Court Opinion

ID: 9768262
Source: CourtListenerOpinion
Date Created: 2023-08-29 05:53:20.819085+00
Date Added: 2024-06-11T07:30:38.831676
License: Public Domain

*543REYNOLDS, Chief Justice.
Doctor Alvin W. Bronwell appeals from a judgment rendered against him upon the jury’s verdict in this medical malpractice action brought by Vivian L. Williams. The gravamen of the action is that the doctor negligently severed her common bile duct during gall bladder surgery, thereby injuring her.
On appeal, Dr. Bronwell complains of the absence of required medical evidence to sustain the action and the court’s failure to submit his requested jury instructions. Mrs. Williams contends that she is entitled to her medical expenses as a matter of law. Under this record, the complaints and contention do not warrant the disturbance of the judgment. Affirmed.
On 24 May 1973,1 Dr. Bronwell, a Lubbock surgeon, undertook to perform a chole-cystectomy — the removal of the gall bladder — on Mrs. Williams. In her abdomen, the doctor saw a small duct which he traced to the point it entered a duct he “assumed . was the common bile duct.” He traced the duct back up to and into the gall bladder. It was normal. Once he identified the two points, the duct was cut flush with the duct into which it entered.
Within thirty minutes after the surgery, Dr. Bronwell dictated his medical notes on the operation for the hospital records. He reported that he palpated, i. e., sensed by touch, the common bile duct which, he twice noted, was normal to palpation. Relating that the “common duct was not explored,” the doctor gave this account: “The gallbladder was removed, by dissecting free the cystic duct and artery and clamping and dividing and ligating them separately and gallbladder was removed by sharp dissection and the bed was closed . . . The only abnormality he recorded was some fibrous tumor in the uterus.
Mrs. Williams was released from the hospital on May 30; however, because of her complaints, she was readmitted the following day. Responsive to Mrs. Williams’ complaints, Dr. Bronwell told her she had hepatitis and, although he admittedly did not know then what was wrong with her, informed her that her condition “is in no way responsible to your operation.” Jaundice, which could be caused intrahepatic or ex-trahepatic, developed. Dr. Pridmore, called into consultation by Dr. Bronwell, noted that Mrs. Williams had become increasingly jaundiced and then recorded: “The operative note reports that her common bile duct appeared normal at the time of surgery. It was not explored.”
Mrs. Williams was given systematic treatment until a mass appeared in her stomach. A day or two later on June 26, Dr. Bronwell reoperated, discovering that the mass was a collection of two quarts of bile. An intensive search revealed that Mrs. Williams’ common bile duct had been severed during the first operation, allowing the bile to drain into her abdominal cavity. The doctor performed an anastomosis by inserting twenty-four inches of Mrs. Williams’ intestine where the common duct, which normally is three to four inches in length, had been cut.
Fifteen minutes after the operation, Dr. Bronwell dictated his notes for the hospital records. His stated diagnosis was “biliary peritonitis due to common bile duct obstruction” which, he readily admitted at trial, was not what he found. Thereafter in the body of the report, he made this observation: “[I]t was noted that at the time of the previous operation the patient had an abnormality in which the common bile duct was a part of the gallbladder which had been inadvertently removed.”
A few hours after the second operation, Dr. Bronwell and Mrs. Williams had a conversation. Her version is that the doctor said “that he had goofed . . that the common duct had been cut and that he had made this certain arrangement and that he felt that I could live a normal life with that arrangement.” The doctor denied saying “goofed,” his recollection being that he told Mrs. Williams he found something he had never seen before, there had been an interruption of the common bile *544duct, and it was necessary for him “to make a new hookup.” The next day there was another conversation, and both agreed that the doctor said Mrs. Williams was a very abnormal person.
Mrs. Williams was discharged from the hospital on July 6 and was attended until October 26 by Dr. Bronwell. Subsequently, she submitted, at the hands of other surgeons, to seven operations, three of which Dr. Bronwell knew to be to repair a stricture occurring where the common duct was cut, and all of which were to facilitate the drainage of bile. However, at trial time, bile drainage was mechanically controlled by means of a perforated tube inserted in Mrs. Williams’ body and exiting through two surgically made body openings.
The first of the seven operations, performed in January of 1974 by Dr. Woolam, was for a stenosis of the anastomosis, i. e., a stricture occurring after Dr. Bronwell’s second operation at the place where the common duct had been cut. The operative report of Dr. Woolam contains this information: “This woman apparently underwent a cholecystectomy several months previously at another hospital, at which time according to the records received, that congenital anomaly was found and the patient apparently suffered a common bowel [s/c] duct injury.”
On 28 January 1974, Mrs. Williams instituted this litigation to recover from Dr. Bronwell damages proximately caused by his negligence in severing her common duct.2 After Dr. Bronwell answered, his deposition was taken in October of 1974. The trial commenced 1 May 1978 before a jury. Dr. Bronwell was the only medical witness; Dr. Culp, Mrs. Williams’ family physician who admitted her to the hospital and assisted Dr. Bronwell in the two operations, did not testify.
By the time he first operated on Mrs. Williams, Dr. Bronwell had performed some two thousand similar operations and had seen another fourteen hundred. By the time of the trial, the doctor had performed an additional thousand or so gall bladder operations.
It was explained by Dr. Bronwell that the liver is divided into the right and left lobes from which come the right and left hepatic ducts. These ducts go to join the common duct which takes bile generated by the liver to the duodenum. From its juncture with the common duct, the cystic duct leads a few centimeters to the gall bladder and exists to carry bile in and out of the gall bladder. It is, the doctor acknowledged, important to identify the common duct in order to perform gall bladder surgery safely-
It was established by Dr. Bronwell that, according to the standard of surgical performance in the Lubbock area, a surgeon will not cut the common bile duct in a normal gall bladder operation. If everything is normal and the surgeon cuts the common duct, he has not met the standard of medical care. If the common duct is cut and not recognized and repaired, bile will be freed in the peritoneal cavity causing a chemical irritation. Sooner or later the bile will have to be drained, but it subjects the patient to liver damage which, over a period of time, goes to the point of causing death.
At the time of the first operation, Dr. Bronwell, identifying the duct he considered to be the common duct, was persuaded the common duct had not been injured. During the second operation in Dr. Bronwell’s search for the source of the bile, he was made aware he previously had cut the common duct without recognizing the fact. The awareness came, the doctor said, when he cut the suture used to close the bed of the gall bladder in the first operation, the bed opened up, and he could see the stub of the common duct. In his words, “The common duct was found — the right hepatic and left hepatic where they join the common duct was found in the gall bladder bed in the liver.”
At this point in the testimony, the following is recorded:
Q [by Mrs. Williams’ counsel]. Now, are you going to try to deny to this Jury *545that you as a surgeon cut the common duct and let the bile flow out into this woman’s peritoneal cavity?
A [by Dr. Bronwell]. No, I don’t deny that, I said that from the beginning. I said, though, it was an anomaly.
Explanatorily, Dr. Bronwell said there was an abnormality in that Mrs. Williams’ common duct went into her gall bladder and not into her duodenum. He never had seen the anomaly before in any of the patients undergoing gall bladder surgery. At all times, he said, he had exercised the standard of care and accepted procedure in the area in performing the surgery; however, because of Mrs. Williams’ congenital anomaly, the common duct still would be cut, for Mrs. Williams “is just an unfortunate person that has a duct that lies in such an area that the usual safeguards cannot be followed,” and “I do not know a way to prevent the same kind of injury.”
There was no way, Dr. Bronwell declared, that the doctors performing the third and succeeding operations could identify the location of the common duct coming out of the liver as he found it in his second operation. After his second operation, the doctor said, “the anatomical landmarks are completely erased,” and “the anatomy is so distorted that it [the location of the common duct] cannot be proven.” It would have been an impossibility, the doctor stated, for the other doctors to determine an abnormality because the landmarks are destroyed.
When his deposition was taken in 1974, Dr. Bronwell declared that he neither knew nor had heard of a single instance of a common duct so made that it drained into the gall bladder. In the forepart of his trial testimony, the doctor stated that he had not found, either in his operations or in medical literature, an identical case, but he had researched further and found five literary articles on cases “so similar that if they were dissected out, they could have been the same way.” Later in his trial testimony, the doctor said that in all of his approximately four thousand gall bladder operations, he never had seen the anomaly he found in Mrs. Williams, he never had read of it in literature at any time, and he never heard it presented during his attendance at many seminar and medical society talks on gall bladder surgery, including anomalies that might be found in the human body.
It was Dr. Bronwell’s trial recollection that, in discussing the type of repair that should be made during his second operation, he telephonically discussed the facts with Dr. Rutledge, his partner; and, in the afternoon, he discussed Mrs. Williams’ abnormal anatomy with Dr. Culp and with Dr. Prid-more. He said he told Dr. Pridmore that Mrs. Williams had an abnormality he never had seen before. He further testified that he had made no written report of the condition, but in the spring of 1974 he had orally presented the facts of Mrs. Williams’ abnormality, together with seventeen hundred other cases, at a meeting of surgeons. However, through his October, 1974 deposition, Dr. Bronwell testified that he had had no discussion at all of Mrs. Williams’ abnormality with his medical colleagues, except Dr. Woolam, nor any discussion with any professor of surgery, except for an October, 1974 discussion with Dr. Salem. The response of Dr. Woolam and Dr. Salem was that each had never seen anything like this and hoped that he did not.
After deliberation on the evidence, the jury found that: (1) Dr. Bronwell failed to exercise ordinary care when he cut the common bile duct of Mrs. Williams; (2) such failure was a proximate cause of the damages sustained by Mrs. Williams; and (3) $200,000 would fairly and reasonably compensate Mrs. Williams for her damages. Judgment was rendered on the verdict.
Appealing with eight points of error, Dr. Bronwell presents complaints which may be sorted into two categories. First, he asserts there was no competent evidence to support the submission of, or the jury’s answers to, the negligence and proximate cause issues, and that there is insufficient evidence to support the jury’s answers thereto. Second, Dr. Bronwell alleges the trial court erred in refusing to instruct the jury that negligence and proximate cause *546could be established only by the testimony of expert medical witnesses. Replying to the doctor’s points of error with two counterpoints, Mrs. Williams also uses a counterpoint to contend the trial court erred in refusing to grant her motion for judgment for medical expenses.3 All points for relief are overruled.
To sustain her pleaded cause of malpractice against Dr. Bronwell, Mrs. Williams had to prove by expert medical evidence that his surgery was such as to constitute negligence and that it was a proximate cause of her injuries. See Bowles v. Bourdon, 148 Tex. 1, 219 S.W.2d 779, 782 (1949). More explicitly, she had the burden to prove by expert medical evidence what a reasonable and prudent medical practitioner of the same school4 and same or similar community would have done under the same or similar circumstances, that Dr. Bronwell departed from that standard, causation and damages. Dr. Bronwell was the only witness with the required medical expertise; so, if the requisite proof of negligence and proximate cause exists, it must be found in the evidence adduced from and through him. Cf. Wilson v. Scott, 412 S.W.2d 299, 303 (Tex.1967) (holding that the defendant doctor’s own testimony may establish the medical standard), and Humphreys v. Roberson, 125 Tex. 558, 83 S.W.2d 311, 312 (1935) (holding that the defendant doctor’s act of negligence was established by his own admission).
The doctor offers his trial testimony showing the abnormal location of Mrs. Williams’ common duct and expressing his opinion that, because of the anomaly, the common duct would be cut in the exercise of the standard of care and standard of accepted procedure in the community in performing this surgery. He then reasons that because his testimony is not contradicted by expert medical testimony, it is binding and establishes the absence of negligence and proximate cause. Alternatively, he submits that if the jury could disregard his testimony concerning his exercise of ordinary care, there is still no evidence to support the jury finding of negligence or proximate cause, for disbelief of the testimony constitutes no evidence that the opposite is true. At least, the doctor argues, these legal standards ensure the evidence is factually insufficient to support the jury findings of negligence and proximate cause. Despite this rationale, an accurate analysis of the evidence in this somewhat unique evidential record compels adherence to legal principles different from those urged by Dr. Bronwell.
Emerging from the evidence adduced from and through Dr. Bronwell is the standard of surgical performance which, depending upon the location of the common duct in the patient’s anatomy, was either departed from or observed. If the common duct is normally located, it will not be cut in a gall bladder operation unless there is a departure from the medical standard. If the common duct is in the abnormal location described by Dr. Bronwell, the duct will be cut in the same operation without a departure from the medical standard.
The critical inquiry, then, becomes: Was Mrs. Williams’ common duct in a normal or abnormal location? If her common duct was normally located, Dr. Bronwell departed from the medical standard in severing the duct, proximately causing injury to Mrs. Williams; otherwise, if she had the congenital anomaly attributed to her by Dr. Bron-well, he met the medical standard and, thereby, is not legally responsible for the results of his operation.
The doctor did testify he became aware at the second operation that the common duct was in an abnormal location, and no other expert medical witness disputed the testimony; yet, the testimony is contradict*547ed by and inconsistent with the doctor’s sensory observations of, and his own written report recording, the normalcy of the common duct in the first operation, at which time the doctor was persuaded the duct had not been injured. Harmonious with the doctor’s trial testimony of the abnormal position of the common duct is that portion of his written report of his second operation, dictated within minutes after surgery, which did record the abnormality; however, that report states a diagnosis which the doctor conceded was incorrect, and in the same sentence which records the abnormality, the doctor declared that the duct “had been inadvertently removed (emphasis added).” “Inadvertently” carries the accepted meaning of “heedlessly,” “inatten-tatively,” “negligently.” See Webster’s New International Dictionary (2d ed.). The doctor’s characterization of the removal is consistent with his statement, related by Mrs. Williams, “that he had goofed.” In this connection, the extrajudicial admissions of the defendant doctor have the same legal competency as direct expert testimony in establishing the plaintiff’s cause, provided the doctor’s statements constitute an admission of negligence. 70 C.J.S. Physicians and Surgeons § 62d(2).
The conflict of normality vis-a-vis abnormality is not dispelled by other expert medical evidence and it is impossible to do so because, in Dr. Bronwell’s second operation, all anatomical landmarks were destroyed. Moreover, the conflict is magnified by the internal incongruence in Dr. Bronwell’s written reports; by the incompatibility between the doctor’s second-operation written report of the abnormality and his testimonial declarations, made at least twice, that he had not made a written report of the abnormality; by the contradictions in the testimony of the first post-operation conversation; and by the inconsistencies revealed by Dr. Bronwell’s deposition and trial testimony concerning what discussions, if any, he had with his medical colleagues and, if so, with whom.
In brief, there is expert medical evidence of both a normal and an abnormal location of Mrs. Williams’ common duct. Thus, in the final analysis, the condition of her anatomy must turn on the credibility of Dr. Bronwell. The doctor was an interested party through whom evidence of both the normal and abnormal location of the common duct was adduced, and his trial testimony of the anomaly could not be contradicted by other medical experts if it was untrue. In these circumstances, the evidence presents the issue for the jury’s determination. James T. Taylor, etc. v. Arlington Ind. School Dist., 160 Tex. 617, 335 S.W.2d 371, 376 (1960). Because portions of the evidence adduced from and through Dr. Bronwell contradict other portions of his evidence, conclusive effect cannot be given to any contradictory portion of it to establish the normality or abnormality of Mrs. Williams’ anatomy. Again in these circumstances, a fact issue was created for the jury’s resolution. Robinson v. Ashner, 364 S.W.2d 223, 226 (Tex.1963). This is especially true because reasonable minds could differ as to the inferences to be drawn from the doctor’s evidence, even though he has attempted to declare his position upon the ultimate issue. 3 R. McDonald, Texas Civil Practice § 11.28.6 (1970).
Consequently, only the jury could determine the true condition of Mrs. Williams’ anatomy and, being advised of the medical standard by a medical expert, the jury was the only fact finder to determine whether Dr. Bronwell’s actions constituted negligence or malpractice. Snow v. Bond, 438 S.W.2d 549, 550-51 (Tex.1969). Given some evidence of probative nature raising the issues of negligence and proximate cause, the issues were required to be submitted to the jury. Air Conditioning v. Harrison-Wilson-Pearson, 151 Tex. 635, 253 S.W.2d 422, 425 (1952). We have considered the quantum and quality of the evidence, the summary of which has been set out above, under the principles of review enunciated in Garza v. Alviar, 395 S.W.2d 821, 823 (Tex.1965). Having done so, we conclude and find that the evidence is both legally and factually sufficient to support the jury findings of negligence and causation.
*548By his last point, Dr. Bronwell alleges the court prejudicially erred in refusing to give his requested instructions advising the jury, among other information, that “negligence and proximate cause can only be established by expert medical witnesses.” His argument is not supported by any authority sanctioning the specific jury instruction, and understandably so. The proposed instruction is an incorrect statement of the law. What constitutes negligence or malpractice is a mixed question of law and fact for determination by the trier of fact, and a medical expert is not competent to express an opinion thereon. Snow v. Bond, supra, at 550-51. Furthermore, in this light, such an instruction would violate the command in Rule 277 of the Texas Rules of Civil Procedure that the trial court, in giving an instruction, shall not comment directly on the weight of the evidence.
Mrs. Williams did not secure the submission of an issue to determine the reasonable and necessary amount of her medical expenses. By a counterpoint, which is adequately developed for consideration as a cross-point, she contends that she established medical expenses of $26,000 as a matter of law. We disagree.
Mrs. Williams testified that her medical expenses are more than $26,000. Then, Dr. Bronwell was questioned about “the charges that have been made to her in excess of $25,000” as being “reasonable and necessary in an effort to heal her condition.” First disclaiming any knowledge in the field of the reasonableness of medical charges, the doctor, when pressed, said the charges sound reasonable to him. When asked if the treatment Mrs. Williams received has been necessary, Dr. Bronwell replied, “She has been in good hands.”
Notwithstanding that medical charges have been made to Mrs. Williams, she was entitled to recover only those medical expenses which were reasonably and necessarily incurred as the result of the operation. Kulms v. Jenkins, 557 S.W.2d 149, 154 (Tex.Civ.App.—Amarillo 1977, writ ref’d n. r. e.). The testimony on the subjects is without the specificity of reasonableness or necessity required to conclusively establish a reasonable and necessary amount of medical expenses. Obviously, there is no specification of necessity for charges totaling $26,000, and the testimony showing only the nature of the injuries, the character and need for services rendered, and the amounts charged therefor does not constitute evidence of a probative nature that the charges were reasonable. Dallas Railway & Terminal Company v. Gossett, 156 Tex. 252, 294 S.W.2d 377, 383 (1956).
The judgment is affirmed.
DODSON, J., dissents with opinion.

. All dates are in the calendar year 1973, except where otherwise designated.

. Also pleaded, but not pursued, as a theory of recovery was the doctrine of res ipsa loquitur.

.The function of a counterpoint is to reply to an appellant’s point of error; a cross-point should be used by an appellee to assert error in some ruling by or action of the trial court. Jackson v. Ewton, 411 S.W.2d 715, 717 (Tex.1967).

.The “same school” rule has its exceptions. See, e. g., Porter v. Puryear, 153 Tex. 82, 262 S.W.2d 933 (1953).