Burks v. Allen , 238 Md. App. 418 ( 2018 )

BURKS, ET AL. v. ALLEN, ET AL., No. 2361, September 2016 Term
EXPERT TESTIMONY – GENERAL CAUSATION – FRYE-REED TEST –
EVIDENTIARY HEARING – GENERAL ACCEPTANCE IN MEDICAL
COMMUNITY.
Decedent was admitted to University of Maryland Medical Center (UMMC) with
multi-system diagnoses, including renal and liver failure. When he experienced an
episode of bradycardia, Dr. Burks treated him for presumed hyperkalemia, which was
later confirmed. The treatment included Kayexalate given in a suspension with sorbitol
and hemodialysis. Shortly thereafter decedent developed ischemic colitis which quickly
progressed to necrosis of the colon. Surgical intervention failed and decedent died.
Survival and wrongful death actions were brought alleging medical malpractice. The
plaintiffs’ expert witnesses theorized that the decedent’s ischemic colitis was caused by
the Kayexalate with sorbitol and opined that the standard of care required treatment with
dialysis alone. Six weeks prior to trial, defense counsel filed a request for a Frye-Reed
hearing, arguing that it was not generally accepted in the relevant medical community
that Kayexalate with sorbitol, as given in this case, can cause ischemic colitis, and
therefore plaintiffs’ experts should be precluded from testifying on causation. The
plaintiffs filed an opposition and supplements were filed. The assignment office did not
schedule a hearing. The request was addressed on the morning of trial, by the judge who
had just been assigned the case. The judge held a hearing on whether a Frye-Reed
hearing should be held and ruled that the causation issue did not warrant a Frye-Reed
hearing and, alternatively, if Frye-Reed was implicated, the Frye-Reed general
acceptance test was satisfied. The case went to trial and the jury returned a verdict for the
plaintiffs. Dr. Burks and UMMC appealed.
Held: Judgment affirmed. Ordinarily, when the admissibility of proposed expert
testimony is challenged under Frye-Reed, and Frye-Reed is implicated, an evidentiary
hearing should be held to decide whether the testimony satisfies the Frye-Reed test. The
Court of Special Appeals assumed without deciding that Frye-Reed applied to the
proposed expert testimony and affirmed the trial court’s alternative ruling, made without
holding an evidentiary hearing, that that testimony satisfied the Frye-Reed test. The
materials submitted to the court in support of and opposition to the request for Frye-Reed
hearing comprehensively addressed the substance of the Frye-Reed issue. They included
medical and scientific articles, FDA warning labels, UMMC Guidelines for Treatment of
Hyperkalemia, medical records of the decedent, and deposition testimony of the relevant
experts. The arguments made in the written submissions and to the court on the first day
of trial focused not on whether a hearing was needed but on the substance of the Frye-
Reed issue. In fact, practically nothing was said about what a Frye-Reed hearing would
include that was not already before the court to consider. In that circumstance, with the
trial about to commence, the court did not err or abuse its discretion by deciding the
Frye-Reed issue without holding an evidentiary hearing. On the merits, the evidence
before the trial court, in the request for Frye-Reed hearing and opposition, supported a
legally correct conclusion that, although the causal connection between Kayexalate with
sorbitol and ischemic colitis is not considered definitive, i.e., beyond question,
Kayexalate with sorbitol is generally recognized by the relevant medical community as a
cause of ischemic colitis in critically ill patients, such as the decedent.
Circuit Court for Baltimore City
Case No. 24-C-15-003384 REPORTED
IN THE COURT OF SPECIAL APPEALS
OF MARYLAND
No. 2361
September Term, 2016
______________________________________
ALLEN BURKS, ET AL.
v.
CYNTHIA ALLEN, ET AL.
____________________________________
Eyler, Deborah S.,
Wright,
Berger,
JJ.
______________________________________
Opinion by Eyler, Deborah S., J.
______________________________________
Filed: August 30, 2018
Arthur, Kevin F., J., did not participate in the
Court’s decision to report this opinion pursuant
to Md. Rule 8-605.1.
2018-08-30
14:27-04:00
In the Circuit Court for Baltimore City, Cynthia Allen, individually and as
Personal Representative of the Estate of Dennis Allen (“the Estate”), and seven of her
adult children, appellees/cross-appellants,1 brought medical malpractice wrongful death
and survival actions against Allen Burks, M.D., and the University of Maryland Medical
Systems Corporation (“UMMS”), appellants/cross-appellees.2 The allegations arose out
of Dr. Burks’s treatment of Mr. Allen in March 2013, when he was an inpatient at the
University of Maryland Medical Center (“UMMC”). Specifically, the Allens alleged that
Dr. Burks breached the standard of care by treating Mr. Allen’s elevated potassium levels
with a formulation of Kayexalate3 combined with 35.8 percent sorbitol and by doing so
without obtaining his informed consent; and that the medication caused him to develop
ischemic colitis and ultimately to die. They alleged that UMMS was liable for Dr.
Burks’s negligence under the doctrine of respondeat superior.
Dr. Burks filed a pre-trial request for a Frye-Reed hearing, arguing that the
Allens’s theory that Kayexalate can cause ischemic colitis is not generally accepted in the
1
The adult children who are parties are Sara Allen, Ruth Allen, Dennis Allen, Jr.,
Daniel Allen, Sr., Donna Allen, Sherry Scipio, and Yolanda Allen. Cynthia’s oldest
daughter, Shelly Allen-Rainey, originally also was a plaintiff. She is not Mr. Allen’s
biological daughter. Mr. Allen treated Shelly as his daughter and she had her last name
legally changed to reflect that she considered him her father. Shelly voluntarily dismissed
her claims with prejudice on April 8, 2016. For ease of discussion, we shall refer to
Cynthia and her children by their first names and collectively as “the Allens” or “the
Allen family.”
2
For ease of discussion, we shall refer to the appellants/cross-appellees
collectively as “Dr. Burks,” except when necessary to distinguish between them.
3
As we shall discuss, Kayexalate is the brand name for a drug that is now most
often administered in its generic form.
relevant medical community, and therefore their expert witness testimony on that issue
was not admissible. The Allens opposed the request. The court held a hearing and ruled
that a Frye-Reed hearing was not required but, even if it was and the court applied the
Frye-Reed test to the evidence provided in the motion and opposition, the challenged
evidence was admissible.
After a ten-day trial, the jury returned a verdict in favor of the Allens, awarding
$2,000,000 in non-economic damages to the Estate, and $1,000,000 in non-economic
damages to Mr. Allen’s wife and each of his seven children, for a total of $10,000,000 in
damages.
Dr. Burks filed a motion for new trial or, in the alternative, for remittitur. The
court did not grant a new trial but granted a remittitur, reducing the non-economic
damages award to $906,250 pursuant to the cap on non-economic damages in Md. Code
(1974, 2013 Repl. Vol.), section 3-2A-09 of the Courts and Judicial Proceedings Article
(“CJP”).
Dr. Burks noted an appeal, presenting three questions, which we have rephrased
slightly:
I. Did the trial court abuse its discretion by denying his motion for a pre-
trial evidentiary Frye-Reed hearing on the Allens’s causation theory?4
II. Did the trial court err by denying his motion to exclude certain evidence
on informed consent?
4
Dr. Burks’s first question presented also asks whether the court erred by not
holding a hearing on admissibility of the Allens’s causation evidence under Rule 5-702.
There was no request below that the court do so, however.
2
III. Did the trial court err by permitting the Allens to introduce evidence
about Dr. Burks’s failure to order and administer calcium gluconate or
calcium chloride and his failure to request a blood draw on the morning of
March 18, 2013?
The Allens noted a cross-appeal, presenting one issue:
I. Does the cap on non-economic damages violate the equal protection
clause of the 14th Amendment and Article 24 of the Maryland Declaration
of Rights?
For the following reasons, we shall affirm the judgment of the circuit court.
FACTS AND PROCEEDINGS
Events of March 2013
On March 10, 2013, Dennis Allen, age 63, was transported by ambulance to
Northwest Hospital Center in Randallstown for complaints of increasing “[w]eakness of
the arms and legs.” He was suffering from hepatitis C, cirrhosis of the liver, end stage
liver disease, renal failure, and congestive heart failure, and already had been hospitalized
twice in 2013—both times at UMMC—for a total of twenty-eight days. Blood tests
performed at Northwest Hospital Center revealed that Mr. Allen also was suffering from
acute rhabdomyolysis, a condition in which muscle fibers break down, releasing muscle
proteins into the bloodstream. Rhabdomyolysis causes muscle weakness and pain, can
lead to kidney failure if untreated, and can cause elevated potassium levels, especially for
patients with renal insufficiency.
Mr. Allen was transferred from Northwest Hospital Center to UMMC the next day
and was admitted to the intermediate care unit. Dr. Burks was the attending physician
assigned to him. His primary admission diagnoses were rhabdomyolysis, chronic kidney
3
disease, and hepatitis C cirrhosis. Nephrology was consulted and from March 13 through
16, 2013, Mr. Allen underwent daily hemodialysis for his kidney failure. During that
time, his bloodwork showed that his rhabdomyolysis was continuing to worsen. Mr.
Allen did not receive dialysis on March 17, 2013.
On March 18, 2013, Dr. Burks arrived at UMMC sometime between 7 a.m. and 8
a.m. He had ordered routine laboratory tests for Mr. Allen to be performed in the early
morning hours, but the results were not available.5
Shortly after noon, Mr. Allen experienced a precipitous drop in heart rate, setting
off the heart monitor alarms. Dr. Burks ordered an immediate EKG, which was
performed at 12:18 p.m. It showed bradycardia (an abnormally slow heart rhythm) and
life-threatening heart rhythms. Dr. Burks made a preliminary diagnosis of hyperkalemia,
i.e., an elevated level of potassium in the blood. Hyperkalemia results when the kidneys
are not able to excrete potassium in the urine. A potassium level over 5.5 mmol/L is
hyperkalemic.6 If left untreated, excess potassium can interfere with the electrical signals
in the heart, causing a fatal cardiac arrhythmia.
At 12:25 p.m., Dr. Burks ordered a stat blood draw to evaluate Mr. Allen’s
potassium level. Given the emergency nature of the problem, he decided to begin the
treatment protocol for hyperkalemia while awaiting the lab results.
5
As we shall discuss, Dr. Burks’s failure to follow up on the absence of laboratory
test results was a subject of some testimony and evidence at trial.
6
Some witnesses testified that a potassium level over 5.1 mmol/L was
hyperkalemic.
4
There are three phases to the hyperkalemia treatment protocol: stabilization,
redistribution, and removal. The first phase addresses the danger of a fatal arrhythmia by
stabilizing the heart muscle. Either calcium gluconate or calcium chloride is
administered intravenously for this purpose and works within 2 to 3 minutes. In the
redistribution phase, potassium in the blood stream is moved back into the cells to
prevent it from interfering with the heart rhythm. Insulin, which works within 20
minutes, and sodium bicarbonate and albuterol, which work within 30 minutes, are
prescribed in combination to achieve redistribution. Because insulin lowers blood sugar,
dextrose is administered to counteract that effect. Insulin and dextrose are given
intravenously; sodium bicarbonate is given orally; and albuterol is given through a
nebulizer.
The third phase of the hyperkalemia treatment protocol is removal of the excess
potassium from the body. There are three treatments by which potassium can be
removed: diuretics, which cause the potassium to be excreted in the urine; hemodialysis,
which removes the potassium directly from the bloodstream; and sodium polystyrene
sulfonate (“SPS”), usually referred to by its brand name, Kayexalate,7 which removes the
potassium through the stool. Diuretics are not an option for a patient in renal failure,
such as Mr. Allen. Dialysis begins to work within 30 minutes of being initiated and is
7
Experts in the case at bar testified that although most physicians prescribe SPS in
its generic form it is generally known as Kayexalate. For that reason, we shall use the
brand name.
5
very effective to remove potassium from the body. The potassium stops being removed
when the dialysis is stopped, however.
Kayexalate, approved by the FDA in 1958 to treat hyperkalemia, is an “ion-
exchange resin” medication, also known as a “cation exchange resin.” The resin contains
sodium ions that are exchanged for potassium ions in the bloodstream in the colon. The
potassium ions bind to the resin and then are excreted in the stool. Because Kayexalate
produces constipation and sometimes fecal impaction, it usually is given in combination
with sorbitol, an osmotic laxative. Osmotic laxatives increase the amount of water
secreted into the bowels, which softens the stool, making it easier to pass. Kayexalate
begins to work within 2 hours after it is administered. It reaches peak effectiveness
approximately 4 to 6 hours after being administered and can continue to work for up to
24 hours. It can be administered either in an oral suspension formula or by enema.
At 12:37 p.m., Dr. Burks used a UMMC electronic order set for hyperkalemia to
order calcium gluconate stat, insulin stat, dextrose stat, sodium bicarbonate stat, and
Kayexalate.8 At 12:54 p.m., he ordered albuterol. At some time between 12:18 p.m. and
1:00 p.m., he also ordered a stat nephrology consult so hemodialysis could be started.
Dr. Burks was advised by a UMMC pharmacist that calcium gluconate was not
available due to a nationwide shortage. As we shall discuss, there was conflicting
evidence at trial as to whether Dr. Burks gave an oral order to substitute calcium chloride
8
Dr. Burks testified that although the order stated that Kayexalate was to be
administered on a routine basis he made clear that it was to be administered stat and that
in fact happened.
6
for calcium gluconate. In any event, neither drug was administered. It is undisputed that
the failure to administer those drugs did not cause any injury to Mr. Allen.
At 12:55 p.m., and continuing for 10 to 15 minutes, Mr. Allen received albuterol
via a nebulizer. At 1:09 p.m., insulin and dextrose were administered intravenously. At
1:15 p.m., Mr. Allen was given sodium bicarbonate and 30 milligrams of Kayexalate
orally. The Kayexalate was in a suspension solution containing 35.8 percent sorbitol.
Dr. Burks did not inform Mr. Allen about the risks and benefits of Kayexalate prior to its
being administered.
At 1:26 p.m., Mr. Allen’s lab results were returned, revealing that his blood-
potassium level was 7.3 mmol/L. That confirmed the diagnosis of hyperkalemia. A
blood potassium level of 7.3 mmol/L is considered dangerously high and can quickly lead
to a fatal arrhythmia. At 1:30 p.m., a nephrologist assessed Mr. Allen and ordered
hemodialysis on a stat basis. Dialysis began at 2:45 p.m. and was completed at 5:45 p.m.
Mr. Allen had two bowel movements during dialysis. After dialysis, Mr. Allen’s
potassium level was 4.5 mmol/L, which is within the normal range.
Dr. Burks left for the day around 8:00 p.m. Overnight, Mr. Allen had seven more
bowel movements, several of them bloody, and began experiencing extreme abdominal
pain. He told Cynthia he felt like he was “burning up inside.”
At 3:00 a.m., on March 19, 2013, Mr. Allen’s lab results showed that his
potassium levels were slightly elevated again, at 5.7 mmol/L. At 6:12 a.m., the physician
assigned to Mr. Allen overnight wrote a note in his chart that he had had “several
episodes of stool mixed with blood overnight.” When Dr. Burks returned to UMMC
7
around 7 a.m., he learned that Mr. Allen was experiencing “copious bloody bowel
movements.” Over the course of that morning, Mr. Allen’s blood pressure dropped
precipitously and could not be raised with fluid boluses.
Around noon, Mr. Allen was transferred to the intensive care unit (“ICU”) to be
prepped for exploratory surgery. Dr. Burks met with Cynthia and some of the Allen
children. According to the family members, Dr. Burks told them he had “made a
mistake” and was sorry. He said he had given Mr. Allen a drug that damaged his
intestines, but that Mr. Allen was going to have surgery to correct it and everything
would be all right. He estimated that the surgery would take 45 minutes to 2 hours.
After Mr. Allen was transferred to the ICU, Dr. Burks wrote a “discharge
summary.” In it, he noted that Mr. Allen’s “differential diagnosis” included “intestinal
ischemia due to hepatitis C related vasculitis versus intestinal ischemia due to
concomitant Kayexalate and lactulose use versus hepatic decompensation with
coagulopathy and lower GI bleed.”9 In other words, Dr. Burks listed Kayexalate use in
the face of laxative use as a possible cause of Mr. Allen’s intestinal ischemia, if that was
what Mr. Allen was experiencing.
Mr. Allen’s surgery lasted over six hours and confirmed the diagnosis of ischemic
colitis. The exterior of his small intestine and colon (large intestine) appeared normal
and there was a “palpable pulse” in the superior mesenteric artery, the largest artery
9
Lactulose is a laxative that was being given to Mr. Allen to treat hepatic
encephalopathy, i.e., mental confusion caused by toxins in the colon entering the
bloodstream due to liver failure.
8
supplying blood to the bowels. A colonoscopy performed during the surgery revealed
“multiple areas of mucosal ischemia with ulceration and bleeding,” however. The severe
ischemic ulceration necessitated removal of almost all of Mr. Allen’s colon. In his
operative note, surgeon Ronald Tesoriero, M.D., wrote:
[During the colonoscopy,] [w]e were able to advance the scope to the level
of the transverse colon. There were multiple areas of mucosal ischemia
with ulceration and bleeding in the colon. We were unable to pass beyond
the transverse colon; however, it was clear at this point that the patient had
significant mucosal level ischemic colitis. Given the overall state of the
patient’s perfusion, this may have likely been induced by the Kayexalate.[10]
(Emphasis added.)
Mr. Allen never regained consciousness. He died the next day, March 20, 2013.
His death certificate records the cause of death as “ischemic colitis.” On autopsy, his
cause of death was determined to be “[m]ultiple complications in the setting of hepatitis
C/cirrhosis.” In the “Discussion” section, pathologist Rupal I. Mehta, M.D., noted:
Ischemic necrosis [was] seen within [Mr. Allen’s] residual small intestine,
with scattered basophilic crystals, consistent with recent [K]ayexalate use.
The findings may be suggestive of [K]ayexalate colitis, which could have
exacerbated the patient’s underlying medical disease.
(Emphasis added.) Because Mr. Allen’s colon had been removed during surgery, it was
not a part of the autopsy. Dr. Mehta noted, however, that the “[p]rior colectomy
specimen showed extensive bowel necrosis and hemorrhage.”
Lawsuit by the Allens
10
The operative note does not bear a dictation date. It was signed by Dr.
Tesoriero on March 23, 2013.
9
On June 25, 2015, the Allens filed suit against Dr. Burks and UMMS. Trial was
scheduled to commence on September 7, 2016. On July 21, 2016, Dr. Burks filed a
request for a Frye-Reed hearing, which was opposed. On the first day of trial, the court
held a hearing and denied the request. We shall discuss that hearing and the court’s
ruling in detail below.
In their case-in-chief, the Allens called three expert witnesses: Richard Goldstein,
M.D., a colorectal surgeon; James D. Leo, M.D., an internist; and Robert T. Odze, M.D.,
a pathologist. They also called thirteen fact witnesses: Siu Yan Amy Yeung, a clinical
pharmacy specialist at UMMC; John Ashworth, III, the corporate designee for UMMS;
Dr. Burks; Demetrius Jones, a phlebotomist at UMMC; Cynthia Allen; and all the Allen
children. We summarize the pertinent testimony.
Ms. Yeung testified that in 2012 she served on the three-member UMMC team of
pharmacists that developed internal guidelines for the treatment of hyperkalemia (“the
UMMC Guidelines”). The UMMC Guidelines were reviewed by physicians in the
nephrology department, the UMMC pharmacy committee, and the UMMC therapeutic
committee. Upon approval, they were added to UMMC’s internal computer database,
which is accessible to doctors and nurses.
The UMMC Guidelines, entitled “Management of Hyperkalemia,” contain a table
listing each “Agent” used to manage hyperkalemia; the dose; the mechanism; how to
administer it; how quickly it works; how long it works; how its effectiveness is
monitored; and any “Comments” about the use of the agent. The table lists all the drugs
and treatments we have discussed above, including Kayexalate. The “Comments”
10
column advises that the “[m]ajor complications” of Kayexalate are “intestinal necrosis
and bowel perforation,” and warns that Kayexalate “[s]hould not be used in patients with
evidence of bowel obstruction, ileus or ischemia or to renal transplant patients in the
early post operative phase.” (Emphasis in original.) Ms. Yeung testified that these
comments were included based on medical literature she had reviewed that reported the
risk of intestinal necrosis and bowel perforation from Kayexalate to be between 0.27
percent and 1.8 percent. In a flow chart for the management of hyperkalemia that
appears in the UMMC Guidelines, Kayexalate is listed as the third agent to be used to
treat acute severe hyperkalemia, after the stabilization and redistribution agents have been
administered and before hemodialysis. According to Ms. Yeung, the only preparation of
Kayexalate available for use at UMMC was the oral suspension in 35.8 percent sorbitol
that Mr. Allen received.
Dr. Goldstein explained that the submucosal layer of the colon, which is beneath
the lining of the colon (the mucosa), is filled with thin-walled blood vessels that absorb
most of the water in the digestive fluid flowing into the colon from the small intestine,
leaving solid stool. The celiac, superior mesenteric, and inferior mesenteric arteries
supply blood to these vessels and to the small intestine, liver, appendix, and other organs.
Compromised blood flow, i.e., ischemia, to the submucosal vessels cuts off the oxygen
supply to the lining of the colon. That causes the tissue in the mucosal layer to break
down, ulcers to form, and bacteria from the colon to enter the bloodstream, further
breaking down the surrounding tissue. The loss of blood flow and the spread of bacteria
throughout the submucosal layer of the colon causes necrosis, i.e., tissue death. As the
11
volume of bacteria in the bloodstream increases, the body attempts to fight off the
infection, causing the blood pressure to fall.
Dr. Goldstein opined that Mr. Allen died from intestinal necrosis caused by
Kayexalate. In his view, the Kayexalate “cause[d] the[] blood vessels . . . under the
lining of the colon [to] stop working.” He could not say “how [K]ayexalate damages the
lining of the intestine and produces intestinal ischemia,” only that it has been “observed
over and over and over again with the use of [K]ayexalate.” Dr. Goldstein was
questioned about the defense theory that Mr. Allen’s necrosis-producing ischemic colitis
was caused by several periods of generalized decreased blood flow to the colon due to
low blood pressure during dialysis. He rejected that theory, explaining that the colon can
sustain a 75 percent reduction in blood flow for up to 12 hours “without irreversible
injury,” and that the “very brief periods” of low blood pressure documented in Mr.
Allen’s chart would not have been sufficient to cause his severe necrosis. Moreover, Dr.
Tesoriero’s observation during surgery of a strong pulse and no clots in the superior
mesenteric artery was inconsistent with generalized low blood flow having caused Mr.
Allen’s injury. Dr. Goldstein noted that other organs supplied by the same arteries—such
as the appendix and the liver—were not necrotic, which was strong evidence of no
general compromise of blood flow.
On cross-examination, Dr. Goldstein acknowledged that there are “multiple causes
of ischemic colitis” and that “99 out of 100 times when a patient has ischemic colitis it’s
idiopathic[,]” meaning the cause is unknown. In reaching his opinion that Kayexalate
caused Mr. Allen’s ischemic colitis, Dr. Goldstein relied upon the medical literature, the
12
UMMC Guidelines, Dr. Burks’s differential diagnosis in his discharge note, and Dr.
Tesoriero’s observations in his operative note. He also relied upon the “sequence of
events,” explaining that, until Mr. Allen was given Kayexalate, he did not have
abdominal pain, diarrhea, or bloody stools. He viewed the timing of the onset of Mr.
Allen’s symptoms of ischemic colitis and the administration of Kayexalate as evidence of
a causal link. Finally, Dr. Goldstein opined that although Mr. Allen was chronically ill
none of his other health conditions was “imminently about to kill [him].”
Dr. Leo, an expert in emergency medicine, internal medicine, and critical care
medicine, testified that the standard of care for treating Mr. Allen’s acute hyperkalemia
was to stabilize his heart immediately with calcium gluconate or calcium chloride;
redistribute the potassium from his bloodstream into his cells by administering insulin
(with dextrose), albuterol, and sodium carbonate; and remove the potassium by
hemodialysis ordered urgently. Because Mr. Allen already had a catheter for dialysis in
place and was being treated by UMMC’s nephrology team, there was no risk of delay in
starting dialysis; and, in fact, dialysis was started just over an hour after the nephrology
consult. Dr. Leo opined that given the availability and superior effectiveness of dialysis
Kayexalate was unnecessary, and therefore its use was not in accordance with the
standard of care. According to Dr. Leo, the “infrequent” but very serious risk of ischemic
colitis from Kayexalate was not outweighed by any potential benefit from its use, given
that dialysis was available and more effective.
Dr. Leo also testified that Dr. Burks breached the standard of care by not obtaining
Mr. Allen’s informed consent before giving him Kayexalate. After the stabilization and
13
redistribution drugs had been administered, which resolved the emergency, Dr. Burks
should have informed Mr. Allen that Kayexalate works more slowly and less effectively
than dialysis and that it has a “very infrequent but very dangerous side effect that it can
cause [a] condition called ischemic colitis in which the large intestine can basically die
because of loss of blood flow.” Dr. Leo further opined that the Kayexalate caused Mr.
Allen’s ischemic colitis and death. Mr. Allen had lived with his chronic medical
conditions for some time, but never had “manifested evidence of ischemic colitis.” “He
did not have any other reasonable causes for ischemic colitis to occur during [the March
2013] hospital admission.” Like Dr. Goldstein, Dr. Leo rejected the defense theory that
episodes of low blood pressure caused Mr. Allen’s ischemic colitis, opining that those
episodes were “too short a duration, too mild in degree and too far in time prior to the
development of the ischemic colitis for those to have been connected.”
Dr. Odze, an expert in pathology with a subspecialty in gastrointestinal and liver
pathology, testified, based upon a review of Mr. Allen’s pathology slides and medical
records, that Mr. Allen’s ischemic colitis and death were caused by Kayexalate or
Kayexalate and sorbitol in combination. He explained that the “mechanism [of the bowel
injury caused by Kayexalate and sorbitol] is poorly understood[, b]ut the consequence is
very well understood.” One theory is that sorbitol, a hyperosmotic agent, draws water
out of the bloodstream and into the stool to counteract the constipating effects of
Kayexalate and, in doing so, deprives the bowel tissue of oxygen. Dr. Odze did not “find
any evidence in this case . . . that there was any other cause of ischemia in Mr. Allen’s
colon other than the ischemia caused by the Kayexalate.” The “features in the tissue”
14
showed an “acute injury” and there was no “lack of blood flow” from outside the colon
that contributed to or caused the ischemia. Had there been a generalized lack of blood
flow, one would expect to see “widespread ischemic injury,” including to the small
intestine and appendix, which are more susceptible to ischemic injury than the colon is.
The “pattern of destruction” in Mr. Allen’s case was “inconsistent” with “an overall lack
of blood flow.” In the prior 25 years, Dr. Odze had conducted pathology reviews in
“more than a dozen cases” in which a patient had “ingested Kayexalate Sorbitol mixture
and then died.” He saw Mr. Allen’s case as a “classic example of Kayexalate induced
ischemic necrosis of the bowel.”
On cross-examination, in response to a series of questions about his understanding
of the “mechanism” of injury caused by Kayexalate, Dr. Odze stated that it is not
uncommon in medicine for the mechanism of a disease or condition to be poorly
understood but for the “cause and effect” to be well understood. He opined that among
gastrointestinal specialists, the causal connection between Kayexalate and ischemic
colitis is well known. To the extent the defense experts would opine that there was
insufficient evidence of a causal relationship, they were “[u]ninformed and incorrect.”
Dr. Burks (called adversely) testified that when he treated Mr. Allen for
hyperkalemia he was unaware of any reported association between Kayexalate with
sorbitol and ischemic colitis. Ordinarily, he did not review UMMC Guidelines when
considering treatment options for patients. Rather, he used “Up to Date,” a peer-
reviewed subscription website for physicians. Although an article about hyperkalemia on
that website included information about the association between Kayexalate and ischemic
15
colitis, it was not “something that [Dr. Burks] paid particular attention to.” Dr. Burks
could not “disagree with [the] statement [in the UMMC Guidelines that a major
complication of Kayexalate use is intestinal necrosis and bowel perforation] at this
point[.]” In his view, it did not matter that he was unaware of the rare risk of ischemic
colitis from Kayexalate use because that would not have changed the course of treatment.
Even if he had known that dialysis could be started in 10 minutes, he still would have
ordered Kayexalate, because Kayexalate continues to remove potassium from the
bloodstream for up to 24 hours, whereas dialysis only works during the several hours in
which it is being administered. After dialysis ends, the potassium levels can immediately
begin to rise again.
Dr. Burks further testified that he discussed Mr. Allen’s hyperkalemia with Mr.
Allen and his wife after the cardiac event but before Kayexalate was administered. He
did not discuss any risks of Kayexalate with Mr. Allen and did not offer him the option to
have dialysis only, instead of in conjunction with Kayexalate. After Mr. Allen was
transferred to the ICU, he met with members of the Allen family. He advised them that
Mr. Allen had “developed injury to [his] intestines” and gave them an “incomplete list of
possible reasons . . . [including] . . . Kayexalate.” As of the time of trial, Dr. Burks’s
view remained that Kayexalate was a “possible but unlikely” cause of Mr. Allen’s
ischemic colitis.
On cross-examination, Dr. Burks elaborated that treating hyperkalemia with
Kayexalate in conjunction with dialysis satisfied the standard of care. In his opinion, Mr.
Allen’s elevated potassium levels were caused by rhabdomyolysis, an ongoing condition
16
that warranted a multi-faceted approach to removing the excess potassium from his body.
Dr. Burks emphasized that even with the Kayexalate and dialysis Mr. Allen’s potassium
levels rose to 5.7 mmol/L (above normal) by 3:00 a.m. on March 19, 2013. Because of
the emergency nature of Mr. Allen’s condition, Dr. Burks did not think he was required
to obtain Mr. Allen’s informed consent.
Shelly testified that she was present when Dr. Burks spoke to the Allen family.
He told them that the surgery would last about 2 hours. Cynthia testified that she stayed
with Mr. Allen overnight. She informed the nursing staff when she began observing
blood in her husband’s stool. He was screaming and crying in pain. Dennis, Jr., Daniel,
and Sarah also were present in the hospital on the evening of March 18, 2013, and the
next morning. They testified that they remembered their father being in severe pain and
passing numerous bloody stools.
On March 19, 2013, Dennis, Jr., was in the waiting area when Dr. Burks came to
speak to him and some of his siblings. Dr. Burks told them that he had “administered
some medicine to [Mr. Allen] that began to attack his bowels,” but if it was “caught early
enough . . . he would be fine.” He told them Mr. Allen would be having “routine
surgery” lasting between “one to two hours.”
At the close of the Allens’ case, counsel for Dr. Burks moved for judgment. He
argued with respect to all the claims that although the Allens had presented evidence that
Kayexalate had caused Mr. Allen’s ischemic colitis they had failed to present any
evidence that he would have survived if the drug had not been given to him. With respect
to the informed consent claim, he argued that the Allens had failed to present any
17
evidence that Mr. Allen would have declined to take Kayexalate had Dr. Burks advised
him of the risk of ischemic colitis, and that the evidence showed that the emergency
exception to the informed consent doctrine applied. The court denied the motion.
In his case, Dr. Burks called four expert witnesses: David Kaplan, M.D., an
internist specializing in gastrointestinal and liver disease; Michael Schweitzer, M.D., a
general surgeon; Michael Seneff, M.D., a critical care doctor; and Philip Buescher, M.D.,
an internist and critical care doctor.
Dr. Kaplan, an expert in internal medicine, gastroenterology, and hepatology,
including liver diseases and liver transplant medicine, opined that Dr. Burks complied
with the standard of care for the treatment of severe hyperkalemia, which is to give
Kayexalate and to begin dialysis as soon as possible. According to Dr. Kaplan,
Kayexalate is a “safe medication” that is “highly effective at removing potassium from
the body.” Dr. Burks was not required to obtain Mr. Allen’s informed consent before
administering Kayexalate as this was a cardiac emergency and there was no significant
risk associated with the drug. In Dr. Kaplan’s view, the medical literature does not
support the premise that Kayexalate causes ischemic colitis and, to the extent it does, the
risk is so small that it is not material. It would have been a breach of the standard of care
for Dr. Burks to have delayed giving Mr. Allen Kayexalate to obtain informed consent.
Dr. Kaplan opined that Mr. Allen developed ischemic colitis from “multiple
insults to the bowel” caused by repeated episodes of low blood pressure combined with
his “overall clinical condition.” He pointed to documented episodes of very low blood
pressure during dialysis on March 13 and March 15, 2013, and noted that Mr. Allen may
18
have experienced other episodes of low blood pressure that were not reflected in his chart
because he was not on a continuous blood pressure monitor. Dr. Kaplan testified that low
blood pressure is “[t]he most common cause of ischemic colitis” and that low blood
pressure lasting as little as 15 minutes can “lead to an episode of ischemic colitis . . .
within 24, 48, even 72 hours [later.]” “Repeated bouts of low blood pressure can cause
vasospasm meaning spasm of the small blood vessels that feed the colon and that spasm
if it continues causes the . . . mucosa . . . to not have enough blood flow and the cells die .
. . .” Mr. Allen’s cirrhotic liver also could have been a contributing factor. The colon
“drain[s] into the liver,” so when the liver is “under high pressure that drainage from the
colon is also under high pressure . . . [making the colon more sensitive] to changes in
blood pressure.” In Dr. Kaplan’s opinion, there was not “sufficient evidence to claim that
[K]ayexalate caused the injury” to Mr. Allen’s colon. Mr. Allen was “predispose[d]” to
ischemic colitis and the medical literature did not “substantiate[]” a causal relationship
between Kayexalate and ischemic colitis. Moreover, Mr. Allen’s medical prognosis at
the time of his March 11, 2013 admission to UMMC was grim. His likelihood of dying
within 90 days was 85 percent.
On cross-examination, Dr. Kaplan was asked whether he would have expected to
see ischemic injury to the appendix if the cause was a vasospasm occasioned by
generalized low blood pressure. He replied, “[n]ot necessarily,” elaborating that
vasospasm often affects the small blood vessels in a “patchy” way and that it would not
be “surprising” to see a patient with ischemic colitis and a normal appendix.
19
Dr. Schweitzer, an expert in “general surgery including the care and treatment of
ischemic colitis and multiple comorbidities that affect a patient’s prognosis[,]” testified
about causation. He had performed between 50 and 100 bowel surgeries for ischemic
colitis. He opined that there are many known causes of ischemic colitis, including scar
tissue, vascular problems causing clotting in the arteries that supply the colon, episodes
of very low blood pressure during dialysis, and certain medications, such as estrogen and
diuretics. In his opinion, Mr. Allen’s ischemic colitis was caused by “end stage liver
disease, renal failure, rhabdomyolysis, [and] congestive heart failure[.]” Dr. Schweitzer
explained that with liver failure the pressure in the abdominal veins increases, causing
blood to be “shunted to other areas and [not to] go through the organs like the small and
large bowel very well.” Mr. Allen’s rhabdomyolysis could have contributed because the
inflammation and pain associated with that condition can cause small blood vessels to
constrict. Similarly, congestive heart failure can restrict blood flow. Dr. Schweitzer
agreed with Dr. Kaplan that episodes of hypotension during dialysis could have been a
contributing cause.
Dr. Schweitzer further opined that Kayexalate was not a cause of Mr. Allen’s
ischemic colitis. The medical literature establishes a “very rare association[], not
necessarily a cause” between “[K]ayexalate with high sorbitol” and ischemic colitis. The
cases where such an association has been seen were in patients whose “bowels aren’t
moving[.]” It is for that reason that Kayexalate is not recommended for patients who are
post-operative or otherwise are experiencing constipation. Mr. Allen was not post-
operative, did not have constipation, and did not have a bowel obstruction. Dr.
20
Schweitzer testified that he had treated five to ten patients who, like Mr. Allen, were not
experiencing constipation (post-operative or otherwise) or an obstruction but were in
renal failure, developed hyperkalemia, were treated with Kayexalate, and developed
ischemic colitis. In his view, those patients did not develop ischemic colitis from
Kayexalate.
Dr. Schweitzer testified that Mr. Allen was not going to survive his hospitalization
under any circumstance. His rhabdomyolysis was worsening, he had end stage liver
disease, and he was in stage four renal failure. In Dr. Schweitzer’s view, Mr. Allen did
not “have the reserve[s] to overcome” all those serious medical conditions.
On cross-examination, Dr. Schweitzer was asked about the lack of injury to the
appendix. He replied that because the appendix is tiny, it “doesn’t take much blood to fill
[it],” whereas the colon requires much more blood flow.
Dr. Seneff was accepted as an expert in critical care medicine, including the
“diagnosis, care and treatment of . . . liver disease, liver cirrhosis, kidney disease
requiring dialysis, rhabdomyolysis, . . . severe hyperkalemia [and other conditions].”
He opined that giving Kayexalate in conjunction with dialysis, as Dr. Burks did, is within
the standard of care for the treatment of severe hyperkalemia. It is Dr. Seneff’s practice
to order Kayexalate for patients with severe hyperkalemia “even [while] in the process of
getting dialysis.” He noted that the UMMC Guidelines direct that Kayexalate be
administered before starting dialysis, i.e., that both are to be given.
Dr. Seneff was aware of case reports showing an association between Kayexalate
and ischemic colitis. He opined that the association is “very rare[,] . . . [o]ne in 100,000,
21
maybe less than that.” It “primarily [was] reported with the 70 percent sorbitol solution,”
which no longer is used. He opined that he would not give Kayexalate to a patient with a
bowel obstruction but otherwise he “would never hesitate to give it.” For the same
reasons, there was no obligation to obtain informed consent prior to administering
Kayexalate.
In Dr. Seneff’s opinion, Mr. Allen’s ischemic colitis could not have been caused
by Kayexalate because he “already had the ischemic colitis before the [K]ayexalate was
administered[.]” This opinion was based upon Mr. Allen’s lab results from March 18,
2013. His blood was drawn at 12:57 p.m., before the Kayexalate was given. According
to Dr. Seneff, the laboratory results from that blood draw showed that, over the preceding
30 hours, Mr. Allen’s bicarbonate levels had dropped from a normal level of 24 to an
abnormal level of 11. That change resulted from Mr. Allen’s producing excess acid.
Acid production rises when organs become ischemic. The change in Mr. Allen’s acid
production was an “om[ino]us sign” that the ischemic colitis already had begun. Dr.
Seneff opined that Dr. Burks would not have been able to determine prospectively from
those lab results that Mr. Allen was ischemic, however, and, even if he had recognized
the lab results as a sign of ischemia, there was no way to know where in Mr. Allen’s body
the ischemia was occurring. Dr. Seneff agreed with Drs. Kaplan and Schweitzer that Mr.
Allen’s ischemic colitis was caused by episodes of hypotension coupled with increased
venous pressure in his intestines.
Dr. Philip Buescher was accepted as an expert in internal medicine and critical
care medicine, including, inter alia, the diagnosis and treatment of liver disease, kidney
22
disease, and hyperkalemia, and the prescription of Kayexalate. He opined that Dr. Burks
did not breach the standard of care by ordering Kayexalate for Mr. Allen, even if dialysis
was immediately available, and that Dr. Burks was not required to obtain informed
consent before administering it. Dr. Buescher testified that he had ordered Kayexalate
for patients with acute hyperkalemia at least 900 times in his career and had “not seen a
single case of ischemic colitis” among his patients. He agreed with Dr. Seneff that Mr.
Allen’s ischemic colitis developed before the Kayexalate was administered to him, based
upon his lab results showing low bicarbonate levels. He also agreed with Dr. Schweitzer
that it was unlikely that Mr. Allen would have survived his hospitalization given his
deteriorating condition overall. On cross-examination, Dr. Buescher acknowledged that
he could not say whether the administration of Kayexalate to Mr. Allen accelerated and
exacerbated the ischemic colitis that, in his view, already was developing. He reiterated,
however, that Mr. Allen would have died during this hospitalization regardless of
whether he had been given Kayexalate.
In their rebuttal case, the Allens played the video deposition of Carla Williams, the
assistant director of UMMC’s pharmacy clinical services. Her testimony, which we shall
discuss in more detail, infra, was pertinent to the issue of the shortage of calcium
gluconate.
At the close of all the evidence, Dr. Burks renewed his motion for judgment and
the court denied it.
On September 22, 2013, the case was sent to the jury on a special verdict. The
jury returned a verdict that same day. It found that Dr. Burks had breached the standard
23
of care by treating Mr. Allen with “Kayexalate Sorbitol mixture”; that that breach was a
cause of injury to Mr. Allen and was the cause of Mr. Allen’s death; that Dr. Burks had a
duty to obtain informed consent before treating Mr. Allen with Kayexalate; that a
“reasonably prudent person in [Mr.] Allen’s position would have withheld his consent” to
that course of treatment had he been informed of the risks; and that the failure to obtain
informed consent also was a cause of Mr. Allen’s injury and was the cause of his death.
As noted previously, the jury awarded the Estate $2 million in non-economic
damages and awarded Cynthia and Mr. Allen’s seven biological children $1 million each
in non-economic damages; and the court later reduced the damages award in accordance
with the statutory cap on non-economic damages. The reduced damages award totaled
$906,250 and was apportioned as follows: $181,250 to the Estate and $90,625 to Cynthia
and to each of the seven children plaintiffs.
This timely appeal followed.
DISCUSSION
APPEAL
I.
Frye-Reed
(a)
As mentioned, Kayexalate first was approved by the FDA in 1958 as a treatment
for hyperkalemia. It was marketed in powder form. Shortly after it was introduced,
physicians found that Kayexalate frequently caused severe constipation that could result
in life threatening intestinal impaction. That problem could be avoided by mixing the
24
powder with sorbitol. As a result, the FDA approved labeling for Kayexalate powder
encouraging it to be administered with sorbitol. In 1982, a premade suspension of
Kayexalate in 33-36 percent sorbitol was approved for distribution. The availability of
the premade formulation contributed to an increase in the use of Kayexalate. Sometime
thereafter, the FDA approved a premade suspension of Kayexalate in 70 percent sorbitol.
Some of the history that followed is recounted in a 2010 “Clinical Commentary”
published in the Journal of the American Society of Nephrology by Richard Sterns, M.D.,
et al., titled Ion-Exchange Resins for the Treatment of Hyperkalemia: Are They Safe and
Effective? (hereinafter Sterns). The Sterns commentary was cited by Dr. Burks in his
motion for Frye-Reed hearing and by the Allens in their opposition. By 2005, the FDA
had received 35 adverse event reports of serious bowel injuries following oral and rectal
administration of Kayexalate in sorbitol. That year, the FDA removed the
recommendation for concomitant use of sorbitol from the label for the powdered form of
Kayexalate. In 2006, the largest manufacturer of the premixed oral suspensions met with
the FDA and was permitted to continue manufacturing the 33-36 percent sorbitol and
Kayexalate combination because, since 1982, it had not received any adverse reports of
colonic necrosis with administration of that suspension; the only adverse reports
concerned the 70 percent sorbitol suspension. In September 2007, the FDA asked all
manufacturers of the 70 percent suspension to reformulate their products. The 70 percent
suspension has not been manufactured since.
In 2009, the FDA issued a “black box” warning for Kayexalate powder, as
follows:
25
Cases of colonic necrosis and other serious gastrointestinal adverse events
(bleeding, ischemic colitis, perforation) have been reported in association
with Kayexalate use. The majority of these cases reported the concomitant
use of sorbitol. Risk factors for gastrointestinal adverse events were present
in many of the cases including prematurity, history of intestinal disease or
surgery, hypovolemia, and renal insufficiency and failure. Concomitant
administration of sorbitol is not recommended.
According to Dr. Sterns, that same year, an article was published reporting 11 new
cases of colonic necrosis over a nine-year period in a single clinical center, four of them
fatal, several in patients without end stage renal disease, and some in patients with
noncritical illnesses. Some of the fatalities were in patients given the Kayexalate oral
suspension with 33-36 percent sorbitol. Dr. Sterns recommended: “Clinicians must
weigh uncontrolled studies showing benefit against uncontrolled studies showing harm.
It would be wise to exhaust other alternatives for managing hyperkalemia before turning
to these largely unproven and potentially harmful therapies.” Sterns, at 3.
In 2011, the FDA revised its “black box” warning for powdered Kayexalate to
state:
WARNINGS
Colonic Necrosis
• Cases of intestinal necrosis, which may be fatal, and other serious
gastrointestinal adverse events (bleeding, ischemic colitis, perforation)
have been reported in association with Kayexalate use.
• Do not use in patients who do not have normal bowel function. This
includes postoperative patients who have not had a bowel movement
post surgery.
• Do not use in patients who are at risk for developing constipation or
impaction (including those with a history of impaction, chronic
constipation, inflammatory bowel disease, ischemic colitis, vascular
intestinal atherosclerosis, previous bowel resection, or bowel
obstruction).
26
• Discontinue use in patients who develop constipation. Do not administer
repeated doses in patients who have not passed a bowel movement.
PRECAUTIONS
• Concomitant use of Sorbitol with Kayexalate has been implicated in
cases of colonic intestinal necrosis, which may be fatal.
(Bold in original.) (Italics added.)
In the case at bar, on July 21, 2016, Dr. Burks filed a request for a Frye-Reed
hearing, memorandum in support, and numerous exhibits. He sought to preclude the
Allens from introducing their proposed expert medical causation testimony, which was
based on the premise that Kayexalate can cause ischemic colitis. He argued that although
it is generally accepted in the relevant medical community that Kayexalate, in
combination with sorbitol, has been associated with a small number of cases of ischemic
colitis it is not generally accepted that Kayexalate, sorbitol, or some combination of the
two actually cause ischemic colitis. Rather, there is considerable controversy over that
general causation question. Moreover, they asserted that most of the adverse events
reported in the medical literature involve a different formulation of Kayexalate (powder
versus liquid suspension), a different concentration of sorbitol (70 percent versus 33-36
percent), and a different mode of administration (enema versus oral). Thus, even to the
extent the medical literature supports a causal connection between that formulation of
Kayexalate and ischemic colitis, that formulation was not used to treat Mr. Allen and
therefore could not serve as the basis for the Allens’ medical experts to opine that the
Kayexalate in sorbitol administered to Mr. Allen caused his ischemic colitis.
27
Dr. Burks’s exhibits included several articles and studies, the earliest of which was
an experiment on rats published in 1987 in Surgery by Keith D. Lillemoe, M.D., et al.,
Intestinal necrosis due to sodium polystyrene (Kayexalate) in sorbitol enemas: Clinical
and experimental support for the hypothesis (hereinafter Lillemoe). That study was
performed after five patients suffered necrosis of the colon (four fatal) after receiving
Kayexalate with sorbitol enemas. In the study, some of the rats were given Kayexalate
with sorbitol, some were given sorbitol alone, and some were given Kayexalate alone.
The mode of administration was enema for all of them. Seven out of ten of the rats who
received sorbitol alone developed colonic necrosis, and six of the ten rats who received
Kayexalate with sorbitol developed colonic necrosis. None of the rats who received
Kayexalate alone developed colonic necrosis.
Also appended were articles by Maura Watson, D.O., et al., in 2012, published in
the American Journal of Kidney Disease, and Ziv Harel, M.D., et al., in 2013, published
in the American Journal of Medicine. See Association of Prescription of Oral Sodium
Polystyrene Sulfonate With Sorbitol in an Inpatient Setting With Colonic Necrosis: A
Retrospective Cohort Study (hereinafter Watson); Gastrointestinal Adverse Events with
Sodium Polystyrene Sulfonate (Kayexalate) Use: A Systematic Review (hereinafter
Harel).
Dr. Watson described colonic necrosis as a “rare but potentially fatal event” that
has been reported after Kayexalate use, “most often in postoperative or intensive care
settings and most frequently with rectal [Kayexalate]/sorbitol (particularly 70% sorbitol),
rather than [Kayexalate] alone.” Watson, at 409. The estimated frequency among
28
hospitalized patients is 0.27% in all cases occurring after surgery. Id. Because it is so
rare, a very large population would be required to assess the risk factors and show an
association between colonic necrosis and Kayexalate. Dr. Watson concluded that there is
not enough evidence to show an association between colonic necrosis and exposure to
Kayexalate. The precise mechanism of injury is unknown. She observed that use of
Kayexalate may be associated with serious gastrointestinal adverse events, but a
controlled trial is needed to make that determination.
Dr. Harel conducted a literature review to “identify eligible reports of adverse
gastrointestinal events associated with [Kayexalate] use” and then applied the World
Health Organization (“WHO”) causality assessment system to those reports to determine
inclusion in the review. Harel, at 264.e9. Ultimately, out of 553 articles describing
adverse events, 30 articles describing 58 cases were included because they “satisf[ied] at
a minimum a possible level of certainty [under the WHO system].” Id. at 264.e10-e11.
The study found evidence that Kayexalate, not sorbitol, might be the pathogenic agent
causing adverse gastrointestinal events, but emphasized that the literature review could
not “ensure that the relationship between [Kayexalate] and the described gastrointestinal
adverse events is certain.” Id. at 264.e14. Moreover, the authors could not calculate the
risk of such an association because they lacked data on the prevalence of Kayexalate use.
Id.
Dr. Burks also cited a 2015 rat experiment study by Isabelle Ayoub, published in
PLOS One, that, unlike Lillemoe, showed that Kayexalate, not sorbitol, “is the main
culprit for colon necrosis[.]” See Colon Necrosis Due to Sodium Polystyrene Sulfonate
29
with and without Sorbitol: An Experimental Study in Rats, at 7. Dr. Burks argued that
these contradictory studies show that the data is insufficient to support a generally
accepted theory that the oral suspension of Kayexalate with 33-36 percent sorbitol is
causally connected to ischemic colitis that produces necrosis of the colon.
Dr. Burks’s exhibits also included his expert witness designations; the deposition
of Dr. Sterns, who had been identified as an expert by the Allens (but was not called to
testify at trial); and the depositions of Drs. Leo, Goldstein, Buescher, Seneff, and
Schweitzer.
The Allens filed an opposition to the request for a Frye-Reed hearing, in which
they argued that the medical literature establishes a general causal link between
Kayexalate, given in conjunction with sorbitol, and ischemic colitis. They pointed to the
2009 and 2011 FDA “black box” warnings, and in particular to the 2011 warning, which
states, “PRECAUTIONS Concomitant use of Sorbitol with Kayexalate has been
implicated in cases of colonic intestinal necrosis, which may be fatal.” (Emphasis in
original.) The Allens maintained that, used in that context, “implicated” means causally
connected, i.e., that there is a cause and effect relationship between Kayexalate with
sorbitol, given orally, and necrosis of the colon. The Allens provided as an exhibit the
FDA “Guidance for Industry: Warnings and Precautions, Contraindications, and Boxed
Warning Sections of Labeling for Human Prescription Drug and Biological Products - -
Content and Format,” October 2011 (“FDA Guidance”), which states, in part, at page 3:
The WARNINGS AND PRECAUTIONS section [of the label] is intended
to identify and describe a discrete set of adverse reactions and other
potential safety hazards that are serious or are otherwise clinically
30
significant because they have implications for prescribing decisions or for
patient management. To include an adverse event in the section, there
should be reasonable evidence of a causal association between the drug
and the adverse event, but a causal relationship need not have been
definitively established.
(italics in original) (bold added) (footnote omitted).
The Allens also relied upon the UMMC Guidelines, which, as noted, identify
ischemic colitis as a “major complication” associated with Kayexalate, and the UMMC
medical records for Mr. Allen, reflecting that Drs. Burks, Tesoriero, and Mehta all
expressed the view that Mr. Allen’s ischemic colitis may have been caused by
Kayexalate. They attached the autopsy report as an exhibit.
The Allens argued that the medical literature cited by Dr. Burks in his request for
a Frye-Reed hearing did not show the absence of a causal relationship but only showed
that some researchers think there is a need for further study to quantify more precisely the
risk of colonic necrosis from Kayexalate administered in sorbitol. They attached as
exhibits medical literature supporting a cause and effect relationship, including:
• A 2001 article by Susan Abraham, M.D., published in the American Journal of
Surgical Pathology, studying 11 patients who were given Kayexalate and were
found to have Kayexalate crystals on biopsy, which concluded that “Kayexalate in
sorbitol can result in injury to the upper gastrointestinal tract in addition to the
more commonly appreciated risk of colonic necrosis.” Upper Gastrointestinal
Tract Injury in Patients Receiving Kayexalate ([SPS]) in Sorbitol, at 643
(emphasis added). The article, citing a 1997 study by Rashid and Hamilton, states:
“Kayexalate . . . in sorbitol has been demonstrated to cause colonic necrosis in a
subset of uremic[11] patients who are administered the cation exchange resin for
hyperkalemia.” Id. at 637.
11
“Uremia” is the “entire constellation of signs and symptoms of chronic renal
failure[.]” Dorlands Illustrated Medical Dictionary, at 2006 (32nd ed. 2012). As
Continued…
31
• A 2008 article by Lawrence Weisberg, M.D., in Critical Care Medicine, reviewing
the medical literature pertinent to management of hyperkalemia and stating, with
citations:
There are numerous case reports of patients who have
developed intestinal necrosis after exposure to [Kayexalate]
in sorbitol as an enema, and as an oral agent. A retrospective
study estimated the prevalence of colonic necrosis to be 1.8%
among postoperative patients receiving [Kayexalate]. Thus,
the slow onset of action and serious, albeit infrequent, toxicity
make [Kayexalate] a poor choice for the treatment of urgent
hyperkalemia.
Management of severe hyperkalemia, at 3249 (citations omitted).
• A 2009 article by C.E. McGowan, M.D., in the Southern Medical Journal,
studying pathology records of 29 patients who received oral Kayexalate. Eleven
patients had confirmed intestinal necrosis and four died. The article concluded:
[Kayexalate] in sorbitol has been implicated in the
development of intestinal necrosis, primarily mediated by the
sorbitol component. Previous studies documented these
findings almost exclusively in postoperative, renal transplant,
and critically ill patients. Our study highlights that all patients
are potentially susceptible, including those without previously
described comorbidities. The indications for [Kayexalate]
use, as well as alternate vehicles for its delivery, should be re-
evaluated. [Kayexalate]-induced ischemia remains an under
recognized, easily avoided complication, associated with
significant morbidity and mortality. Physicians who routinely
use this agent in sorbitol should be aware of its life-
threatening complications.
Intestinal Necrosis due to Sodium Polystyrene Sulfonate (Kayexalate) in
Sorbitol, at 497.
…cont’d
discussed above, Mr. Allen was suffering from renal failure, which is why he had been
undergoing hemodialysis.
32
• A 2010 case study by Mohamad Erfani, in Practical Gastroenterology,
documenting colonic necrosis in a patient who received oral Kayexalate in sorbitol
for hyperkalemia. Sodium Polystyrene Sulfonate (SPS): Sorbitol-induced Colonic
Necrosis. The study concluded:
Intestinal necrosis following [Kayexalate]-sorbitol
administration is a rare clinical condition that may have
significant morbidity and mortality. [Kayexalate]-sorbitol
should be used with caution, especially in the postoperative
setting, in uremic or ill patients . . . When clinically indicated
other measures to treat hyperkalemia should be considered
instead of [Kayexalate]-sorbitol. Physicians need to be aware
of [Kayexalate]-sorbitol GI side effects while managing
hyperkalemia.
Id. at 49.
• A 2015 “Up to Date” article by David Mount, M.D. (and edited by Dr. Sterns),
generally reviewing the treatment and prevention of hyperkalemia in adults, and
stating: “A major concern with [Kayexalate] in sorbitol is the development of
intestinal necrosis, usually involving the colon and ileum, which is frequently a
fatal complication.” Treatment and prevention of hyperkalemia in adults, at 8
(citations omitted).
In addition, the Allens attached as exhibits to their opposition deposition
transcripts of Mrs. Allen and Drs. Sterns, Kaplan, Goldstein, and Odze.
In a reply memorandum, Dr. Burks argued that the conflicting medical opinions in
the literature cited by the Allens and the literature he cited showed that there is
disagreement about whether Kayexalate can cause intestinal necrosis; therefore, that
proposition is not generally accepted in the relevant medical field, and expert testimony
should not be permitted, under Frye-Reed. He argued further that the UMMC Guidelines
do not establish a causal relationship either, as they are based on the same disputed
literature, and his statement to the Allens about Mr. Allen’s differential diagnosis and
what might have caused his bowel problem merely was a repetition of what the medical
33
community has not reached an agreement about. Nor, he argued, are the FDA “black
box” warnings evidence of general acceptance by the medical community.
In a supplement, the Allens attached deposition testimony by Ms. Yeung, in which
she stated that the UMMC Guidelines, listing intestinal necrosis as a major complication
of Kayexalate use, were based on the FDA “black box” warnings.
This case was not specially assigned, and the assignment office did not schedule a
pre-trial hearing on Dr. Burks’s request for a Frye-Reed hearing. Consequently, the
request was taken up by the court at the outset of the first day of trial. The trial judge,
who only was assigned the case that morning, first saw the request, opposition, and
appended materials then. Nevertheless, she held a comprehensive hearing for
approximately one hour and fifteen minutes, during which she queried counsel about the
medicine and the Frye-Reed cases. At one point, she remarked about the important
distinction between a controversy over the means by which an agent causes a particular
harm and a controversy over whether the agent can cause the harm at all. After counsel
finished their arguments, the judge took a twenty-minute recess to further review the
materials provided, denied the request for a Frye-Reed hearing, and explained the reasons
for her ruling.
The ruling was made in the alternative. First, relying primarily upon this Court’s
decisions in Myers v. Celotex Corporation, 88 Md. App. 442 (1991), cert. denied, 325
Md. 249 (1992), and CSX Transportation, Inc. v. Miller, 159 Md. App. 123 (2004), cert.
granted, 384 Md. 581, cert. dismissed, 387 Md. 351 (2005), the judge concluded that the
medical causation opinions being offered by the Allens’ expert witnesses were not of the
34
type requiring a Frye-Reed analysis. The judge emphasized that the Allens’ experts were
not using new or novel scientific techniques but were using the accepted differential
diagnosis method to reach a conclusion about the etiology of Mr. Allen’s ischemic colitis.
The judge also distinguished cases such as Blackwell v. Wyeth, 408 Md. 575 (2009),
which applied Frye-Reed to medical causation opinions, because, unlike in those cases,
here there was no discernible “analytical gap” between the underlying science and the
ultimate conclusions reached by the experts.
Second, and alternatively, the judge concluded that if the proffered medical
causation opinions of the Allens’s expert witnesses were subject to the Frye-Reed general
acceptance test, they satisfied it. The judge stressed that the 2009 and 2011 FDA “black
box” warnings were based on there being a “causal association” between Kayexalate and
ischemic colitis and that the use of the word “implicated” in the 2011 warning supported
the conclusion that acceptance of a causal connection between Kayexalate with sorbitol
and necrosis of the colon is not novel or new. The judge also found persuasive the fact
that the UMMC Guidelines themselves “demonstrate[] that there is some
acknowledgement on the part of at least one Defendant that there is an associative
causative link.” The judge ruled that as the Frye-Reed test was satisfied, there was no
need for a Frye-Reed hearing.
We note at this point that the oral argument before the trial court focused almost
exclusively on the substance of the Frye-Reed dispute—whether there is general
acceptance in the relevant medical community of a causal link between Kayexalate with
sorbitol and ischemic colitis and necrosis—and not on whether an evidentiary hearing
35
was needed for the court to make that determination. At the beginning of the hearing, the
court correctly described it as not being a Frye-Reed hearing, but a hearing on whether to
hold a Frye-Reed hearing. However, counsel on both sides did not direct their arguments
to why an evidentiary hearing was necessary, instead providing reasons why the court
should find that the general acceptance test applied and was not met (the defense) or that
the general acceptance test did not apply or was satisfied in any event (the plaintiffs).
Except for one brief remark by defense counsel at the very close of the argument, there
was no proffer as to who the defense (or the plaintiffs) would call to testify at an
evidentiary hearing on Frye-Reed and what information would be provided to the court at
such a hearing beyond what already had been provided in the articles and deposition
transcripts submitted as exhibits. Defense counsel’s single remark was that if Matthew
Weir, M.D., the Chief of Nephrology at UMMC, “can find a time that he’s available,” the
defense would call him to testify “that there is no definitive evidence that [K]ayexalate
causes bowel ischemia.” An article by Dr. Weir that did not concern Kayexalate was one
of the exhibits to the Allens’s opposition to the Frye-Reed hearing request.12 Otherwise,
Dr. Weir had no connection to the case and had not been identified as an expert witness
by any party.
12
The 2015 article published in the New England Journal of Medicine by Dr. Weir
concerned a study on the use of patiromer, a slow-acting potassium binding resin
medication recently approved by the FDA for treatment of non-urgent hyperkalemia.
Matthew R. Weir, George L. Bakris, David A. Bushinsky, et al., Patiromer in Patients
with Kidney Disease and Hyperkalemia Receiving RAAS Inhibitors, N Engl J Med 2015;
372:211–221.
36
(b)
On appeal, Dr. Burks contends the circuit court erred by denying his pre-trial
request for a Frye-Reed hearing on the general causation question whether Kayexalate
(either with or without sorbitol) can cause ischemic colitis. He focuses on the causation
question itself, arguing that a cause and effect relationship between Kayexalate and
ischemic colitis is “not generally accepted in the medical community and is unsupported
by the medical literature” and therefore does not satisfy Frye-Reed. He asserts that in
ruling on the admissibility of a medical expert’s opinion the court must assess whether
the data on which the opinion is based is supported by the underlying science. 13 That test
was not met here, according to Dr. Burks, because the medical literature the Allens’s
experts relied upon merely established an association, not a causal connection, between
Kayexalate (given in sorbitol) and ischemic colitis and the preparation of Kayexalate
administered to Mr. Allen differed from the preparations associated with virtually all the
adverse events reported in the literature. In one paragraph of his opening brief, Dr. Burks
argues that given the “widespread dispute” over whether Kayexalate causes ischemic
colitis, evidence bearing on the admissibility of the Allens’s causation theory should have
13
Dr. Burks also argues that recent case law makes clear that there is a significant
overlap between Frye-Reed and Rule 5-702(3) and suggests that the court’s ruling
violated that rule. In this case, there was no motion in limine filed under Rule 5-702, and
no objection to the expert testimony based on that rule, and so whether the requirements
of the rule were satisfied was neither raised nor decided below. Accordingly, the sole
issue before us concerns the request for a Frye-Reed hearing. See Alford v. State, 236 Md.
App. 57, 72 (2018) (holding that appellate court will not uphold, under Rule 5-702, trial
court’s decision to exclude expert witness’s proffered testimony when the issue whether
that testimony satisfied Rule 5-702 was not raised or decided below).
37
been presented to the trial court before it ruled on admissibility. He does not say what
that evidence would have been. He asks this Court to vacate the judgment and remand
for a new trial.
The Allens respond that there was no need for a Frye-Reed hearing on the general
causation question whether Kayexalate in sorbitol “may cause intestinal necrosis
(ischemic colitis)” because the medical literature, the FDA “black box” warnings, and the
UMMC Guidelines show a general level of acceptance of that theory of causation within
the relevant medical community. Furthermore, the observations by Drs. Burks and
Tesoriero in their medical and operative notes provide further support for a cause and
effect relationship between Kayexalate in sorbitol and ischemic colitis.
(c)
In Frye v. United States, 293 F.1013 (D.C. Cir. 1923), the District of Columbia
Court of Appeals held that for expert testimony predicated on a novel scientific principle
or discovery to be admissible, the principle or discovery must be generally accepted in
the relevant scientific field. When the Court of Appeals adopted the Frye general
acceptance test in Reed v. State, 283 Md. 374 (1978), it explained that the test governs the
admissibility of novel scientific evidence. Until the 2000s, the Frye-Reed test was not
applied outside that context. In the meantime, in Daubert v. Merrell Dow
Pharmaceuticals, Inc., 509 U.S. 579 (1993), the United States Supreme Court held that
Federal Rule of Evidence 702 had superseded Frye and established, in its place, a non-
exclusive list of factors, including general acceptance, for federal district courts to
consider in ruling on the admissibility of scientific expert testimony. A few years later,
38
in General Electric Co. v. Joiner, 522 U.S. 136, 146 (1997), the Supreme Court upheld
the exclusion of expert testimony that PCBs caused a plaintiff’s lung cancer because
there was “too great an analytical gap between the data and the opinion proffered.”
In the mid-2000s, the Court of Appeals expanded the Frye-Reed general
acceptance test to include techniques that are not novel and also to include scientific
conclusions, as well as techniques. See Montgomery Mutual Ins. Co. v. Chesson, 399
Md. 314 (2007) (“Chesson I”); Blackwell, 408 Md. at 575; and Chesson v. Montgomery
Mut. Ins. Co., 434 Md. 346 (2013) (“Chesson II”). Indeed, in Blackwell, the Court
approved the “analytical gap” concept articulated by the Supreme Court in Joiner. Now,
under Frye-Reed, the admissibility issue is whether “the expert[s] bridged the ‘analytical
gap’ between accepted science and [their] ultimate conclusions in [this] particular case.”
Savage v. State, 455 Md. 138, 160 (2017).
In Chesson I, which marked the first “drift” by the Court of Appeals toward
adopting the Daubert “analytical gap” concept, see Savage, 455 Md. at 187 (Adkins, J.,
concurring, joined by Barbera, C.J., and McDonald, J.) (discussing the “jurisprudential
drift” towards Daubert), the Court held that a circuit court abused its discretion by not
holding a Frye-Reed hearing to consider the admissibility of testimony by a medical
doctor on behalf of plaintiff workers that they were suffering from “sick building
syndrome” from mold in the building where they worked. The employer had requested a
Frye-Reed hearing, arguing that it was not generally accepted in the medical community
that “sick building syndrome” is a recognized disease and that the protocol the expert had
39
devised to make that diagnosis and form his causation opinions was not generally
accepted.
The Court of Appeals remanded the case for a Frye-Reed hearing. It held that the
circuit court should have “determine[d] whether the medical community generally
accepts the theory that mold exposure causes the illnesses that [the workers] claimed to
have suffered, and the propriety of the tests [their expert] employed to reach his medical
conclusions.” Chesson I, 399 Md. at 328. In other words, the Frye-Reed test applied not
only to the expert’s own novel diagnostic testing methods but also to the analysis he had
employed in concluding that there was a causal relationship between mold exposure and
the cluster of symptoms he had dubbed “sick building syndrome.” The Court rejected the
workers’ argument that under Myers, 88 Md. App. at 442 (medical doctor opining that
lung cancer was caused by asbestos fibers), and CSX Transportation, Inc. v. Miller, 159
Md. App. at 123 (medical doctor opining that arthritis was caused by years of walking on
ballast), Frye-Reed did not apply because their expert merely was making a medical
diagnosis of an illness. The Court commented that the case “involve[d] more than a
generally accepted medical opinion and diagnosis. [The workers’ expert] employ[ed]
medical tests to reach a conclusion that is not so widely accepted as to be subject to
judicial notice of reliability.” Chesson I, 399 Md. at 332. The Court also stated that
“novel medical theories regarding the causes of medical conditions have been subject to
Frye analysis. Reed, 283 Md. at 383 . . . (noting that the Frye test has been applied to
‘medical testimony regarding the cause of birth defects’).” Chesson I, 399 Md. at 333.
40
The Court disposed of the appeal by means of a limited remand for the circuit court to
hold a Frye-Reed hearing.14
In our recent review of the evolution of Frye-Reed in Sissoko v. State, 236 Md.
App. 676 (2018), cert. denied __ Md. __ (July 12, 2018), we discussed the Myers and
CSX cases. CSX, the more recent of the two, having been decided in 2004, stated that the
Frye-Reed general acceptance test only applied to “new and novel scientific
techniques[,]” and that “[a] doctor’s opinion as to the etiology of his patient’s arthritis is
simply not the type of thing contemplated by the phrase ‘new and novel scientific
technique.’” Id. at 186–87 (quoting Reed v. State, 283 Md. at 380). Rather,
[w]hat is contemplated are new, and arguably questionable, techniques such
as lie detectors tests, breathalyzer tests, paraffin tests, DNA identification,
voiceprint identification, as in the Reed case itself, and the use of polarized
light microscopy to identify asbestos fibers, as in Keene Corporation v.
Hall, 96 Md. App. 644, . . . (1993).
Id. at 187. In Sissoko, where, after a Frye-Reed hearing, the circuit court ruled that the
State’s expert testimony about abusive head trauma, formerly known as shaken baby
syndrome, was admissible, we explained that Myers and CSX did not support one of the
State’s arguments, that Frye-Reed had no application at all:
These cases are not helpful to the State’s position because they were
decided before the Court of Appeals extended the reach of Frye-Reed
beyond the bounds of novel scientific tests and techniques. We do not
14
The limited remand in Chesson I resulted in the circuit court’s holding a Frye-
Reed hearing and ruling that the workers’ expert witness’s opinions were admissible. In
a second appeal, Chesson II, the Court of Appeals reversed, holding that the evidence
adduced at the Frye-Reed hearing and the Court’s own research showed that the expert’s
opinions were the product of a flawed methodology and his theory of general causation
was not generally accepted in the medical community.
41
mean to suggest that if they were decided today their outcomes would
differ, only that the analysis employed necessarily would be more
expansive.
236 Md. App. at 715.15
In the case at bar, the trial court cited Myers and CSX in making its first alternative
ruling, that whether Kayexalate with sorbitol as administered to Mr. Allen can cause
ischemic colitis was not subject to a Frye-Reed analysis to be admissible. We conclude
that it is not necessary in this appeal to decide whether that ruling was legally correct.
Assuming without deciding that the Allens’s proposed expert witness testimony that
medical causation exists in fact was subject to a Frye-Reed analysis to be admissible, we
nevertheless hold that the trial court did not abuse its discretion by deciding the Frye-
Reed issue without an evidentiary hearing and in ruling that Frye-Reed was satisfied.
15
As noted in Chesson I, the Reed Court cited a case in which Frye was applied to
the issue of the cause of a birth defect. That case—Puhl v. Milwaukee Automobile Ins.
Co., 99 N.W.2d 163 (Wis. 1959)—clearly would not warrant a Frye-Reed hearing today,
or in 1983, when Reed was decided. The plaintiff alleged that injuries she sustained in an
automobile accident, when she was 12 weeks pregnant, caused the baby she was carrying
to be born with Down syndrome. At trial, the plaintiff’s medical expert, who was not an
expert in Down syndrome, testified, based on literature he had read, that Down syndrome
can be caused by lack of oxygen to a fetus and that the plaintiff’s placenta may have been
partially torn during the accident, causing such a lack of oxygen. The defendant’s expert
testified that the cause of Down syndrome was not known but that it might be a defect in
the sperm or egg. There was no pretrial hearing based on Frye. The jury found in favor
of the plaintiff.
On appeal, the Supreme Court of Wisconsin held that the evidence of a causal
connection between lack of oxygen and Down syndrome was legally insufficient, as it
established nothing more than an unproven, speculative hypothesis by an expert who was
not qualified in the field of Down syndrome.
The Wisconsin Supreme Court’s opinion was reported ten months after
publication of the discovery that Down syndrome is caused by a chromosomal defect.
See Gautier, Marthe & Harper, Peter, Fiftieth anniversary of trisomy 21: returning to a
discovery (available at https://perma.cc/D46J-97AV). The opinion does not mention that.
42
(d)
In Clemons v. State, 392 Md. 339 (2006), the Court of Appeals held that
Comparative Bullet Lead Analysis (“CBLA”), a scientific test that had been generally
accepted as a forensic tool for decades, was no longer generally accepted in the relevant
scientific community and therefore was not admissible in evidence under Frye-Reed. In
the circuit court, the defendant filed a pre-trial motion in limine to exclude the State’s
CBLA evidence. At the suggestion of the court, the parties deferred a ruling on the
motion until trial. When the State’s CBLA expert took the stand, voir dire was
conducted first by the prosecutor and then by the defense, in the presence of the jury.
Those examinations explored whether CBLA remained a generally accepted forensic
tool. The court ruled that the expert could give his CBLA opinions, thereby denying the
motion in limine.
Before the Court of Appeals, that ruling was challenged under Frye-Reed. The
Court addressed the challenge, even though no Frye-Reed hearing had been held.
Admonishing that “Frye-Reed examinations are better conducted in pre-trial hearings”
outside the hearing of a jury, id. at 347 n. 6, the Court went on to state:
If the issue is to be dealt with at trial, it should be addressed, in its entirety,
as a preliminary matter prior to admission of the challenged evidence, not,
as here, by having the challenge made only to [the expert’s] status as an
expert during the [proponent party’s] case and then receiving most of the
evidence bearing on whether the inferences to be drawn from the [scientific
evidence] are generally accepted in the relevant scientific community
during the [opponent party’s] case, after the challenged inferences have
already been admitted. If a party raises a Frye-Reed objection, all evidence
bearing on admissibility of the challenged evidence should be presented
and considered before a ruling is made on the challenge.
43
Id. (emphasis in original). As noted, however, notwithstanding the absence of a Frye-
Reed hearing, the Court reviewed the question whether the expert opinion on CBLA
should have been excluded as not satisfying Frye-Reed.
Clearly, when a motion has been filed in which a party seeks to preclude the
admission of scientific evidence based on Frye-Reed, it is preferable for the court to
schedule a pre-trial hearing at which evidence may be taken, to the extent the court agrees
that Frye-Reed applies. As Clemons demonstrates, however, that is not an ironclad
requirement. In the case at bar, Dr. Burks filed his request for a Frye-Reed hearing,
accompanied by a request for a hearing on that request, approximately six weeks before
trial, and the Allens filed their opposition on August 8, 2016. The case had not been
specially assigned, and the assignment office did not schedule any hearing date before
trial. For that reason, the Frye-Reed matter was not taken up until the first day of trial.
Therefore, through no one’s fault, least of all the fault of the judge who was assigned the
case the morning of trial, the question whether the Allens’s expert witnesses would be
precluded from testifying because their opinions did not satisfy Frye-Reed first came to
the court’s attention on the day of trial.
The request, opposition, reply, and supplement were all-encompassing on the issue
of whether the expert opinion evidence in question was admissible under Frye-Reed. In
addition to thorough discussions of the law, they attached deposition transcripts of the
expert witness testimony in question and of the contrary expert witness testimony; the
relevant hospital and medical records, such as the UMMC Guidelines; the FDA “black
box” warnings; and published medical literature on the causal connection, if any, between
44
Kayexalate, with and without sorbitol, and ischemic colitis/intestinal necrosis. The
request did not identify any witnesses that Dr. Burks intended to call in an evidentiary
Frye-Reed hearing, nor did it proffer the substance of any such witness’s testimony. As
noted above, the only mention by Dr. Burks of a witness who might be called was the
remark at the conclusion of the hearing on the first day of trial, referencing, tentatively,
Dr. Weir.
In his brief in this Court, Dr. Burks focuses his argument on the trial court’s
alternative ruling, that the proffered testimony of the Allens’ expert witnesses on medical
causation satisfied Frye-Reed, saying almost nothing about the court’s ruling against
holding a Frye-Reed hearing. As mentioned earlier, in one paragraph of his opening brief
Dr. Burks states, in general terms, that because there is “widespread dispute” over
whether Kayexalate causes ischemic colitis evidence bearing on the admissibility of the
Allens’s experts’ opinions should have been presented to the trial court. Beyond that, he
says nothing about what that evidence should have been or, significantly, what difference
having an evidentiary hearing rather than a hearing on a comprehensive record, such as
took place, would have made.
We see nothing in this record to support a conclusion that the absence of an
evidentiary Frye-Reed hearing was prejudicial to Dr. Burks. To be sure, as we have
explained and as Clemons made clear, there is a strong preference in favor of Frye-Reed
issues being decided after a hearing at which evidence may be presented. Given the
particular circumstances and procedural posture in this case, however, we hold that there
45
was no harm to Dr. Burks from the trial judge ruling on the Frye-Reed question after
holding a hearing at which substantial evidence, but no live evidence, was presented.
(e)
The final Frye-Reed appellate issue is whether the trial court was legally correct in
ruling that the proffered medical causation testimony by the Allens’s expert witnesses
satisfied the Frye-Reed test. Our standard of review is de novo. Sissoko, 236 Md. App. at
711.
In a nutshell, the Frye-Reed issue in this case is whether it is generally accepted in
the relevant medical community that the drug Kayexalate, given orally in a formulation
with 35.8% sorbitol, can cause ischemic colitis in a patient such as Mr. Allen. As the
Court of Appeals has explained, “[g]eneral acceptance [under Frye-Reed] does not equate
to unanimity of opinion within a scientific community, nor universality, and is not subject
to a quantum analysis.” Chesson II, 434 Md. at 356; see also U.S. Gypsum v. Baltimore,
336 Md. 145, 183 (1994) (holding that without being directed to any information
indicating “that the divergence of opinion over the use of [surface dust sampling for
asbestos] amounts to the type of ‘fundamental division in the scientific community’
which necessitates the exclusion of such testimony[,]” the dust sampling evidence was
admissible) (quoting Reed, 283 Md. at 392)). Although there have been changes in the
scope of the Frye-Reed test over the past decade, this principle has remained.
In addition to the cases discussed above, the Court of Appeals’s decision in
Rochkind v. Stevenson, 454 Md. 277 (2017), although made under Rule 5-702, is helpful
to our analysis. Stevenson brought a lead paint case, claiming she developed Attention
46
Deficit Hyperactivity Disorder (“ADHD”) from exposure to lead paint as a young child.
The Court of Appeals addressed the question whether the trial court abused its discretion,
under Rule 5-702(3), by admitting Stevenson’s expert’s testimony of general causation
between lead paint exposure and ADHD. That rule requires, among other things, that
there be a sufficient factual basis for the expert’s opinion; and that cannot be shown
unless the opinion is based on an “adequate supply of data[.]” 454 Md. at 287. The
expert, a pediatrician, based her general causation opinion on an EPA epidemiological
paper that concluded, from a compendium of studies, that there is an association between
childhood lead exposure and ADHD.
The Court of Appeals held that the EPA paper did not supply adequate data to
support the expert’s opinion. Because the paper did not properly account for various
potential confounding factors, such as parental education level, socio-economic status,
parental caregiving quality, and the strong familial component to ADHD, it did not show
a causal connection between childhood exposure to lead and ADHD. Moreover, in
offering her opinion, the expert failed to differentiate between the specific symptoms of
ADHD and the general symptoms of attention deficits, did not factor in that many
symptoms of ADHD are symptoms of other disorders and learning disabilities, and
overstated the known effects of lead exposure. In the Court’s view, the expert’s opinion
merely was conjecture and speculation.16
16
Because the Court concluded that the expert’s opinion was not based on an
adequate supply of data, it did not assess whether she used a reliable methodology in
reaching her opinion. Also, because it held that the expert’s opinion should have been
Continued…
47
More recently, in Sugarman v. Liles, __ Md. __, No. 80, Sept. Term 2017 (filed
July 31, 2018), the Court of Appeals revisited the same EPA epidemiological paper
discussed in Rochkind, holding that it supplied a sufficient factual basis under Rule 5-
702(3) for a pediatrician’s general causation opinion that elevated blood lead levels can
cause deficits in auditory encoding and processing speed. In so holding, the Court
discussed cases from other jurisdictions addressing the “analytical gap” concept,
including King v. Burlington North Santa Fe Railroad Co., 762 N.W.2d 24 (Neb. 2009).
In that case, the Supreme Court of Nebraska reversed a trial court order excluding an
expert’s opinion that exposure to diesel exhaust fumes had caused the plaintiff’s late
husband to develop multiple myeloma, a form of blood cancer, because the expert relied
upon epidemiological studies that did not “draw definitive conclusions on causation.”
762 N.W.2d at 48. In Liles, the Court of Appeals cited King with approval, explaining
that an expert may rely on scientific studies that do not make “definite conclusions of a
causal relationship,” so long as they are “qualified to interpret and extrapolate from the
relevant studies.” Liles, slip. op. at 30. Thus, the pediatrician expert witness was
permitted to extrapolate from the EPA epidemiological paper’s finding that exposure to
lead can cause attention decrements to opine that it also could cause slower processing
speed and auditory encoding deficits, which were “factors of attention.” Id. at 31.
…cont’d
excluded under Rule 5-702, the Court did not address whether the circuit court abused its
discretion by not holding a Frye-Reed hearing.
48
We return to this case and the question whether the trial court erred in its ruling.
The uncontroverted facts that were disclosed to the court in support of and in opposition
to the request for a Frye-Reed hearing, and as further developed at trial, show that Mr.
Allen developed ischemic colitis, which led to necrosis of the tissue in his colon and
death. In plain language, lack of oxygen to his large intestine caused the tissue to break
down and die, which killed him. Ischemic colitis is a well-recognized and established
medical condition with a clearly defined reason behind it: reduced or absent blood flow
that deprives cells in the colon of oxygen, damaging the tissue. The dispute in this case
was not over the existence or nature of that medical condition or its immediate cause—
deprivation of oxygen to the colon. Rather, the dispute was over how Mr. Allen’s colon
came to be oxygen deprived.
Although not essential to our decision, we note that this case is very different from
virtually all the general medical causation cases in Maryland in which expert witness
testimony has been found to be subject to Frye-Reed. “Sick building syndrome”
(Chesson I and Chesson II) is not even a recognized syndrome (a group of symptoms
consistently appearing together) or medical condition. The claimed injury in the other
cases was a syndrome or generally described condition without a clearly identified or
understood cause, or at least where the cause was an ongoing topic of widespread debate:
Wilson v. State, 370 Md. 191 (2002) (sudden infant death syndrome), Blackwell (autism),
Sissoko (abusive head trauma/shaken baby syndrome), and, although decided under Rule
5-702, Rochkind (ADHD). Here, we have an established, acute medical condition in
which the colon is deprived of oxygen and the question whether Kayexalate in sorbitol,
49
administered orally, can cause a decrease in oxygen to the colon to bring about that
condition.
There was substantial evidence offered by the Allens in opposition to Dr. Burks’s
motion that strongly supports a finding that, while there may be some disagreement
among experts in the field, there is not a “‘fundamental division in the scientific
community’” that necessitated exclusion of the Allens’s expert witness testimony. First,
several pieces of evidence showed that UMMC, Dr. Burks, and other UMMC health care
providers involved in Mr. Allen’s care already had accepted the proposition that
Kayexalate with sorbitol is causally connected to ischemic colitis. The UMMC
Guidelines, in effect since 2012, and made available to guide doctors at that institution in
the treatment of hyperkalemia, expressly identify “intestinal necrosis,” i.e., death of
intestinal tissue, as a “[m]ajor complication” of Kayexalate administration. In the
differential diagnosis Dr. Burks gave in his discharge summary, upon Mr. Allen’s
transfer to the ICU for surgery, he included “intestinal ischemia due to concomitant
Kayexalate and lactulose use.” (Emphasis added.) So, before Mr. Allen even was
operated on, Dr. Burks thought that he could have intestinal ischemia brought on by the
treatment with Kayexalate in combination with the laxative Mr. Allen was being given to
address his liver problems. (And at trial, Dr. Burks acknowledged that the Kayexalate
given to Mr. Burks was a possible cause of his ischemic colitis.) Thus, it was never Dr.
Burks’s position that the Kayexalate given to Mr. Allen could not have caused his
ischemic colitis. Likewise, in his operative note, Dr. Tesoriero said Mr. Allen’s ischemic
colitis “may have likely been induced by Kayexalate”; and, in his pathology note, Dr.
50
Mehta commented that the ischemic necrosis and crystals in Mr. Allen’s small intestine
“may be suggestive of kayexalate colitis . . . .”
In addition, the FDA “black box” warnings for Kayexalate, and for the generic
SPS suspension (which also was provided in the papers in support of and opposition to
the request for a Frye-Reed hearing), support a finding that there is a cause and effect
relationship between Kayexalate given with sorbitol, as Mr. Allen received, and ischemic
colitis. Both the 2009 and 2011 Kayexalate warnings state that cases of necrosis of the
colon “have been reported in association with Kayexalate use.” The 2009 warning
includes in the risk factors for adverse gastrointestinal events, such as ischemic colitis,
“renal insufficiency and failure. Concomitant administration of sorbitol is not
recommended.” The 2011 warning goes further, stating, “Concomitant use of Sorbitol
with Kayexalate has been implicated in cases of colonic intestinal necrosis, which may be
fatal.” The FDA label for the suspension of SPS in sorbitol likewise warns that intestinal
necrosis has been reported in association with SPS use and that risk factors include renal
insufficiency and failure. And in the drug interaction section, it too states that
“Concomitant use of sorbitol with [Kayexalate] has been implicated in cases of intestinal
necrosis, which may be fatal.”
The FDA Guidance explains that “[t]o include an adverse event in the [warnings]
section, there should be reasonable evidence of a causal association between the drug and
the adverse event, but a causal relationship need not have been definitively established.”
FDA Guidance at 3 (footnote omitted) (emphasis added). Thus, as used in an FDA drug
warning, “association” means something more than a mere coincidental occurrence but
51
less than a “definitive” causal connection and therefore reasonably can include likely
cause and effect relationships. See Liles, slip. op. at 31 (experts may extrapolate from
scientific data that show less than a “definite conclusions of a causal relationship”). In
addition, we agree with the Allens and the trial court that the word “implicated” carries a
causal meaning, i.e., that the use of Kayexalate with sorbitol is involved in causing
colonic necrosis. Given that there is a specific warning for the powder form of
Kayexalate about its being given with sorbitol, there is no reason to think that, because
the warning is for the powder, it is irrelevant to Kayexalate given in a suspension made
from a combination of Kayexalate and sorbitol.
The medical articles furnished by the Allens in opposition to the motion for Frye-
Reed hearing lend further support to the proposition that within the relevant medical
community, a cause and effect relationship between Kayexalate, in the formulation given
to Mr. Allen, and ischemic colitis is generally accepted. As early as 2001, Dr. Abraham
wrote that colonic necrosis was a “commonly appreciated risk” of Kayexalate with
sorbitol and that Kayexalate with sorbitol had been “demonstrated to cause” colonic
necrosis in patients with kidney failure. One of Mr. Allen’s multiple system problems
was kidney failure. Dr. Weisberg’s 2008 medical literature review commented on the
many case reports of patients developing intestinal necrosis after being given Kayexalate
with sorbitol, both by enema and orally, and warned that Kayexalate was a “poor choice”
for treatment of hyperkalemia for that reason. Dr. McGowan’s 2009 article studied
pathology records of patients receiving Kayexalate and observed that “[Kayexalate]-
induced ischemia remains an under recognized, easily avoided complication” when used
52
with sorbitol, especially in certain populations, including the “critically ill,” which Mr.
Allen certainly was. The articles by Erfani, in 2010, and Mount, in 2015, likewise
supported a causal link, and warned against using Kayexalate with sorbitol, especially in
patients with kidney failure. The articles submitted by Dr. Burks did not offer any reason
to contradict a cause and effect relationship when Kayexalate is administered in
conjunction with sorbitol but took the position that more studies should be done to
investigate the causal connection between Kayexalate with sorbitol and colonic necrosis.
The studies offered to the court weighed in the direction of the medical community
generally recognizing a cause and effect relationship especially in the population of
critically ill patients experiencing renal failure, such as Mr. Allen.
To be sure, neither the medical literature nor the expert testimony by Drs. Leo and
Odze, whose depositions were submitted to the court in support and opposition to the
Frye-Reed motion, delved deeply into the reason, or reasons, for the causal relationship.
Dr. Goldstein theorized that Kayexalate affects the lining of the colon such that the web
of thin-walled blood vessels that absorb most of the water in the digestive fluid entering
the colon stop working. That in turn decreases oxygenation to the lining of the colon.
Although Dr. Odze’s theory focused on the sorbitol that is combined with the Kayexalate,
it was similar to the theory espoused by Dr. Goldstein: the sorbitol, acting as a
hyperosmotic, draws water from the web of blood vessels in the lining of the colon,
thereby depriving the bowel tissue of oxygen. These experts rejected the causation
theory offered by Dr. Burks’s experts—that there was a generalized decrease in
oxygenation to the colon caused by episodes of low blood pressure during dialysis—
53
explaining that there would have been damage to other organs, not just the colon, if that
were the case. They acknowledged that there are cases of ischemic colitis in which the
cause is unknown, but made clear that administering Kayexalate with sorbitol, especially
in a patient with Mr. Allen’s conditions, is a recognized cause of ischemic colitis.
The evidence before the circuit court on the request for a Frye-Reed hearing and
opposition was sufficient to support a legal finding that, although there is not universal
acceptance in the medical community that Kayexalate with sorbitol can cause ischemic
colitis, that proposition is generally accepted, and that the risk of ischemic colitis from
Kayexalate with sorbitol is “commonly appreciated.” Accordingly, the court’s ruling was
not in error.
II.
Denial of Motion to Exclude Certain Evidence on Informed Consent
After the court denied Dr. Burks’s motion to preclude expert witness testimony
under Frye-Reed, Dr. Burks moved in limine to exclude the same testimony for purposes
of informed consent. Dr. Burks’s reasoning was that the court had ruled in favor of the
Allens on the Frye-Reed issue because there was some association, although not a causal
connection, between Kayexalate as given to Mr. Allen and ischemic colitis, and if there is
not an actual causal connection then the risk of experiencing ischemic colitis in
conjunction with administration of Kayexalate with sorbitol is fortuitous and therefore
not material. The court rejected that argument. Dr. Burks makes the same argument on
appeal.
54
For the same reasons we have explained in addressing the first question presented,
this contention lacks merit. The trial court found, on several bases, that there was general
acceptance in the relevant medical community of a causal connection between
Kayexalate as given to Mr. Allen and ischemic colitis. Therefore, the contention rests on
a faulty premise. Neither at trial nor on appeal does Dr. Burks make any other argument
that there was insufficient evidence that the risk of developing ischemic colitis from the
Kayexalate and sorbitol as given was not a material risk.
III.
Admission of Evidence about Calcium Gluconate and Calcium Chloride
and about Blood Draw
(a)
As mentioned above, the UMMC Guidelines for treatment of hyperkalemia call
for calcium gluconate or calcium chloride to be given in the first phase to protect the
patient from a heart attack due to dangerous arrhythmias. Dr. Burks ordered calcium
gluconate stat. In his deposition, Dr. Burks testified that the pharmacy informed him that
calcium gluconate was not available, due to a nationwide shortage, and that he gave an
oral order to the nurse assigned to Mr. Allen (Nurse Michelle Frock) to substitute calcium
chloride in place of calcium gluconate. UMMC protocol requires that a nurse receiving
an oral order document it in the patient’s chart within 48 hours and that the notation be
signed by the physician who gave the order. An oral order was not documented in Mr.
Allen’s chart, however, and the calcium chloride never was administered. In her
55
deposition testimony, Nurse Frock said she did not recall Dr. Burks giving an oral order
and if one had been given, she would have documented it in Mr. Allen’s chart.17
Before trial, Dr. Burks filed a motion to preclude the Allens from introducing
evidence that he failed “to administer calcium gluconate or calcium chloride.” He argued
that the only possible relevance of the evidence was to the standard of care, but because it
was undisputed that Mr. Allen did not suffer any injury from the failure to administer
calcium gluconate and/or calcium chloride, the evidence of a breach in the standard of
care had no causal significance and therefore was irrelevant. The court granted the
motion.
At the beginning of the second day of trial, before Dr. Leo, the Allens’s sole
standard of care expert, took the stand, counsel for the Allens asked the court to revisit
that ruling. He argued that the evidence was admissible to challenge the veracity of the
defense theory that, when confronted with Mr. Allen’s severe, life-threatening case of
hyperkalemia, Dr. Burks did everything in his power to treat it. Counsel for the Allens
maintained that evidence that Dr. Burks did not give either calcium gluconate or calcium
chloride to Mr. Allen to treat the most dangerous aspect of the hyperkalemia cast doubt
on the credibility of Dr. Burks’s defense that he used every available tool to treat the
emergency. Dr. Burks’s counsel responded that the evidence was not relevant to the
standard of care and any bearing on credibility it might have was outweighed by the
confusion it would cause, as the jury would have to make sense out of the collateral
17
Nurse Frock did not testify at the trial.
56
dispute over whether Dr. Burks did or did not give an oral order for calcium chloride.
The court agreed with the Allens that the evidence was admissible for credibility
purposes and reversed its earlier ruling.
Dr. Leo testified that the UMMC Guidelines stated that calcium—in either of its
two forms—be administered as the first line drug to counteract hyperkalemia; that it was
“the most important and most urgent medication that Mr. Allen needed”; and that the
hospital records reflect that calcium gluconate was unavailable and that calcium chloride
was never ordered for or administered to Mr. Allen. As discussed, Dr. Leo opined that
Dr. Burks breached the standard of care by administering Kayexalate because dialysis
was a safer and readily available alternative. Relatedly, he opined that Dr. Burks could
have administered repeated doses of calcium gluconate or calcium chloride to stabilize
Mr. Allen’s heart muscle and to “buy . . . more time” pending the initiation of dialysis.
When Dr. Burks testified at trial (as an adverse witness called by the Allens), he
stated that after he ordered calcium gluconate, he received a call from the UMMC
pharmacy advising him that calcium gluconate was not available due to a nationwide
shortage. He further testified that he believed that he gave a verbal order to Nurse Frock
and he thought, from not being told anything to the contrary, that his order was followed
and that Mr. Allen was given calcium chloride. He also testified that it was possible that
the UMMC pharmacy advised him that there was a hospital-wide shortage of calcium
chloride and, if that were the case, he would not have given an oral order to Nurse Frock
to administer it. He could not recall with any confidence which of those scenarios had
57
occurred, however. He agreed that Mr. Allen’s medical record did not reflect that
calcium chloride ever was administered.
During the defense case, Dr. Kaplan testified on cross-examination that the
standard of care required Dr. Burks to order calcium gluconate (which he did), but that he
did not breach the standard of care by not administering that drug because he was advised
that it was unavailable. Dr. Kaplan then was shown UMMC records reflecting that
calcium gluconate was administered to another patient at the hospital on March 18, 2013.
Dr. Kaplan responded that he could not speak to whether there were limited supplies of
calcium gluconate available at UMMC on March 18, 2013. Dr. Kaplan further opined
that calcium chloride was not an appropriate substitute in Mr. Allen’s case because he did
not have a central IV line in place and the drug could not be safely administered through
a peripheral IV line.
Dr. Seneff also was cross-examined on this issue. He testified that calcium was
the “first” drug a physician would want to administer during a hyperkalemic emergency
but disagreed that it was the “most important.” In his view, all the drugs in the three-
phases, in combination, were equally important.
On rebuttal, the Allens played the videotaped deposition of Carla Williams, the
assistant director of UMMC’s Pharmacy Clinical Services division. She testified that
when there is a shortage of a drug the UMMC pharmacy pulls the supply of those drugs
from the “Omnicells,” which are the secure drug storage facilities available to doctors
and nurses on each unit in the hospital, and instead stores the drug at the central
pharmacy location. In March 2013, there was a shortage of both calcium gluconate and
58
calcium chloride, and both had been pulled from the “Omnicells” as a result. A small
supply of the drugs would have been available in the emergency department and
operating room Omnicells, however, and in crash carts on each unit, unless it had already
been used. There was no way for Ms. Williams to determine from the UMMC records
the actual quantities of calcium gluconate and calcium chloride available at UMMC on
March 18, 2013.
On appeal, Dr. Burks challenges the court’s ruling admitting the evidence that Mr.
Allen was not given calcium gluconate or calcium chloride. 18 He contends the evidence
was not relevant, as it had no tendency to prove a breach in the standard of care that
caused injury to Mr. Allen, and should not have been admitted for credibility as it was
extrinsic evidence on a collateral matter.
The Allens respond that the evidence properly was admitted because it was
relevant to “undermine the credibility of the defense[, i.e.,] . . . [that] Dr. Burks did
everything he could in order to respond to Mr. Allen’s medical emergency.” They
maintain that evidence that Dr. Burks failed to ensure that Mr. Allen received either one
of the two drugs that were, according to all of the experts, most crucial to prevent him
from suffering a fatal heart arrhythmia had a tendency to show that Dr. Burks was not
18
In his reply brief, Dr. Burks argues for the first time that the court also erred by
improperly admitting into evidence three exhibits relative to the calcium
gluconate/calcium chloride issue: a printout of the Omnicell records from March 13,
2013; a billing record for Mr. Allen that reflected he never was charged for calcium
chloride; and a print-out showing medications stocked in the UMMC crash carts.
“[A]ppellate courts ordinarily do not consider issues that are raised for the first time in a
party’s reply brief” and we decline to address the admission of these exhibits. Gazunis v.
Foster, 400 Md. 541, 554 (2007).
59
meticulous in his treatment of Mr. Allen, which made it more probable that he (Dr.
Burks) did not carefully assess whether Kayexalate was necessary or appropriate as a
treatment for Mr. Allen’s hyperkalemia. We agree.
Evidence is relevant if it has “any tendency to make the existence of any fact that
is of consequence to the determination of the action more probable or less probable than
it would be without the evidence.” Md. Rule 5-401. A court “does not have discretion to
admit irrelevant evidence[.]” Ruffin Hotel Corp. of Md., Inc. v. Gasper, 418 Md. 594,
620 (2011); see also Md. Rule 5-402 (“Evidence that is not relevant is not admissible.”).
In his opening statement, Dr. Burks’s attorney told the jury that all of the actions
his client took on March 18, 2013, were aimed at preventing Mr. Allen from “suffering
an immediate, life-threatening emergency that would have stopped his heart”; that Dr.
Burks’s treatment of Mr. Allen “prevented [him] from dying from a heart arrhythmia”;
and that when faced with “a patient [who] could die . . . in front of him[, Dr. Burks] used
every avenue possible to stop that from happening.” During defense counsel’s
examination of Dr. Burks, who, as mentioned, was called adversely by the Allens, he
affirmed that Mr. Allen was experiencing an “immediately life threatening emergency”
around noon on March 18, 2013; that Dr. Burks took “prompt and urgent action to
respond to that life threatening emergency”; that he ordered a “cocktail” of drugs,
including calcium gluconate, to avert the emergency; and that absent that treatment, Mr.
Allen was “certain to die from the elevated potassium level.” The defense experts
testified, likewise, that Mr. Allen was in danger of dying of a fatal heart arrhythmia and
that Dr. Burks’s treatment prevented that outcome. Thus, the defense theory was not
60
simply that the administration of Kayexalate was within the standard of care (and, in any
event, did not cause Mr. Allen’s ischemic colitis), but that Dr. Burks responded to a
cardiac emergency and prevented him from dying from a hyperkalemic arrhythmia.
Evidence that Dr. Burks did not ensure that Mr. Allen received calcium chloride
after he learned from the UMMC pharmacy that calcium gluconate was unavailable was
relevant to the overall credibility of Dr. Burks’s defense. Dr. Burks’s alleged
carelessness in providing a drug crucial to treating Mr. Allen’s life threatening
emergency had a tendency to make it more probable that he also was careless in his
decision to prescribe Kayexalate, i.e., that he didn’t consider whether that course of
action was necessary or appropriate in Mr. Allen’s particular case, given his renal failure
and the availability of dialysis, a safer and more effective alternative. Moreover, the
evidence that Dr. Burks misrepresented during his deposition testimony that he had given
an oral order to Nurse Frock to substitute calcium chloride in place of the calcium
gluconate, despite no entry in Mr. Allen’s medical record to substantiate that that
occurred, was relevant to his credibility. See, e.g., Hill v. Wilson, 134 Md. App. 472, 480
(2000) (a “witness’s credibility is always relevant”) (citation omitted).
Of course, the court had discretion to exclude the evidence pursuant to Rule 5-403
if its “probative value [was] substantially outweighed by the danger of unfair prejudice,
confusion of the issues, or misleading the jury . . . .” Dr. Burks maintains that the court
abused its discretion by not excluding the evidence pertaining to calcium gluconate and
calcium chloride because it was both highly prejudicial and misleading. He relies
primarily on Lai v. Sagle, 373 Md. 306 (2003). In that case, the Court of Appeals held
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that a trial court abused its discretion by not granting a mistrial in a medical malpractice
action after plaintiff’s counsel mentioned in opening statements that the defendant
physician had been sued for medical malpractice on five prior occasions. Analogizing
that evidence to “prior bad acts” evidence, the Court reasoned that the jury could use the
evidence that a defendant had been sued previously to infer, improperly, that the
defendant was negligent in those cases and that he or she had a propensity to be
negligent.
In the instant case, the challenged evidence concerned Dr. Burks’s treatment of
Mr. Allen, not prior medical malpractice suits. It did not create, as Dr. Burks suggests, a
mini-trial on a collateral issue because, as we have explained, evidence that neither
calcium gluconate nor calcium chloride was ordered/administered was relevant to a
central issue at trial: the propriety of Dr. Burks’s treatment decisions in the immediate
aftermath of Mr. Allen’s bradycardia. For all these reasons, the court did not err or abuse
its discretion by denying Dr. Burks’s motion in limine or by admitting the challenged
evidence.
(b)
At trial, Dr. Burks testified that when he arrived on the floor on the morning of
March 18, 2013, between 7:00 a.m. and 8:00 a.m., he learned that the results of Mr.
Allen’s routine blood tests were not back. He asked Nurse Frock about this, and she told
him that Mr. Allen “may have refused” to have his blood drawn that morning. Dr. Burks
believed that he then gave an oral order for the labs to be drawn that morning but
acknowledged that there was no notation in Mr. Allen’s medical record to that effect and
62
the labs were not drawn. He acknowledged that if the lab results had been available they
likely would have revealed an elevated potassium level and he would have ordered a
nephrology consult, which would have resulted in dialysis that morning. Had that
happened, Mr. Allen would not have experienced a cardiac event and Kayexalate would
not have been prescribed.
On appeal, the appellants contend the Allens should not have been permitted to
elicit testimony that Dr. Burks “did not request a blood draw after learning that Mr.
Allen’s blood work had not been completed” earlier that morning because that evidence
had no tendency to prove a breach in the standard of care that caused injury to Mr. Allen.
We conclude that this issue is waived.
All the challenged testimony was elicited on direct examination of Dr. Burks,
who, as mentioned, was called adversely.19 During the entire line of questioning
pertaining to the blood draw, which spans thirteen pages of the trial transcript, counsel for
Dr. Burks did not lodge any objections directed at the substance of the questions and
never argued to the court that, in his view, the subject of the questions was irrelevant and
prejudicial. Having failed to object to the challenged testimony, Dr. Burks has waived
this contention of error. See Md. Rule 2-517(a) (“An objection to the admission of
19
When Dr. Burks testified, he was asserting an affirmative defense of
contributory negligence based upon Mr. Allen’s alleged refusal of a blood test during the
early morning hours of March 18, 2013. After Dr. Burks testified, his attorney withdrew
that defense. As a result, the court ruled that the issue as to whether Mr. Allen actually
had refused his blood draw was collateral and precluded further evidence on that subject.
63
evidence shall be made at the time the evidence is offered or as soon thereafter as the
grounds for objection become apparent. Otherwise, the objection is waived.”).
CROSS APPEAL
I.
In their cross-appeal, the Allens contend the trial court violated their constitutional
rights by reducing the $10,000,000 verdict to $906,250, consistent with the statutory cap
on noneconomic damages in actions for medical malpractice (“the cap”) codified at CJP
section 3-2A-09.20 They argue that the cap creates a discriminatory classification scheme
prohibited by the Equal Protection Clause of the Fourteenth Amendment to the federal
constitution, and Article 24 of the Maryland Declaration of Rights because it
“discriminates against the most severely injured” and against “larger families,” such as
the Allens. They assert that the cap cannot survive rational basis scrutiny and must be
struck down.
It is not within this Court’s purview to revisit the constitutionality of the cap,
which the Court of Appeals repeatedly has upheld in the face of challenges premised on
the same arguments made by the Allens in the instant appeal.21 See Murphy v. Edmonds,
20
When Mr. Allen died in 2013, the cap on noneconomic damages in a wrongful
death action premised upon medical malpractice brought by “two or more claimants or
beneficiaries” was 125% of $725,000 ($906,250) for “all claims for personal injury and
wrongful death arising from the same medical injury[.]” CJP § 3-2A-09(b)(2).
21
Most of the appellate cases consider the constitutionality of the cap on non-
economic damages codified at CJP section 11-108, which, in its current form, applies to
all personal injury and wrongful death actions that are not premised on medical
Continued…
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325 Md. 342, 367–70 (1992) (holding that the constitutionality of the cap is scrutinized
under the deferential rational basis test and that the “legislative classification drawn . . .
between tort claimants whose noneconomic damages are less than [the cap] and tort
claimants whose noneconomic damages are greater than [the cap], and who are thus
subject to the cap, is not irrational or arbitrary”); DRD Pool Serv., Inc. v. Freed, 416 Md.
46, 66-67 (2010) (holding that the cap “does not create a classification between affected
parties, and certainly not a classification subject to heightened scrutiny”); Dixon v. Ford
Motor Co., 433 Md. 137, 169 (2013) (holding that by capping the total gross award in
wrongful death actions, the legislature did not “create irrational classifications among the
claimants”); Martinez v. The Johns Hopkins Hospital, 212 Md. App. 634, 656 n.19
(2013) (“it is well settled that the [c]ap is constitutional. The Court of Appeals has
consistently upheld the constitutionality of the [c]ap, explaining that it has become
‘embedded in the bedrock of Maryland law.’”) (quoting DRD Pool, 416 Md. at 68). We
are bound by the direct precedent governing this issue and decline to further address it.
JUDGMENT AFFIRMED. COSTS
TO BE PAID BY THE
APPELLANTS.
…cont’d
malpractice. As all the parties agree, the reasoning of those cases is equally applicable to
CJP section 3-2A-09, which applies only to medical malpractice actions.
65