical malpractice case may, in certain circumstances, proceed

to trial without expert medical testimony when duty, breach, causation, and

injury are readily apparent within the common knowledge of a jury has been

frequently described as the “layman’s exception” in this case, but that term is a

bit of a misnomer. The “layman’s exception” is in fact nothing other than the

application of res ipsa loquitur—the thing speaks for itself. Perkins v.

Hausladen, 828 S.W.2d 652, 654-55 (Ky. 1992); Lewis, 581 S.W.3d at 578. It

seems from this case that this doctrine is in danger of becoming unmoored

from its foundational principles, necessitating some exposition on its content

and application. Indeed, it is not the first time in recent history this Court has

felt the need to check an unwarranted expansion of res ipsa loquitur for

questions of causation in the medical context. Lewis, 581 S.W.3d at 579.

      Res ipsa loquitur applies in medical malpractice cases when “any layman

is competent to pass judgment and conclude from common experience that

such things do not happen if there has been proper skill and care” or “when

‘medical experts may provide a sufficient foundation for res ipsa loquitur on

more complex matters.’” Hausladen, 828 S.W.2d at 655 (quoting Paintsville

Hosp. Co. v. Rose, 683 S.W.2d 255, 256-57 (Ky. 1985)). The former is

“illustrated by cases where the surgeon leaves a foreign object in the body or

removes or injures an inappropriate part of the anatomy.” Id. at 654. The latter

occurs when expert testimony establishes the “type of injury was not an

ordinary risk of the surgery, that the method by which it occurred was within

                                         9
the exclusive control of the defendant, and that the injury was not due to any

voluntary action or contribution on the part of the plaintiff.” Id. at 655. 2 In

other words, “when the circumstances and the probabilities as to the causative

factors of an accident lie within the ken of experts, expert evidence is necessary

to establish a foundation that gives rise to an inference of negligence.” 65A

C.J.S. Negligence § 820 (emphasis added).

      Crucial to remember is res ipsa loquitur “allows an inference of negligence

in certain cases, not causation; established causation is a prerequisite to the

application of the doctrine.” Id. at § 821 (emphasis added). “A lack of knowledge

as to the cause of the accident does not call for the application of the doctrine.”

Cox v. Wilson, 267 S.W.2d 83, 84 (Ky. 1954). That “[t]he plaintiff's injury must

have resulted from the accident[,]” is a basic element of res ipsa loquitur in

Kentucky. Id. See also Quillen v. Skaggs, 25 S.W.2d 33, 34-35 (Ky. 1930). Res

ipsa loquitur “must be linked with the injury suffered. There may be an

inference of negligence when, according to common knowledge and experience,

the accident would not have happened except for the wrongful act of the

defendant.” Jos. N. Rice Co. v. Grayson, 341 S.W.2d 238, 239 (Ky. 1960). The

doctrine is therefore inapplicable where more than one cause can be inferred

from the evidence. Schroerlucke v. McDaniel Funeral Home, Inc., 291 S.W.2d 6,

      2 There is also a second type of case that does not require expert medical

testimony on the part of the plaintiff, and which we distinguish from res ipsa
loquitur—“where the defendant physician makes certain admissions that make his
negligence apparent.” Sietsema, 533 S.W.3d at 179 (quoting Blankenship, 302 S.W.3d
at 670)).

                                          10
8 (Ky. 1956). “[T]he doctrine [can] be applied only when the nature of the

accident itself not only clearly supports the inference of negligence on the part

of the defendant but excludes all other inferences that it might be due to one or

more causes of which the defendant is not responsible.” Id. at 9.

      Arnsperger has steadfastly maintained that the December 18 collision

was a “re-injury” and that no other incident occurred between December 14

and 18 that could have “re-injured” his left ankle. He (and the Court of

Appeals) focuses on the hospital staffer and the collision to argue this “re-

injury” could not have happened but for negligence. But this use of the word

“re-injury” and the narrow focus on the December 18 collision is a linguistic

sleight-of-hand meant to avoid the fact that whether the left ankle had been

properly aligned after the December 14 surgery was an open question at the

time the collision occurred on December 18. His own physician, Dr. Shamsi,

could not make that conclusion definitively without x-rays. The injury is not

linked to the accident 3 to such a degree that a layman can infer, without the

aid of expert testimony, that it is more probable than not the injury would not

have occurred but for the collision. Id. at 8; Hausladen, 828 S.W.2d at 656.

      3 Indeed, Dr. Shamsi’s deposition reveals that on December 17, 2015,

Arnsperger reported to Dr. Shamsi’s assistant that he had hit his left foot and was
prevented from taking the x-rays on that day as a result of the collision. So not only is
there a dispute as to whether the hospital staffer’s alleged negligence on December 18,
2015, caused Arnsperger’s ankle displacement, but there is evidence in the record to
suggest that a collision on December 17, 2015, occurred as well that Arnsperger has
not made a claim of negligence for. This underscores how critical the element of
causation is in this case and why a jury cannot infer from the mere occurrence of the
December 18, 2015, collision that said collision caused his claimed injury.
                                           11
      A second issue is that Arnsperger has throughout the litigation

maintained that his claim is not a medical malpractice claim, but one of

ordinary negligence, and therefore expert medical testimony is not necessary.

As we have said, not every medical malpractice case requires expert testimony,

Sietsema, 533 S.W.3d at 177; but that does not mean that every ordinary

negligence case amounts to res ipsa loquitur. Cox, 267 S.W.2d at 84. Only when

the

      (1) [t]he defendant had full management and control of the
      instrumentality which caused the injury[;] (2) . . . according to
      common knowledge and the experience of mankind, the accident
      could not have happened if those having control and management
      had not been negligent[; and] (3) [t]he plaintiff’s injury must have
      resulted from the accident[,]
does res ipsa loquitur apply, even in ordinary negligence cases. Id. Since

causation is a prerequisite to the rule’s application, a case wherein causation is

a matter of good-faith dispute precludes its application. We are content to

concede that Arnsperger and the Court of Appeals are correct that the standard

of care for a hospital staffer pushing a wheelchair-bound patient needs no

expert testimony. But that overlooks the fact that Arnsperger has always

assumed the collision with the desk caused his injury, whereas his medical

history in the days preceding the collision and the medical testimony of Dr.

Shamsi and Dr. Patel call that assumption into doubt. The thing does not

speak for itself. The instrumentality which caused the injury is disputed, thus,

that the injury was caused by the desk collision is also disputed.

      This disputed question of causation is beyond the common knowledge of

the jury. The error of the Court of Appeals lay entirely on its narrow focus on

                                       12
the elements of duty and breach for the hospital staffer pushing Arnsperger in

his wheelchair, when the issue is whether the act of pushing Arnsperger into

the desk caused his claimed injuries. As such, the fact that Arnsperger only

days earlier had a surgery on the left ankle, and the successful outcome of that

surgery was in question at the time of the injury, is critical to properly

determining the question before us. In as simple terms as possible, the

question is whether a jury could conclude that the lateral displacement in

Arnsperger’s left ankle was caused by the desk collision on December 18

merely from the fact that the desk collision occurred. It could not.

      As recounted in Section I, Arnsperger has an extensive medical history

involving his left ankle, including surgeries prior to the two involved in this

case. He also has Complex Regional Pain Syndrome in the same ankle—a

syndrome that magnifies the pain response in the sufferer beyond what an

ordinary person would feel if they had been touched or impacted in the same

manner. And most importantly to our decision are the facts that only four days

prior to the collision, Arnsperger underwent a surgery in which the surgeon

fractured the bone, was unable to realign the bone as originally planned due to

a traumatic drill bit failure, and was unable to conclusively determine without

x-rays whether the ankle bone had been properly aligned despite the drill bit

failure. It is beyond the common knowledge of the jury to simply look at these

facts and infer that the ankle had been properly aligned at the December 14

surgery and that, therefore, the lateral displacement found on December 18

must have been caused by desk collision. Such a question is manifestly beyond

                                        13
the competence of a layman. Neither Dr. Shamsi nor Dr. Klickovich offered any

testimony as to that causal fact, and Dr. Patel’s expert disclosure stated that

he would be offering testimony that the lateral displacement found on

December 18 was a result, i.e., caused by, the December 14 surgery, and not

the desk collision.

      Even assuming this is not a medical malpractice case in the strict sense,

causation is still a disputed element of Arnsperger’s negligence tort claim and

the trial court concluded that expert testimony was necessary. The necessity of

expert testimony is an evidentiary question committed to the sound discretion

of the trial judge. Sietsema, 533 S.W.3d at 178. The Court of Appeals opined

that this case was similar to Young v. J.B. Hunt Transp., Inc., 781 S.W.2d 503

(Ky. 1989), and concluded “an expert medical witness was not needed to testify

to the negligence of the driver or drivers of the vehicles involved. Similarly, no

expert medical testimony is necessary to determine the duty of a hospital

staffer driving a wheelchair or to gauge whether that duty was breached.” With

due respect to the lower court, that is a misreading of Young. Not one word in

Young addressed the necessity of expert medical testimony regarding the

negligence of a vehicle driver. What Young addressed was the attempt by the

defendant in that case “[a]t the conclusion of testimony, but before the close of

their evidence . . . [to admit] a large volume of hospital records without there

having been any witness [to] comment upon or explanation of the records to

the jury.” Id. at 508. We affirmed the trial court’s refusal to admit those records

because “without the prior treating physician or any physician available to

                                        14
explain the records, counsel would have been free to draw whatever

conclusions they wished without fear of evidentiary contradiction.” Id. Young is

inapposite to this case. The issue is not elements of duty or breach of the

hospital staffer, but causation of injury. Causation cannot be established from

the mere occurrence of the December 18 desk collision given the December 14

surgery and its disputed result.

                                   IV.    Conclusion
      The trial court concluded expert testimony was necessary as to the

element of causation and Arnsperger needed to produce an expert medical

physician who could opine that the desk collision caused the lateral

displacement in his left ankle. Res ipsa loquitur—colloquially referred to as the

“Layman’s Exception”—is only applicable where causation is established, and

no other inference but the defendant’s negligence is supported. Cox, 267

S.W.2d at 84; Schroerlucke, 291 S.W.2d at 9. This is true whether Arnsperger

has brought a medical malpractice claim or an ordinary negligence claim, since

Kentucky law allows medical experts to testify to establish “sufficient

foundation for res ipsa loquitur on more complex matters.” Hausladen, 828

S.W.2d at 655. Given the peculiar medical history of Arnsperger in the days

leading up to December 18, specifically regarding his left ankle, it is beyond the

common knowledge of the jury to conclude Arnsperger’s laterally displaced

ankle bone was caused by the desk collision merely from the fact that the

collision occurred. Arnsperger has identified no expert who would opine that

the desk collision caused the lateral displacement on December 18. St.

                                         15
Elizabeth has identified an expert who would testify the lateral displacement

was caused by the December 14 surgery. Therefore, Arnsperger has failed to

raise a genuine issue of material fact, and this failure means that under no

circumstances could his claim succeed. The Court of Appeals is reversed, and

we reinstate the summary judgment of the trial court.

      All sitting. All concur.

COUNSEL FOR APPELLANT:

Ellen M. Houston
Michael J. Enzweiler
Dressman Benzinger LaVelle PSC

COUNSEL FOR APPELLEE:

Shane C. Sidebottom
Ziegler & Schneider, PSC

Justin A. Sanders
Rittgers Rittgers & Nakajima

                                       16