Court Opinion

ID: 9458812
Source: CourtListenerOpinion
Date Created: 2023-08-04 21:02:00.229578+00
Date Added: 2024-06-11T17:35:54.004787
License: Public Domain

LAY, Circuit Judge
(dissenting).
I respectfully dissent from the affirmance of the judgment n. o. v.
Although judges properly serve as an ultimate safeguard to prevent a miscarriage of justice and as such possess the legal authority to take away a jury’s finding of fact, nevertheless, the exercise of that power should be used only in exceptional circumstances. Unfortunately, this power is often exercised merely because judges sometimes feel that other results under the evidence are more reasonable than what the jury found. When this occurs we act without judicial authority. Tennant v. Peoria & Pekin Union Ry., 321 U.S. 29, 64 S.Ct. 409, 88 L.Ed. 520 (1944). Judges possess no expertise in evaluating facts or drawing inferences from the evidence. When as judges we act as fact finders we draw from our human experiences and biases just as jurors do. Yet when judges attempt to decide questions of reasonable care and causal connection, we more often fall short of the valued expertise of the jury. In resolving factual issues judges cannot possess the community values and judgment of a composite jury in attempting to equate conduct in terms of the common affairs of life. See Railroad Co. v. Stout, 84 U.S. 657, 664, 21 L.Ed. 745 (1873). When a judge holds that a jury’s verdict is wrong on a factual basis, he substitutes his reasonableness for that of twelve individuals who have resolved their subjective reasoning into an objective analysis and result. *516When this occurs the record should be so void of any substantial evidence that a court can objectively say that no reasonable man could ever differ in the result reached. It is impossible to say this on the present record.
The majority decision emphasizes that there is no expert opinion evidence to prove negligence or causal connection in this medical malpractice case. It is true that in medical malpractice cases it is held that the standard of care of a skilled physician is not within the general knowledge of a lay jury and under these circumstances expert testimony is generally needed. However, this rule is not to be interpreted so strictly as to require that the expert testimony should always be in the standard form which necessarily elicits an opinion as to the negligence and causation. Jurors apply common sense to all factual circumstances in arriving at a fair verdict. This is really their only tool. Trial lawyers seek opinion evidence to corroborate their evidence, seldom to prove the case itself. Indeed, opinion evidence offered by expert witnesses is nothing more than a swearing match by professional witnesses. In this day and age, even in malpractice cases, it is not overly difficult to hire expert opinion evidence on either side of a medical proposition. The law is not so stilted as to depend on such evanescent testimony. Significantly, our jurisprudence leaves it to the nonexperts, the jury, to determine which side of the case is more reasonable and just. In Sentilles v. Inter-Caribbean Shipping Corp., 361 U.S. 107, 80 S.Ct. 173, 4 L.Ed.2d 142 (1959), where the question of trauma as an aggravating cause of a tubercular condition was at issue, the Supreme Court cogently observed in the language of an Indiana case:1 “ ‘Indeed, if it were not for the saving grace of what we call common sense, justice would be defeated in almost every case where opinion evidence is admitted.’ ” 361 U.S. at 110 n. 3, 80 S.Ct. at 175.
Common sense dictated the jury’s verdict here. Although the standard form questions were not asked by plaintiff’s counsel and precise opinion evidence is absent from the record, nevertheless, there exists an abundance of expert testimony which adequately demonstrates the lack of reasonable care by the defendant doctors in making their examination and resulting diagnosis of Mrs. Bryant.
It is true that a mere mistake in judgment is not a basis of liability in a medical negligence case. However, to avail himself of the defense of a mistake of judgment, as has been observed, “it must appear that the physician used reasonable care in exercising that judgment. . . . ” Foose v. Haymond, 135 Colo. 275, 310 P.2d 722, 727 (1957). Iowa law is in full accord. Iowa law recognizes that a physician skilled in his professional calling must make a thorough and professional examination or liability for negligent diagnosis may follow. See Wheatley v. Heideman, 251 Iowa 695, 102 N.W.2d 343, 349 (1960). Application of this rule governs the proof of negligence in this case.
The fundamental issue is whether Dr. Rankin, a skilled practicing surgeon, was aware of and knew there was the possibility of low grade infection existing (even though it be unusual) which would not manifest itself by the usual clinical findings of redness, temperature and a high white blood count. There can be little doubt of this evidence since Dr. Rankin admitted in his own expert testimony his awareness of such a possibility. Once this fact was established and recognizing that a doctor must make a thorough examination, is it unreasonable to inquire as to whether the doctor did anything to rule out this possibility before he made his diagnosis of aseptic necrosis and elected to “wait and see?” The plain and simple fact is that Dr. Rankin admitted he did nothing to rule *517out that possibility.2 Was there a diagnostic technique available to him which was followed in that locality to ascertain whether a low grade infection existed? Again by his own expert testimony he stated “had he suspected a low grade infection he would have aspirated the hip” in order to obtain a culture for study.3 Is a skilled surgeon to be excused because he did not suspect this infection since he relied on the absence of clinical symptoms which one doctor characterized as “Reader’s Digest and Good Housekeeping” signs of infection? At best is not this an issue of fact for the jury? Is this not especially true when the same physician admitted that low grade infection could exist without these symptoms?
Assume the owner of a truck took his vehicle to the garage to have its brakes fixed since they would not hold; assume that all the skilled mechanic did was to check and replace the brake fluid; assume the vehicle was returned and shortly thereafter the truck was involved in a serious accident because the brakes failed to hold when attempting to stop; and assume an inspection then revealed that the brakes were otherwise completley worn out and defective. Would there be any doubt that in the absence of an expert’s opinion the skilled garage mechanic would be held to have been negligent in failing to check out other possible causes for the brake condition? Cf. M. Dietz & Sons, Inc. v. Miller, 43 N.J.Super. 334, 128 A.2d 719 (1957). How is the skilled physician any different or immune from this same standard of care? The ordinary layman is no more a skilled mechanic than a skilled physician. Yet, it does not require an expert opinion to prove that reasonable care was not used in making a thorough inspection of the truck. There is greater reason that the same rule should apply to an examination of the human body. Is it not axiomatic in negligence cases that the standard of care required is commensurate to the risk involved? Foy v. Friedman, 108 U.S.App.D.C. 176, 280 F.2d 724 (D.C.Cir. 1960); Prosser, Law of Torts, § 34 (3d ed. 1964); Restatement (Second) of Torts, § 298 (1965). 4
*518In addition to the defendants’ own admissions,5 which uniformly have been held sufficient to provide the required expert testimony,6 there existed other overall evidence for the jury to consider.
Expert testimony was adduced for the jury to consider that insertion of the Smith-Peterson nail in the femur includes the possibility of infection;7 that infection in any major joint in the body is considered a major medical problem in orthopedic procedures; that the condition of avascular necrosis can be caused by a septic as well as an aseptic condition; that low-grade infection, as found in Mrs. Bryant, is not associated with all of the “Reader’s Digest and Good Housekeeping” signs of infection (swelling, high temperature and general sickness) ; that low-grade infection is as significant as any of the more virulent forms of infection which might result from this type of surgery; that such a low-grade infection requires immediate treatment; and that severe pain as exhibited by Mrs. Bryant is generally associated with infection and not with an aseptic necrosis. In addition to the above evidence, the jury could consider that Dr. Schnell would have included evidence of infection as part of his differential diagnosis as early as October '26, 1965. Dr. Litton testified that his examination of the X-rays revealed the possibility of infection as early as the November 17 X-ray. Moreover, when Mrs. Bryant was transferred to the Columbia Medical Center the attending physicians’ initial diagnosis included the possibility of infection.
The majority opinion reasons that even assuming evidence of negligence there was no expert opinion as to causation.' This again totally and completely ignores the admonition and standard of the United States Supreme Court in the Sentilles case when dealing with a precise challenge to equivocal proof concerning medical causation.8 The Supreme Court observed:
“The jury’s power to draw the inference that the aggravation of peti*519tioner’s tubercular condition, evident so shortly after the accident, was in fact caused by that accident, was not impaired by the failure of any medical witness to testify that it was in fact the cause. Neither can it be impaired by the lack of medical unanimity as to the respective likelihood of the potential causes of the aggravation, or by the fact that other potential causes of the aggravation existed and were not conclusively negated by the proofs. The matter does not turn on the use of a particular form of words by the physicians in giving their testimony. The members of the jury, not the medical witnesses, were sworn to make a legal determination of the question of causation. They were entitled to take all the circumstances, including the medical testimony, into consideration. See Sullivan v. Boston Elevated R. Co., 185 Mass. 602, 71 N.E. 90; Miami Coal Co. v. Luce, 76 Ind.App. 245, 131 N.E. 824. Though this case involves a medical issue, it is no exception to the admonition that, ‘It is not the function of a court to search the record for conflicting circumstantial evidence in order to take the case away from the jury on a theory that the proof gives equal support to inconsistent and uncertain inferences. The focal point of judicial review is the reasonableness of the particular inference or conclusion drawn by the jury. . . . The very essence of its function is to select from among conflicting inferences and conclusions that which it considers most reasonable. . . . Courts are -not free to reweigh the evidence and set aside the jury verdict merely because the jury could have drawn different inferences or conclusions or because judges feel that other results are more reasonable.’ Tennant v. Peoria & Pekin Union R. Co., 321 U.S. 29, 35, [64 S.Ct. 409, 412, 88 L.Ed. 520]. The proofs here justified with reason the conclusion of the jury that the accident caused the petitioner’s serious subsequent illness. See Rogers v. Missouri Pacific R. Co., 352 U.S. 500, [77 S.Ct. 443, 1 L.Ed.2d 493].” (My emphasis.) 361 U.S. at 109-110, 80 S.Ct. at 175.
The majority opinion reasons that both of Mrs. Bryant’s experts testified that had the nail been removed and a spica cast applied in December 1965 or January 1966 rather than in March 1966, the results would probably have been no different. This analysis misses the critical issue. The issue is whether sufficient evidence was adduced upon which the jury could find a reasonable probability that the defendants’ failure to properly diagnose and treat the infection proximately contributed to the radical treatment ultimately required and resulting in Mrs. Bryant’s disabling condition.
Apropos here is comment (b) of the Restatement (Second) of Torts, § 433B (1965):
“b. The plaintiff is not, however, required to prove his case beyond a reasonable doubt. He is not required to eliminate entirely all possibility that the defendant’s conduct was not a cause. It is enough that he introduces evidence from which reasonable men may conclude that it is more probable that the event was caused by the defendant than that it was not. The fact of causation is incapable of mathematical proof, since no man can say with absolute certainty what would *520have occurred if the defendant had acted otherwise. If, as a matter of ordinary experience, a particular act or omission might be expected to produce a particular result, and if that result has in fact followed, the conclusion -may be justified that the causal relation exists. In drawing that conclusion, the triers of fact are permitted to draw upon ordinary human experience as to the probabilities of the case.” (My emphasis.)
It is true that once again plaintiff’s counsel failed to produce any expert testimony specifically stating that the defendants’ action proximately contributed to the plaintiff’s condition. However, Dr. Schnell did testify that infection is always a serious complication in orthopedic surgery and that infection should be detected as early as possible in order to prevent destruction of the joint surfaces. Similarly, Dr. Litton testified that the sooner you find an infection, the better the chance is of obtaining a good result; he further related that as of March 1966 the extent of the infection necessitated removing the nail and placing Mrs. Bryant in a spica cast since “in the face of the infection that we had discovered there, we felt any attempt to do anything else would not be successful. And we knew that if she would get a solid hip fusion, she would have a very serviceable and a painless hip” (my emphasis) ; Dr. Schnell indicated that he would have performed other procedures when the infection was first noted with the expectation of better stabilizing the hip and reducing the amount of leg shortening; Dr. Anderson 9 stated in his deposition that “[a] common cause in someone who you assume had an normal hip a short time previously for the cartilage to disappear is an infection.’’ (My emphasis.) The seriousness and destructive nature of infection is common knowledge to laymen. It should not require a doctor to establish that the presence of infection is not conducive to the body’s healing mechanisms.
In light of the above, it is difficult to reason that there is not sufficient evidence on which a jury could- find it reasonably probable that the failure to detect the infection contributed to Mrs. Bryant’s disabled condition. The fact that there is some testimony that the end result would “probably” be the same or that it is only “possible” that the infection caused deterioration of the femur is not, ipso facto, conclusive evidence that the case should be taken from the jury. Cf. Dickinson v. Mailliard, 175 N.W.2d 588 (Iowa 1970).10
A jury is entitled to draw reasonable inferences from all of the evidence to determine whether there exists sufficient probability that late discovery of the infection contributed to plaintiff’s disability. As the Iowa Suprem’e Court said in Daiker v. Martin, 250 Iowa 75, 91 N.W.2d 747, 752 (1958), “ . . . the question of [proximate cause] . . . was one of fact rather than medical theory or expert opinion and was for the jury to determine.” See also, Wheatley v. Heideman, 251 Iowa 695, 102 N.W.2d 343 (1960); Stickle*521man v. Synhorst, 243 Iowa 872, 52 N.W.2d 504 (1952); cf. Marshall v. Humble Oil & Refining Co., 459 F.2d 355 (8 Cir. 1972). In Fireman’s Fund Insurance Co. v. Aalco Wrecking Co., 392 F.2d 179, (8 Cir. 1972), this court recently observed :
“There are many instances in tort litigation where precise causation becomes difficult to prove. There is no exact way to prove that the harm might have been avoided, because the harm did in fact take place. . A plaintiff does not have the negative burden to show that the harm could not have possibly occurred if the defendant had performed the duty breached. It would be absurd to say that a defendant could hide behind such absence of proof where his own conduct has created the fertile ground for harm and the harm did in fact occur. It has long been recognized that:
‘[I]f the actor’s negligence, either of act or omission, results in harm of the sort from which the duty was designed to protect the other, his negligence may be regarded as a substantial factor in bringing about the harm in spite of the fact that the same harm might possibly have been sustained had the actor not been negligent. Maryland v. Manor Real Estate & Trust Co., 176 F.2d 414, 418 (4 Cir. 1949).’”11
In Weintraub v. Rosen, 93 F.2d 544, 547-548 (7 Cir. 1937) (alleged malpractice in failure to discover and reduce a fracture of the femur), the court of appeals noted:
“That injury proximately resulted to appellant from appellees’ negligence we think there can be no doubt under the evidence. What those injuries were we can not define with accuracy. This is largely true in all such cases. Even had there been no negligence there is no assurance that the patient’s hip would have been in any better condition than it is now. These are matters which are not subject to exact proof, and yet they are matters for the jury’s determination.” (My emphasis.)
In Wilson v. Corbin, 241 Iowa 593, 41 N.W.2d 702, 708 (1950), the Iowa court observed:
“We have frequently held the issue of proximate cause is ordinarily for the jury where there is substantial evidence of a defendant’s negligence. Lindquist v. Des Moines Union Ry. Co., 239 Iowa 356, 362, 371, 30 N.W.2d 120, 123, 127, and citations; Dunham v. Des Moines, Ry. Co., Iowa, [240 Iowa 421] 35 N.W.2d 578, 582.”
Finally, the defendant-doctors argue that the lower court was correct in granting the judgment n.o.v. since the jury verdict necessarily involved speculation and conjecture as to the proximate cause issue. However, the forcefulness of any “speculation and conjecture” argument is effectively undercut by the Court in Lavender v. Kurn, 327 U.S. 645, 653, 66 S.Ct. 740, 744, 90 L.Ed. 916 (1946), where Mr. Justice Murphy states:
“It is no answer to say that the jury’s verdict involved speculation and conjecture. Whenever facts are in dispute or the evidence is such that fair-minded men may draw different inferences, a measure of speculation and conjecture is required on the part of those whose duty it is to settle the dispute by choosing what seems to them to be the most reasonable inference. Only when there is a complete absence of probative facts to support the conclusion reached does a reversi*522ble error appear. But where, as here, there is an evidentiary basis for the jury’s verdict, the jury is free to discard or disbelieve whatever facts are inconsistent with its conclusion. And the appellate court’s function is exhausted when that evidentiary basis becomes apparent, it being immaterial that the court might draw a contrary inference or feel that another conclusion is more reasonable.” (My emphasis.)
See also Jeanes v. Milner, 428 F.2d 598, 604-605 (8 Cir. 1970).
The record in the instant case reveals that the jury was properly charged as to proximate cause and admonished not to conjecture or speculate. The fact that the jury returned a verdict in favor of Mrs. Bryant indicates that they rejected the defendant-doctor’s speculative causal possibilities and in weighing the evidence found reasonable proximate cause.12 Cf. Marshall v. Humble Oil & Refining Co., supra.
I conclude under all of the evidence that the jury could find without opinion evidence13 that the defendants were negligent in failing to consider the possibility of a low-grade infection in making their diagnosis and in failing to use tests- known to them to determine whether infection existed as the cause of the plaintiff’s rapidly developing necrosis. I likewise conclude that the jury could legitimately infer from all of the evidence that the delay in treating the infection causally contributed to plaintiff’s long duration of pain14 and to the radical procedure ultimately used which has crippled a young housewife and mother for life.

. Miami Coal Co. v. Luce, 76 Ind.App. 245, 131 N.E. 824, 826 (1921).

. The majority alludes to the fact that Dr. Rankin relied on the radiologist’s opinion that the X-rays did not demonstrate evidence of infection. This fact has little relevance in determining whether the plaintiff made a prima facie case. Perhaps the jury disbelieved this statement.. It is controverted by plaintiff’s evidence that the early X-rays demonstrated a rapid deterioration of the soft tissue — a product of some kind of necrosis. Dr. Rankin even admitted this. Nevertheless, Dr. Rankin, as a skilled surgeon holding himself out as having the skill of an orthopedic specialist, was in charge of the case. He can hardly delegate his responsibility to make a thorough investigation because a radiologist misreads an X-ray. He knew there was necrosis and it was his duty to make a thorough examination to • determine why.

. The mere fact that a diagnostic technique might not disclose the infection is hardly a defense. However, again this is not relevant here. Dr. Rankin did not suggest this as a reason for not aspirating the hip joint. The other side of this reasoning is that it is a medical technique which might ha/oe disclosed it. It must be remembered that the verdict holder is entitled to the most favorable inference from the evidence. O’Brian v. Stover, 443 F.2d 1013, 1014 (8 Cir. 1971); Kotula v. Ford Motor Co., 338 F.2d 732, 735 (8 Cir. 1964), cert. denied, 380 U.S. 979, 85 S.Ct. 1333, 14 L.Ed.2d 273 (1965); Dobson v. Jewell, 189 N.W.2d 547, 550 (Iowa 1971); Marxen v. Meredith, 246 Iowa 1173, 69 N.W.2d 399, 401 (1955).

. “JSven where the special medical standards is invoked as the touchstone of liability, ‘the proposition that experts alone are qualified to testify as to the manner of treatment of a patient is “sound only when sotmdly applied,” ’ and ‘ “there must be, in the nature of things, many instances where the facts alone prove the negligence, and where it is unnecessary to have the opinions of persons skillful in the particular science to show unskillful and negligent treatment.” ’ And we have differentiated situations ‘where the question turns on the merits and the performance of scientific treatment,’ so that ‘the issue may not be resolved by the jury without the aid of expert opin*518ion,’ from ‘an ordinary ease of negligence, where the jury is able to solve the question by applying thereto their own experiences’ and ‘the test is: How would a reasonably prudent man have acted under the circumstances?’” (My emphasis.) Washington Hospital Center v. Butler, 127 U.S.App.D.C. 379, 384 F.2d 331, 336 (D.C.Cir.1967).

. Turning to the record in the instant case, the following testimony from Drs. Harper and Rankin is noted:
(1) Dr. Harper admitted that one can have both aseptic and septic necrosis at the same time.
(2) Dr. Rankin testified that septic necrosis is not unknown to the field of orthopedic surgery and admitted that it can be dangerous once it occurs.
(3) According to Dr. Rankin, he knew that the low-grade infections do not produce the same demonstrable symptomatology (i. e., fever, etc.) as do the more fulminating type infections.
(4) Dr. Rankin .admitted that had he suspected hip infection, he would have attempted a needle aspiration of -the hip joint.
(5) Dr. Rankin testified that Mrs. Bryant received several white blood count tests since a high WBO would have indicated infection. However, the hospital records reveal only two such WBC tests were taken the entire six months Mrs. Bryant was under the care of the defendant-doctors. Dr. Rankin claims he is “at a loss to explain why they [more WBO tests] are not on . these charts.” Cf. Cooper v. United States, 313 F.Supp. 1207 (D.Neb.1970).

. See Hill v. Gonzalez, 454 F.2d 1201 (8 Cir. 1972); Shepherd v. McGinnis, 257 Iowa 35, 131 N.W.2d 475 (1964); Sheffield v. Runner, 163 Cal.App.2d 48, 328 P.2d 828 (Cal.Dist.Ct.App.1958); Prosser, Law of Torts, § 32 at 167 (3d ed. 1964).

. It was recognized at an early date that an open reduction is a dangerous surgical procedure because of the great possibility of infection. Cf. Maxwell v. Howell, 114 W.Va. 771, 174 S.E. 553 (1934); Sweet v. Douge, 145 Wash. 142, 259 P. 25 (1927).

. The question of which law (federal or state) controls the sufficiency of evidence in a diversity case has never been determined by this court. We have always assumed that both the law of the state *519and the federal law require the same tests in weighing the sufficiency of the evidence. AVe have acknowledged this principle in evaluating diversity cases under Iowa law. Ford Motor Co. v. Mondragon, 271 F.2d 342 (8 Cir. 1959). If this be true then this court should adhere to the standards used by the Supreme Court of the United States in negligence cases. If, under the evidence presented here, we applied the tests set forth in Sentilles v. Inter-Caribbean Shipping Corp., 361 U.S. 107, 80 S.Ct. 173, 4 L.Ed.2d 142 (1959) and Lavender v. Kurn, 327 U.S. 645, 66 S.Ct. 740, 90 L.Ed. 916 (1946), we would leave this jury verdict undisturbed.

. At the time of trial Dr. Anderson was a clinical instructor in orthopedic surgery at the University of Missouri’s Columbia Medical Center.

. In Lavender v. Kurn, 327 U.S. 645, 652-653, 66 S.Ct. 740, 743, 90 L.Ed. 916 (1946), wherein the Supreme Court was faced with reviewing a judgment n. o. v., the Court observed:
“It is true that there is evidence tending to show that it was physically and mathematically impossible for the hook to strike Haney. And there are facts from which it might reasonably be inferred that Haney was murdered. But such evidence has become irrelevant upon appeal, there being a reasonable basis in the record for inferring that the hook struck Haney. The jury having made that inference, the respondents were not free to relitigate the factual dispute in a reviewing court. Under these circumstances it would be an undue invasion of the jury’s historic function for an appellate court to weigh the conflicting evidence, judge the credibility of witnesses and arrive at a conclusion opposite from the one reached by the jury.” (My emphasis.)

. Compare Judge Sobeloff’s observations in Hicks v. United States, 368 F.2d 626, 632 (4 Cir. 1966), where he wrote:
“Rarely is it possible to demonstrate to an absolute certainty what would have happened in circumstances that the wrongdoer did not allow to come to pass. Tlie law does not in the existing circumstances require the plaintiff to show to a certainty that the patient would have lived had she been hospitalized and operated on promptly. Harvey v. Silber, 300 Mich. 510, 2 N.W.2d 483 (1942).”

. Jury Instruction No. 7a reads :
“If you believe from the evidence that the conditions and things of which plaintiff complains were caused or occasioned by or from any cause or causes over which the defendants had no control, or for which they are not responsible, your verdict must be in favor of the defendants. If you believe that it cannot be determined by a preponderance of the evidence whether the conditions of which the plaintiff complains were or were not caused by any act or failure to act on the part of the defendants, or by anything over which they had no control, your verdict must be in favor of the defendants. You are not allowed to conjecture or speculate as to the cause of the injuries, if any, in this case.”

. I emphasize that by lack of expert testimony I mean direct testimony that the defendants’ negligent diagnosis and treatment contributed to the plaintiff’s present physical condition. As the record demonstrates, there was an abundance of expert medical testimony in this case but it was not utilized in the manner typical of most malpractice suits.

. See Wilson v. Corbin, 241 Iowa 593, 41 N.W.2d at 708 where the Iowa court observed:
“Of course the original injury, even if promptly diagnosed and treated, would naturally cause much pain, loss of time, and perhaps some permanent stiffness. And it may be difficult to determine precisely how much of plaintiff’s total damage is due to the injury and how much to defendant’s negligence. Indeed pain is of course incapable of exact pecuniary compensation in any ease. But we think the testimony affords a substantial basis for an intelligent award of damages.”
Cf. Provancial v. United States, 463 F.2d 760 (8 Cir. 1972); Kosak v. Boyce, 185 Wis. 513, 201 N.W. 757 (1925).