v. Vail Clinic , 2020 COA 126 ( 2020 )


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  •      The summaries of the Colorado Court of Appeals published opinions
    constitute no part of the opinion of the division but have been prepared by
    the division for the convenience of the reader. The summaries may not be
    cited or relied upon as they are not the official language of the division.
    Any discrepancy between the language in the summary and in the opinion
    should be resolved in favor of the language in the opinion.
    SUMMARY
    August 20, 2020
    2020COA126
    No. 19CA0356, Trujillo v. Vail Clinic — Evidence — Testimony
    by Experts
    A division of the court of appeals addresses whether the trial
    court erred by ruling that expert testimony about Cranial
    Compression Ischemic Encephalopathy (CCIE) was inadmissible
    under CRE 702. The division concludes that because CRE 702’s
    liberal admission standard requires only that expert testimony be
    reasonably reliable and any expert testimony will be further vetted
    at trial by cross-examination and the presentation of contrary
    testimony, the CCIE testimony here was admissible.
    COLORADO COURT OF APPEALS                                      2020COA126
    Court of Appeals No. 19CA0356
    Eagle County District Court No. 14CV30248
    Honorable Russell H. Granger, Judge
    Brandon Trujillo, by and through his Co-Conservators; Rosalina Chaparro-
    Leyva; and Victor Trujillo,
    Plaintiffs-Appellants,
    v.
    Vail Clinic, Inc., d/b/a Vail Valley Medical Center; Pamela Bock; Gale Santa
    Maria,
    Defendants-Appellees.
    JUDGMENT REVERSED AND CASE
    REMANDED WITH DIRECTIONS
    Division II
    Opinion by JUDGE PAWAR
    Román and Tow, JJ., concur
    Announced August 20, 2020
    Leventhal Puga Braley P.C., James E. Puga, Molly I. Greenblatt, Benjamin I.
    Sachs, Denver, Colorado; Levin Sitcoff PC, Bradley A. Levin, Nelson A. Waneka,
    Denver, Colorado, for Plaintiffs-Appellants
    Hershey Decker Drake, P.L.L.C., C. Todd Drake, Lone Tree, Colorado, for
    Defendants-Appellees
    ¶1    During plaintiff Brandon Trujillo’s birth in 2013, he suffered
    injuries that reduced the supply of oxygen to his brain and left him
    with permanent disabilities. He and his parents, Rosalina
    Chaparro-Leyva and Victor Trujillo, the plaintiffs in this case, sued
    defendant health care providers for causing these injuries. Before
    trial, the district court excluded testimony from plaintiffs’ experts
    about plaintiffs’ theory of causation. The court held that although
    the scientific principles underlying the theory were reliable, the
    theory itself was not because it had not been tested, been published
    in peer-reviewed publications, or gained widespread acceptance in
    the medical field. Based on this ruling, the court granted
    defendants summary judgment, holding that without the excluded
    testimony, plaintiffs could not prove that defendants caused
    Brandon’s injuries. We conclude that the district court erred by
    excluding the expert testimony. We therefore reverse and remand
    with directions.
    I. Background
    ¶2    After being admitted to Vail Clinic, Inc., d/b/a Vail Valley
    Medical Center, for a scheduled induction, Brandon’s mother
    labored for thirty-two hours until Brandon was delivered via
    1
    Cesarean section. For the vast majority of the labor, Brandon’s
    mother received Pitocin, a medication that induces contractions.
    ¶3    When Brandon was born, he was not breathing and required
    cardiac resuscitation. He was subsequently diagnosed with having
    suffered injuries during labor and delivery that significantly reduced
    the blood supply, and therefore oxygen supply, to his brain.
    Brandon now suffers from cerebral palsy, a permanent condition.
    ¶4    Brandon and his parents sued defendants, alleging that their
    professional negligence caused the injuries that led to Brandon’s
    cerebral palsy. They disclosed several experts who were prepared to
    testify about what caused the reduction of the blood supply, and
    therefore the oxygen supply, to Brandon’s brain.
    ¶5    According to these experts, excessively strong, prolonged, and
    frequent contractions can increase the external pressure on a
    fetus’s head to the point that the pressure collapses the blood
    vessels in the fetus’s head, thereby preventing sufficient blood and
    associated oxygen from being circulated to the brain. For ease of
    reference in this opinion, we, like the district court, will refer to this
    2
    phenomenon as Cranial Compression Ischemic Encephalopathy
    (CCIE).1
    ¶6    Plaintiffs’ experts would have opined not only about CCIE
    generally, but that based on a differential diagnosis (diagnosis by
    process of elimination), CCIE caused Brandon’s injuries. They
    would have further opined that defendants’ repeated administration
    of Pitocin over a prolonged period and failure to deliver Brandon by
    Cesarean section sooner contributed to his injuries.
    ¶7    Before trial, defendants moved to limit the testimony of
    plaintiffs’ experts, arguing that CCIE was not a scientifically proven
    phenomenon and therefore any testimony about it generally or as
    the cause of Brandon’s injuries was inadmissible under CRE 702.
    The district court held a multi-day hearing on this issue and
    ultimately granted defendants’ motion in an extensive and helpful
    (for appellate purposes) written order. The court ruled that the
    CCIE testimony was neither reasonably reliable, helpful to the jury,
    nor admissible under CRE 403.
    1 Ischemia is a restricted blood supply to tissue and encephalopathy
    refers to damage to the brain. Therefore, in layman’s terms, CCIE
    means a brain injury caused by cranial compression that reduces
    blood flow to the brain.
    3
    ¶8     Defendants then moved for summary judgment, arguing that
    because CCIE was plaintiffs’ only theory of causation and all
    testimony about it had been ruled inadmissible, plaintiffs could not
    prove that defendants caused Brandon’s injuries. The district court
    granted this motion too, agreeing with defendants that without the
    CCIE testimony, plaintiffs could not establish causation as a matter
    of law.
    ¶9     On appeal, plaintiffs argue that the district court erred by
    excluding the CCIE testimony. They also argue that even if the
    district court properly excluded the CCIE testimony, defendants
    were still not entitled to summary judgment. We agree with
    plaintiffs that the district court should not have excluded the CCIE
    testimony and on that basis conclude that the court erred by
    granting defendants summary judgment.
    II. Excluded Expert Testimony
    ¶ 10   We review the district court’s exclusion of the CCIE expert
    testimony for an abuse of discretion. See Estate of Ford v. Eicher,
    
    250 P.3d 262
    , 266 (Colo. 2011). A court’s ruling on the
    admissibility of expert testimony is an abuse of discretion if it is
    manifestly erroneous.
    Id. 4
                                A. Governing Law
    ¶ 11   CRE 702 provides for the admission of expert testimony,
    which the rule defines as testimony based on scientific, technical,
    or other specialized knowledge. Expert testimony may be admitted
    under CRE 702 only if it is both reliable and relevant. See 
    Ford, 250 P.3d at 266
    . To determine whether the testimony is reliable,
    courts consider whether “(1) the scientific principles underlying the
    testimony are reasonably reliable [and] (2) the expert is qualified to
    opine on such matters.” Id.; see People v. Shreck, 
    22 P.3d 68
    , 77
    (Colo. 2001). Expert testimony is relevant if it would be helpful to
    the jury and satisfies CRE 403 (probative value of the evidence
    cannot be substantially outweighed by the danger of unfair
    prejudice). See 
    Ford, 250 P.3d at 266
    .
    ¶ 12   In conducting the reliability inquiry, there is no mandatory list
    of factors that a court must consider. See Kutzly v. People, 
    2019 CO 55
    , ¶ 12. Many courts, including the district court here, have
    assigned determinative weight to some or all of the factors identified
    in Daubert v. Merrill Dow Pharmaceuticals, Inc., 
    509 U.S. 579
    ,
    593-95 (1993). But our supreme court has repeatedly made clear
    that whether “expert testimony is reasonably reliable requires
    5
    considering the totality of the circumstances surrounding the
    proposed expert testimony and is not contingent on any specific list
    of factors.” Kutzly, ¶ 12.
    ¶ 13   Our supreme court has also emphasized that CRE 702
    requires only that “the underlying scientific principles are
    reasonably reliable.”
    Id. The standard for
    admitting expert
    testimony is liberal because any admitted testimony will be further
    vetted through vigorous cross-examination, presentation of contrary
    evidence, and careful instruction on the burden of proof. 
    Shreck, 22 P.3d at 78
    . The trial court’s inquiry is focused on excluding
    junk science, recognizing that two experts may have conflicting but
    nevertheless equally admissible opinions on a particular issue. See
    Estate of Ford v. Eicher, 
    220 P.3d 939
    , 942 (Colo. App. 2008), aff’d,
    
    250 P.3d 262
    (Colo. 2011); Farmland Mut. Ins. Cos. v. Chief Indus.,
    Inc., 
    170 P.3d 832
    , 835 (Colo. App. 2007). In this way, a trial court
    acts only as a gatekeeper, not the arbiter of which expert’s opinion
    is true or more credible.
    ¶ 14   The trial court found, and the parties do not dispute, that
    plaintiffs’ experts were qualified to give the opinions they offered.
    We agree. We therefore focus our attention on the contested issue
    6
    of the trial court’s determinations that any testimony about CCIE
    generally or as applied to Brandon was not reasonably reliable,
    helpful to the jury, or compliant with CRE 403.
    B. General CCIE Testimony was Reasonably Reliable
    ¶ 15   The expert testimony excluded here was that excessively long,
    frequent, and powerful uterine contractions during labor can
    increase the intrauterine pressure on a fetus’s head to the point
    that it collapses the fetus’s blood vessels in the head and causes an
    ischemic brain injury (CCIE). Plaintiffs’ experts conceded that this
    concept was not widely accepted in the medical field and had not
    been published in peer-reviewed journals. On the other hand,
    during the hearing, plaintiffs’ expert Dr. Barry Schifrin testified that
    the following underlying pathophysiological concepts were widely
    accepted in the medical field, taught in medical schools, and
    published in peer-reviewed journals: (1) excessive external pressure
    on blood vessels can collapse them and cause ischemic injuries; (2)
    during a contraction, the intrauterine pressure on a fetus increases;
    and (3) in response to this rise in external pressure, a fetus raises
    its own internal blood pressure to ensure that blood circulates to
    7
    tissues and organs. The district court found that these concepts
    were reasonably reliable.
    ¶ 16   Put differently, it was beyond dispute that contractions
    pressurize a fetus’s blood vessels. It was also beyond dispute that
    to prevent those blood vessels from collapsing and causing an
    ischemic injury, a fetus raises its own blood pressure, effectively
    overcoming the external pressure of a contraction. The only piece of
    plaintiffs’ experts’ testimony that the trial court found unreliable
    was that the extracranial pressure of a contraction can raise the
    intracranial pressure on a fetus’s blood vessels to the point that a
    fetus cannot sufficiently raise its blood pressure to counteract it,
    resulting in the intracranial blood vessels’ collapse and the brain
    being deprived of necessary blood (and the oxygen it carries). Dr.
    Schifrin, a highly credentialed and experienced expert in maternal
    fetal medicine with years of experience researching the mechanism
    of injury for fetal brain damage, testified that this was possible.
    Defendants’ experts, also highly credentialed and experienced in the
    field, testified that it was not possible.
    ¶ 17   The trial court effectively resolved this conflict in the testimony
    by determining that defendants’ experts’ opinions were reliable
    8
    while those of Dr. Schifrin and plaintiffs’ other experts were not. In
    its order, the trial court discussed CCIE in terms of building blocks
    being added together to form the theory of CCIE. The trial court
    recognized that all of the building blocks were reasonably reliable
    and widely accepted in the medical community. But the court held
    that “support for each block is not the same as support for the
    theory.” The court wrote, correctly, that the assembly of these
    building blocks into the theory of CCIE had not been published in a
    peer-reviewed journal, was not taught in medical schools, had not
    been tested, and was not generally accepted or known in the
    medical field. The court therefore held that the theory was not
    scientifically reliable.
    ¶ 18   The trial court went to admirable lengths to learn about this
    technical medical subject. But we conclude that the trial court
    exceeded the bounds of its role as a gatekeeper charged only with
    keeping junk science from the jury. As mentioned above, the
    standard for admitting expert testimony is liberal because any
    expert opinion will be subject to further vetting at trial.
    Consequently, it is not for the trial court to determine whether an
    expert opinion is unimpeachable. To be admissible, expert opinion
    9
    need only be reasonably reliable based on the totality of the
    circumstances.
    ¶ 19   The trial court erroneously put determinative weight on the
    fact that CCIE, as a complete theory, had not been tested, widely
    accepted in the medical field, or published in peer-reviewed
    journals. While these factors were certainly appropriate for the
    court to consider, the totality of the circumstances also included
    the reliability of the underlying pathophysiological mechanisms and
    concepts on which CCIE is based. This underlying
    pathophysiology, combined with Dr. Schifrin’s testimony that the
    pathophysiology was consistent with and supported the validity of
    CCIE, rendered CCIE reasonably reliable in the context of the
    liberal admission standard for expert testimony.
    ¶ 20   While CCIE is not junk science, its lack of testing, widespread
    acceptance, and publication will almost certainly be the subject of
    cross-examination and countervailing expert testimony at trial and
    may cause a jury to reject CCIE as the cause of Brandon’s injuries
    here. But that determination must be made by a jury, not a judge.
    ¶ 21   Our supreme court’s opinion in Ford illustrates that the
    admission standard for expert testimony is liberal and depends on
    10
    the unique factual circumstances surrounding the testimony. In
    that case, a child was born with a brachial plexus injury (an injury
    to the nerves that originate from the spinal cord in the neck and
    control movement and sensation in the shoulder and arm). 
    Ford, 250 P.3d at 264
    . The plaintiffs alleged that the doctor who
    performed the delivery caused the injury by applying too much force
    when applying traction on the child.
    Id. The defendant doctor’s
    experts intended to testify that the child’s injury was not caused by
    the doctor, but by “maternal intrauterine forces”; in other words,
    that “the internal forces of labor and delivery” caused the injury.
    Id. at 264-65. ¶ 22
      The trial court held that the intrauterine forces theory was not
    scientifically reliable because there was no data available to
    establish its reliability.
    Id. at 265.
    The supreme court reversed,
    explaining that because the nature of the intrauterine forces theory
    made it impossible and unethical to test, the absence of testing and
    data was not a proper ground on which to find the theory
    unreliable.
    Id. at 268-69.
    The supreme court held that the theory
    was reasonably reliable based on the totality of the circumstances,
    which included the fact that other jurisdictions had admitted expert
    11
    testimony on the theory, a body of peer-reviewed literature existed
    challenging the previously accepted theory that applying traction is
    “the sole or primary cause of brachial plexus injuries” under similar
    circumstances, and the American College of Obstetrics and
    Gynecologists (ACOG) had “recognized” the intrauterine forces
    theory.
    Id. ¶ 23
      As we understand Ford, the supreme court did not hold that
    ACOG’s recognition of the intrauterine forces theory and the
    existence of a body of literature challenging a competing theory
    were prerequisites for admission of the intrauterine forces
    testimony. Instead, these were factors that, under the unique
    totality of the circumstances of the case, justified the acceptance of
    the intrauterine forces theory as scientifically reliable.
    ¶ 24   Although the facts of our case are similar to Ford, they are not
    completely analogous. Like Ford, there is no testing data for CCIE,
    and for similar reasons — causing CCIE would be unethical and
    therefore it is impossible to test. But unlike Ford, we are aware of
    no previously accepted theory explaining what causes injuries like
    Brandon’s. The absence of a body of literature challenging that
    nonexistent orthodoxy is therefore irrelevant. We therefore see little
    12
    utility in a fact-by-fact comparison of our case to Ford. Instead, we
    conclude that, because the trial court exceeded the bounds of its
    gatekeeper function in evaluating the totality of the circumstances
    described above, the trial court’s exclusion of the CCIE testimony
    was an abuse of discretion.
    C. Testimony Applying CCIE to Brandon’s Case was Reasonably
    Reliable
    ¶ 25      Having concluded that CCIE testimony generally is reasonably
    reliable, we next turn to the question of whether plaintiffs’ experts’
    testimony that CCIE was the cause of Brandon’s ischemic injuries
    was reasonably reliable. We conclude it was.
    ¶ 26      At the hearing, Dr. Schifrin testified that he had thoroughly
    reviewed Brandon’s medical records and used a differential
    diagnosis to arrive at the conclusion that CCIE caused his hypoxic
    ischemia. A differential diagnosis is a widely accepted diagnostic
    technique that identifies a cause of injury through a process of
    elimination — in other words, ruling out all but one possible cause.
    Dr. Schifrin testified in detail about why all the other potential
    causes of Brandon’s hypoxic ischemia were implausible. He then
    explained that because CCIE fit as a cause of Brandon’s hypoxic
    13
    ischemia, and no other causes were plausible, CCIE likely caused
    Brandon’s injury. This testimony was uncontroverted —
    defendants’ experts did not opine that there was an alternative
    cause of Brandon’s injuries. We therefore conclude that this
    testimony was reasonably reliable as well.
    D. All CCIE Testimony was Relevant and Admissible under CRE
    403
    ¶ 27      The district court determined that the CCIE testimony was not
    relevant because it was not helpful to the jury, and that it was
    inadmissible under CRE 403. We disagree with both rulings.
    ¶ 28      The district court concluded that the CCIE testimony was not
    helpful to the jury because it was not “scientifically valid or
    reasonably reliable” and “cannot be tied to the events of Brandon
    Trujillo’s delivery.” As explained above, the theory was sufficiently
    reliable to survive the court’s gatekeeper inquiry. And plaintiffs’
    experts tied CCIE to Brandon’s injuries through a differential
    diagnosis, a widely accepted diagnostic methodology for
    ascertaining diagnosis. Because the testimony was reliable and
    bore on causation, one of the central issues in the case, we
    conclude that it was helpful to the jury and therefore relevant.
    14
    ¶ 29   We also disagree with the district court’s ruling that the CCIE
    testimony was inadmissible under CRE 403 because “the CCIE
    theory did not exist” at the time of the events in question. The
    theory may not have had an official name or acronym. But, as
    explained above and as the trial court itself stated, the
    pathophysiological concepts on which CCIE is based (excessively
    long, powerful, and frequent contractions can threaten the health of
    a fetus by reducing the circulation of blood and oxygen in the fetus)
    are widely accepted. We therefore conclude that the probative value
    of the CCIE testimony was not substantially outweighed by any
    danger of unfair prejudice.
    ¶ 30   In sum, because the CCIE testimony was reasonably reliable,
    helpful to a jury, and admissible under CRE 403, the district court
    manifestly erred by excluding it. Based on this conclusion, we also
    reverse the district court’s order granting defendants summary
    judgment. The court’s sole basis for granting summary judgment
    was that all expert testimony about plaintiffs’ single theory of
    causation — CCIE — was inadmissible. Because the CCIE
    testimony was admissible, plaintiffs had a causation theory
    sufficient to preclude summary judgment.
    15
    III. Conclusion
    ¶ 31   The order granting defendants summary judgment is reversed
    and the case is remanded to the district court with directions to
    reinstate plaintiffs’ claims and conduct further proceedings
    consistent with this opinion.
    JUDGE ROMÁN and JUDGE TOW concur.
    16