Court Opinion

ID: 9534124
Source: CourtListenerOpinion
Date Created: 2023-08-07 04:37:03.099128+00
Date Added: 2024-06-11T13:29:37.825881
License: Public Domain

Dore, J.
(concurring in part, dissenting in part) — I dissent.
While I agree with the majority that the appointment of a guardian ad litem for Devan Young did not remove his disability for the purposes of the tolling statute (RCW 4.16.190) and that the applicable statute of limitations did not begin to run against him, I dissent from the majority's conclusion regarding summary judgment. The evidence before the trial court was sufficient to show the existence of a genuine issue of material fact. The majority fails to state the facts in full and misapplies the standards governing summary judgment. I would reverse the trial court and remand for trial.
Facts
Plaintiff Devan Young was treated by doctors Ronald L. Case and C. Warren Bierman at Children's Orthopedic Hospital and Medical Center for an acute asthma condition. As treatment for Devan's asthma, Dr. Case prescribed the drug theophylline. The optimal therapeutic range of theophylline is 10 to 20. Blood levels under 10 are not sufficient to treat asthma, while blood levels over 20 are toxic or potentially toxic and can lead to brain damage or death. Because proper levels of the medication are critical to safe, effective treatment with the drug, blood samples must be *232drawn in order to monitor dosage levels soon after medication is taken. How soon after is an issue in this case.
In September 1978, Dr. Case prescribed the theophylline preparation Theo-Dur, 200 mg twice daily. The record indicates that Devan's Theo-Dur dosage was increased to 300 mg twice daily. On January 26, 1979, Devan's theophylline blood level was tested at 11.8, approximately 10 hours after he had been given Theo-Dur. Early in the morning on February 1, 1979, Devan, then 3 years old, was admitted to the Hospital with a theophylline blood level of 68 which resulted in permanent brain damage and rendered him mentally incompetent. He will need custodial care for the rest of his life.
On April 26, 1982, E. Rosa Young was appointed her son's guardian ad litem. In June 1986, she filed this medical malpractice and products liability action in King County Superior Court, naming the Hospital, the treating physicians and the pharmaceutical company as defendants. The guardian alleged that the Hospital and the treating physicians were negligent in their treatment of her son and that the pharmaceutical company was negligent in the labeling and warning with respect to the use of Theo-Dur.
The defendants moved for summary judgment. In an affidavit accompanying the motion for summary judgment, Dr. Case, the treating physician, states that in September 1978, he prescribed Theo-Dur 200 mg twice daily, and that he saw Devan again on November 1, 1978. Dr. Case did not see Devan again until January 31, 1979, the day before Devan suffered a seizure. Dr. Case's affidavit presumes that Theo-Dur 400 mg a day was continued throughout Devan's care period. Based on a Theo-Dur dosage of 400 mg a day, Dr. Case states that Devan's care "was at all times consistent with that of a reasonably prudent allergy and immunology practitioner under similar circumstances." Clerk's Papers, at 58.
In response to the defendants' motion, the plaintiff submitted the affidavit of Stephanie Dotson, a registered pharmacist. Dotson's affidavit points out that, according to the *233Hospital's records, the allergy clinic increased Devan's Theo-Dur dosage to 300 mg twice daily in mid-January 1979. See Clerk's Papers, at 119, 131, 133. In other words, Devan was receiving 600 mg per day in the period just prior to his seizure. Dotson also stated that, according to the professional literature, the maximum dosage for a child Devan's age is 400 mg per day.
In connection with their reply brief on the summary judgment motion, the defendants submitted a second affidavit by Dr. Case and an affidavit by Dr. John Neff, the Hospital's Chief of Staff. In his response to Dotson's affidavit, Dr. Case conceded that she was correct in her statement as to the recommended dosage.
Dr. Neff's affidavit is predicated on the Hospital records of Devan's treatment. As Dotson pointed out, these records show that the allergy clinic increased Devan's Theo-Dur dosage to 600 mg a day shortly before he suffered a seizure. On the basis of these facts, Dr. Neff opines that "[t]he physicians and other staff at Children's Orthopedic Hospital, in their care of Devan Young, exercised that degree of skill, care and learning which was available in the pertinent geographic area at the time of Devan Young's care." Clerk's Papers, at 81.
Although both doctors conclude that the appropriate standard of care was met, it is important to note that they disagree about a key factual predicate of their common conclusion. Doctor Case bases his conclusion on the assumption that Devan received a dosage of 400 mg per day. Doctor Neff, relying on the Hospital records, assumes that Devan received a dosage of 600 mg per day.
The trial court granted summary judgment, holding that the plaintiff's medical malpractice and products liability claims were barred by the applicable statute of limitations. The trial court also ruled that a pharmacist's affidavit submitted in opposition to the health care defendants' summary judgment motions failed to raise a genuine issue of material fact regarding whether the treating physicians or the Hospital breached the standard of care.
*234I would reverse the trial court on the ground that the two doctors' own affidavits raised an issue of material fact. Furthermore, Dotson's affidavit was sufficient to raise an issue of fact over the proper monitoring of Devan's blood levels, based on facts as to which she was competent to testify.
Standards Governing Motions for Summary Judgment
Even aside from its errors regarding the facts and the competence of the pharmacist's affidavit, the majority misapplies the standards of summary judgment by weighing the respective affidavits of the defendants and the plaintiff.
On review of a summary judgment, an appellate court must consider the facts and all reasonable inferences therefrom in the light most favorable to the nonmoving party. Wilson v. Steinbach, 98 Wn.2d 434, 437, 656 P.2d 1030 (1982). Summary judgment can be granted only when the pleadings and the evidence:
show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law.
CR 56(c). A "material fact" is a fact upon which the litigation depends, in whole or in part. Barrie v. Hosts of Am., Inc., 94 Wn.2d 640, 643, 618 P.2d 96 (1980). Once the moving party has made and supported his motion, the nonmoving party must come forward with specific facts showing that a genuine issue of fact exists for trial. CR 56(e).
The respective burdens imposed on the moving and non-moving party by CR 56 are sometimes confusing. Two related points must be kept in mind. First, while the defendant moving for summary judgment is not required to submit affidavits in support of his motion, CR 56(b), this does not mean he does not bear a genuine and substantial burden in supporting his motion. While CR 56(e) requires the nonmoving party to come forward with facts showing a material issue of fact, this does not occur unless and until the defendant meets his initial burden of showing that there is no issue of material fact.
*235Initially the burden is on the party moving for summary judgment to prove by uncontroverted facts that there is no genuine issue of material fact. LaPlante v. State, [85 Wn.2d 154, 531 P.2d 299 (1975)] at 158; Rossiter v. Moore, 59 Wn.2d 722, 370 P.2d 250 (1962); 6 J. Moore, Federal Practice ¶ 56.07, ¶ 56.15[3] (2d ed. 1948). If the moving party does not sustain that burden, summary judgment should not be entered, irrespective of whether the nonmoving party has submitted affidavits or other materials. Preston v. Duncan, [55 Wn.2d 678, 681, 349 P.2d 605 (I960)] at 683, see also Trautman, Motions for Summary Judgment: Their Use and Effect in Washington, 45 Wash. L. Rev. 1, 15 (1970).
(Italics mine.) Jacobsen v. State, 89 Wn.2d 104, 108, 569 P.2d 1152 (1977); accord, Zamora v. Mobil Oil Corp., 104 Wn.2d 199, 208-09, 704 P.2d 584 (1985); Graves v. P.J. Taggares Co., 94 Wn.2d 298, 302, 616 P.2d 1223 (1980).
Second, it is important to note that the affidavit performs a radically different function in the defendant's case as opposed to the plaintiff's. A plaintiff, if he is the non-moving party, must create an issue of fact in order to avoid summary judgment ánd an affidavit asserting any supportable, relevant fact inconsistent with the defendant's position will be sufficient to do so. The defendant's task, to show that there are no disputed facts, is necessarily much more difficult. In contrast to the plaintiff's situation, the mere fact that the defendant does assert some relevant facts will not necessarily meet his burden. The defendant's task of showing that there are no disputed facts means that the facts asserted in his affidavit, together with the plaintiff's allegations taken as true, must support only inferences in the defendant's favor.
Consequently, there is a risk inherent in the defendant's submitting affidavits. When more facts are added to the equation, the range of possible inferences multiplies. Some of the possible inferences may be inconsistent, resulting in the presentation of a jury question. There is no reason to assume, as the majority seems to, that merely because the affidavits are the defendant's that they resolve all factual disputes in his favor. See majority, at 226-27. Clearly, the *236affidavits are just as likely to expose further conflicts in the evidence, making it all the more necessary to send the matter to the jury to decide.
In treating the defendants' affidavits as dispositive, the majority treats the burdens of the parties on summary judgment as burdens of proof, weighing the defendants' affidavits against the plaintiff's. However, CR 56(e) describes only a shift in the burden of presentation. See 9 J. Wigmore, Evidence § 2487, at 292-99 (1981). The rule requires only that the plaintiff come forward with some fact, any fact, relevant to the outcome of the case, which contradicts the defendant's position. Were the court to weigh the persuasiveness of the facts asserted by the plaintiff and defendant, it would infringe on the province of the jury. If any party can be said to have the burden of proof on the motion, it is the defendant, since the evidence is strictly construed against him in order to prevent the court from usurping the jury's fact-finding role.
The case of Celotex Corp. v. Catrett, All U.S. 317, 91 L. Ed. 2d 265, 106 S. Ct. 2548 (1986), cited by the majority, is not to the contrary. In Celotex, the plaintiff argued that the defendant must submit affidavits in support of his motion for summary judgment. The Court of Appeals agreed, but the Supreme Court reversed. The Court noted that the rule specifically states that the defendant may move for summary judgment "with or without supporting affidavits". Celotex, at 323. The issue is whether there is no genuine issue of material fact, and a defendant may demonstrate this solely by reference to the pleadings. It is only the plaintiff who has a duty to submit affidavits, once the defendant has successfully supported his motion as provided in subsection (b) of the rule.
Contrary to the majority's suggestion, however, Celotex does not hold that just any affidavit submitted by the defendant will be sufficient to meet his burden. If the defendant chooses to argue from the pleadings, he must be able to show that all possible inferences from those pleadings are to his favor. If the defendant does submit affidavits, they too must lead only to inferences in his favor. If, *237instead, it is possible to draw any inference in the plaintiff's favor, then to grant judgment to the defendant would be to usurp the role of the jury. It is indeed necessary for the defendant to disprove the plaintiff's claim on summary judgment; not in the sense that his evidence must be more persuasive than the plaintiff's, but in the sense that the defendant must show the plaintiff does not have a leg to stand on.
These points are well illustrated in Zamora. In that case the plaintiff argued that the defendant had failed to odorize its propane gas and that a gas explosion was proximately caused by this failure. The defendant submitted affidavits in which it asserted that the gas had been odorized in compliance with industry practice and applicable regulations. This court held that the defendant was not entitled to summary judgment because its affidavits did not lead solely to inferences in its favor. In the court's words, the defendant's affidavits did not conclusively establish the absence of proximate cause.
The respondent proved only that the gas was odorized in compliance with industry standards and an administrative safety regulation; such compliance, however, does not conclusively establish that the gas was adequately odorized. Rather, that evidence is merely relevant on the issue of proximate cause. Respondent, in moving for summary judgment, had the burden of proof that no genuine issue of material fact existed on the question of proximate cause. Because respondent's evidence of compliance with the safety standards does not conclusively establish absence of proximate cause, appellants are entitled to a trial on that issue as an element of their product liability claim.
(Citations omitted.) Zamora, at 208-09. In this case summary judgment is likewise not proper because the defendants' affidavits did not conclusively establish that their care met the required standard and that their failures were not the cause of Devan's injuries. On the contrary, the defendants' own affidavits undercut their motion.
*238Summary Judgment Was Not Appropriate in This Case
In a medical malpractice action, a plaintiff must establish that (1) a health care provider failed to exercise the degree of care of a reasonably prudent health care provider acting in the same or similar circumstances, and (2) such failure was the proximate cause of injury. RCW 7.70.040. At issue is whether the health care defendants' administration and monitoring of Devan's Theo-Dur dosage breached the standard of care and whether the prescribed dosage proximately caused Devan's injuries.
The defendants themselves created an issue of fact over whether Devan was given the proper dosage of Theo-Dur. Dr. Case stated that a dosage of 400 mg falls within the standard of due care. Dr. Neff stated that the treating physicians met the standard of due care, but based his conclusion on the assumption that Devan was receiving 600 mg of Theo-Dur. The majority contends that the two doctors' conclusions are consistent, despite the fact that each opinion was premised on a different dosage, since there may be a range of dosages consistent with due care. However, that contention in itself constitutes an issue of fact sufficient to preclude summary judgment. Is it true that dosages of 400 and 600 mg both fall within the range of dosages consistent with due care? We do not know, and on the defendants' motion for summary judgment, we are required to construe conflicting evidence in the plaintiff's favor. The doctors' affidavits raise a question of material fact as to whether Devan received a dosage which was within the standard of due care.
There is also a question of fact whether the dosage received by Devan was the proximate cause of his injuries. The defendants concede that Theo-Dur, 400 mg a day is the recommended dosage for a child of Devan's age and weight. A dosage of 600 mg a day is 50 percent more than the recommended maximum daily dosage and 83 percent more than the recommended maintenance daily dosage for a child of Devan's age and weight. Devan's theophylline blood level increased to toxic levels shortly after his Theo-*239Dur dosage was increased to 600 mg a day. Dr. Case in his second affidavit states that it is not unusual for children to be "high metabolizers" of theophylline, thus requiring more than the recommended dosage. However, he does not state that Devan is a "high metabolizer" or that prescribing a Theo-Dur dosage 50 percent higher than the recommended maximum daily dosage was warranted in this case. Therefore an issue of material fact exists on the question of proximate cause.
In short, the defendants' own affidavits undercut their motion for summary judgment because they do not conclusively establish that the defendants met the required standard of care or the absence of proximate cause. From the affidavits the defendants offered, together with the plaintiff's allegations taken as true, it is possible to conclude that Devan received a dosage outside the standard of due care, and that this caused his injuries. The majority's clever manipulation of events leaves a false impression as to the facts, which is unfair to Devan and his mother. The defendants clearly were not entitled to summary judgment, because they did not succeed in establishing that there was no issue of material fact left for the jury to resolve.
The Pharmacist's Affidavit Raises Issues of Material Fact Regarding Due Care
An issue of fact also exists over the proper monitoring of Devan's blood level. The pharmacist's affidavit states that Theo-Dur requires frequent monitoring due to its high potential for toxicity, and that blood levels should be drawn 4 to 6 hours after a dosage is administered. As noted above, on the day before his seizure, Devan's blood was tested some 10 hours after the administration of the drug. If the pharmacist is correct, that test would have been ineffective to determine the proper level of Theo-Dur in the bloodstream. Furthermore, Dotson's affidavit pointed out that the Hospital records showed Devan had received 600 mg of Theo-Dur and that the recommended dosage for a child of his age is 400 mg. If the pharmacist is correct, the failure to monitor would have been a cause of Devan's injury.
*240In rejecting Dotson's testimony as incompetent, the majority fails to recognize that, regardless of Dotson's capacity to offer an opinion on the physician's standard of due care, she was competent to testify as to these facts. Dotson is a registered pharmacist in the state of Washington with extensive education, training and knowledge in her field. RCW 18.64.011(11) defines the practice of pharmacy:
"Practice of pharmacy" includes the practice of and responsibility for: Interpreting prescription orders; the compounding, dispensing, labeling, administering, and distributing of drugs and devices; the monitoring of drug therapy and use; the initiating or modifying of drug therapy in accordance with written guidelines . . . the providing of information on legend drugs[3] which may include, but is not limited to, the advising of therapeutic values, hazards, and the uses of drugs and devices.
(Italics mine.) Dotson had examined the records, the authenticity of which the defendants never questioned, and she was competent by training and experience to offer an expert opinion on the contents of the professional pharmaceutical literature. In addition, in his response to Dotson's affidavit, Dr. Case conceded that she was correct in her statement as to the recommended dosage.
In response to Dotson's affidavit, Dr. Case submitted an affidavit in which he contended that the levels of medication need not be monitored in the 4- to 6-hour period, because: "A clinician can accurately determine a patient's theophylline medication (Theo-Dur) does [sic] by evaluating his peak, through or in between levels."
Here again, Dr. Case created issues of fact with his own affidavit. Is the proper monitoring period 4 to 6 hours, as Dotson states, or is the monitoring period longer, as Dr. Case contends. If that question is resolved in the plaintiff's favor, there is a question of fact whether defendants were negligent in performing blood toxicity tests outside the recommended time period. Therefore, even assuming that *241Dotson was not competent to offer an opinion on the physician's standard of due care, those facts as to which she was competent to testify did raise issues of fact sufficient to preclude summary judgment.
The majority clearly errs in holding Dotson's affidavit insufficient on the sole ground that she is a pharmacist. In addition to her statements regarding the Hospital records and the professional pharmaceutical literature, Dotson avers that through her education, background, training, and experience she is familiar with the standard of care in treating patients such as Devan. Based on her review of Devan's medical records, she states:
The moving defendants failed to exercise that degree of skill, care and learning required of health care providers such as themselves in both prescribing theophylline and in monitoring its blood levels. This failure resulted in Devan experiencing theophylline toxicity.
Clerk's Papers, at 118.
In Harris v. Groth, 99 Wn.2d 438, 449, 663 P.2d 113 (1983), we refused to adopt a per se rule that nonphysicians are disqualified from offering expert testimony in a medical malpractice action. We stated:
The witness need not possess the academic credentials of an expert; practical experience may suffice. Training in a related field or academic background alone may also be sufficient. [ER] 702 states very broadly that the witness may qualify as an expert by virtue of knowledge, skill, experience, training, or education.
Harris, at 449 (quoting 5A K. Tegland, Wash. Prac., Evidence § 289, at 26 (2d ed. 1982)). We further stated:
We agree with the late Dean Wigmore that "the line between chemistry, biology, and medicine is too indefinite to admit of a practicable separation of topics and witnesses".
Harris, at 450 (quoting 2 J. Wigmore, Evidence § 569, at 790 (rev. 1979)). Whether an expert is licensed to practice medicine is an important, but not a dispositive factor to be considered by the trial court. Harris, at 450-51.
*242An affidavit submitted to avoid summary judgment must (1) be made on personal knowledge, (2) set forth such facts as would be admissible in evidence, and (3) affirmatively show that the affiant is competent to testify to the matters therein. CR 56(e). The trial court is vested with discretion to determine whether a witness is competent to testify as an expert on a particular subject and its ruling will not be disturbed except for a manifest abuse of discretion. Orion Corp. v. State, 103 Wn.2d 441, 462, 693 P.2d 1369 (1985); see Harris, at 450.
In light of the trend in Washington to permit nonphysicians to testify in malpractice actions, a trial court in the exercise of its discretion must be lenient toward a nonphysician's affidavit presented by the nonmoving party at a summary judgment proceeding. See PUD 1 v. WPPSS, 104 Wn.2d 353, 361, 705 P.2d 1195, 713 P.2d 1109 (1985). Accordingly, on a motion for summary judgment, the test is whether any trial judge would admit the expert testimony. Contrary to the majority's conclusion, we cannot say, as a matter of law, that no trial court would consider the pharmacist's affidavit.
Our function at this stage is not to decide whether Dr. Case is more persuasive than Dotson, but only to decide whether there is a disputed question of material fact. Clearly, the conflicting affidavits of Dotson and Case on this point do raise a question as to whether the health care defendants' monitoring of Devan's theophylline levels breached the standard of care. The trial court abused its discretion in ruling, as a matter of law, that the affidavit was insufficient to create an issue of material fact.
Conclusion
The evidence introduced by Doctors Case and Neff failed to show that no genuine issue of material fact exists for trial. Material questions of fact exist as to whether prescribing Theo-Dur 400 mg a day or Theo-Dur 600 mg a day is consistent with the standard of care and whether prescribing Theo-Dur 600 mg a day proximately caused toxic levels of theophylline to accumulate in Devan's blood. The affidavits raise material questions of fact as to whether the *243health care defendants monitored Devan's theophylline levels within the required time period or whether, instead, they breached the standard of care.
I would reverse the judgment and remand for trial.
Reconsideration denied May 31, 1989.

3"Legend drugs" are defined as "any drugs which are required by any applicable federal or state law or regulation to be dispensed on prescription only or are restricted to use by practitioners only." RCW 18.64.011(6).