Holzem v. Presbyterian Healthcare Services

IN THE COURT OF APPEALS OF THE STATE OF NEW MEXICO
Opinion Number: _______________
Filing Date: July 17, 2013
Docket No. 30,294
PETER J. HOLZEM, as Personal Representative for the
WRONGFUL DEATH ESTATE OF DOUGLAS R. REID, deceased,
and CHRISTAL REID, individually and as guardian and next friend
of Darian Reed, a Minor,
Plaintiffs-Appellants,
v.
PRESBYTERIAN HEALTHCARE SERVICES
and JOSEPH HELAK, D.O.,
Defendants-Appellees.
APPEAL FROM THE DISTRICT COURT OF RIO ARRIBA COUNTY
Sheri A. Raphaelson, District Judge
John R. Polk Law Offices
John R. Polk
Albuquerque, NM
David A. Archuleta
Albuquerque, NM
for Appellants
Rodey, Dickason, Sloan, Akin & Robb, P.A.
Edward Ricco
Jocelyn Drennan
Albuquerque, NM
for Appellees
OPINION
HANISEE, Judge.
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{1} Peter Holzem, the personal representative of Douglas Reid’s estate, and Christal
Reid, Douglas Reid’s wife, (collectively, Plaintiffs) brought suit against Presbyterian
Healthcare Services and Dr. Joseph Helak (Defendants), seeking damages for the wrongful
death of Reid, under theories of medical negligence, respondeat superior, and corporate
negligence. The district court granted summary judgment in favor of Defendants based on
its conclusion that Plaintiffs lacked competent, admissible expert testimony to support the
elements of duty and negligence with regard to Dr. Helak and to prove that Defendants’
actions or inactions proximately caused or contributed to cause Reid’s death. Plaintiffs
appeal, asserting that genuine issues of material fact exist to preclude summary judgment,
and contending that the district court abused its discretion in excluding both expert testimony
and a medical study supporting Plaintiffs’ theory of the case. Because the district court
abused its discretion in excluding the testimony of Plaintiffs’ proposed expert, Darwin
Palmer, M.D., we reverse and remand.
I. BACKGROUND
{2} Reid, a thirty-four -year-old man, first developed influenza symptoms on either
January 2 or 3, 2005. On January 4, he sought treatment at an urgent care center and was
subsequently sent to an emergency room at Plains Regional Medical Center, both of which
were owned by Defendant Presbyterian Healthcare Services. Dr. Helak treated Reid at the
emergency room where Reid presented with symptoms consistent with influenza or
gastroenteritis. Dr. Helak did not test Reid for influenza. Rather, Dr. Helak provided Reid
with palliative treatment, addressing Reid’s symptoms, but not determining the underlying
cause of his illness. Reid was subsequently sent home from the hospital.
{3} On January 5, Reid’s condition deteriorated, and he was seen by his primary care
physician, Albert Kwan, M.D., who admitted him as a patient into Plains Regional Medical
Center. Reid died there in the intensive care unit at 8:15 a.m. the following day. The
autopsy report, issued on February 7, 2005, concluded that the cause of death was
myocarditis (inflammation of the heart) due to an Influenza B infection.
{4} Plaintiffs subsequently brought this wrongful death action against Defendants.
During the course of the case, Plaintiffs produced evidence from a medical expert, Dr.
Palmer, who attested to breaches of the standard of care owed by Dr. Helak and the
hospital’s nursing staff. The theory of Plaintiffs’ case was that Dr. Helak “failed to perform
a differential diagnosis” when Reid initially presented in the emergency room and “failed
to use an available . . . test for influenza.” Plaintiffs asserted that the “differential diagnosis
is [a] standard practice in emergency rooms in New Mexico[,] medication is available to
treat influenza along with other courses of action[, and that] Reid died of undiagnosed and
untreated influenza.” Plaintiffs concluded that “Defendants failed to possess and apply the
knowledge and use the skill and care owed to [Reid] and, as the proximate result of the
negligence of Defendants, [Reid] died.”
{5} We note that Plaintiffs initiated their case on the primary theory that the negligent
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medical action involved the failure to make a differential diagnosis. Yet the district court
identified the material issue to be Plaintiffs’ ensuing contention that Dr. Helak should have
given Reid Tamiflu, a drug used to prevent replication of the influenza virus, despite
Defendants’ assertion that Reid had been symptomatic for about fifty hours upon arrival at
the emergency room. The district court explained:
If it is true that the negligence in this case is only the failure to make a
differential diagnosis[,] then . . . Plaintiff[]s would fail to be able to show that
omission caused the death. Clearly, the allegation of . . . Plaintiff[s] is that
if [Reid] had been given Tamiflu when he was seen in the emergency
department he would have lived. It is that omission, the failure to give
Tamiflu, that . . . Plaintiff[s are] necessarily saying caused the death.
We agree with the district court’s understanding of the nature of the claim asserted by
Plaintiffs. In fact, to support their contention that a differential diagnosis would have
improved Reid’s chances of recovery and survival, Plaintiffs relied on Dr. Palmer’s
statement that it would have been medically appropriate for Reid to have been given the
antiviral drug, Tamiflu, had the differential diagnosis been made. In his deposition, Dr.
Palmer indicated that he was qualified to testify on this topic because he was an infectious
disease specialist, who taught about and specialized in treating infectious diseases for
twenty-nine years at the University of New Mexico Medical School. The courses he taught
included instruction on the diagnosis and treatment of influenza.
{6} After extensive discovery in which Defendants deposed Plaintiffs’ experts,
Defendants contemporaneously sought summary judgment and exclusion of testimony by
Dr. Palmer. In their motion for summary judgment, which incorporated their separate
motion to exclude opinion testimony by Dr. Palmer, Defendants argued that Plaintiffs failed
to provide competent, admissible evidence to establish Dr. Helak’s breach of the standard
of care or Defendants’ causation of Reid’s injuries and death. Defendants maintained that
“Plaintiffs rely upon only one expert, Dr. Palmer, to express opinions on the standard of care
applicable to Dr. Helak [and] . . . whether Dr. Helak breached that standard.” Defendants
also asserted that Dr. Palmer was unqualified to express opinions as to either breach or
causation because he “does not possess adequate training or experience in emergency
medicine,” and because he “has no practical experience with Tamiflu, and has not otherwise
reviewed or researched . . . this drug[.]”
{7} In his January 2009 deposition, Dr. Palmer stated that he had not practiced
emergency medicine for nearly fifty years and had never specialized in emergency medicine.
As well, Defendant produced evidence showing that Tamiflu was not available for
prescription until 1999 at the earliest, approximately four years after Dr. Palmer retired from
practicing medicine. We note that although Dr. Palmer was licensed to practice medicine
at the time of his 2009 deposition, he testified that he had not worked or had privileges at any
hospital since 1995 and that he had never provided medical care as a private practitioner.
Dr. Palmer testified at his deposition that he could not recall practicing medicine between
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1997 and 2004.
{8} Dr. Palmer further stated when deposed he had not reviewed any literature regarding
Tamiflu in preparation for his deposition and that he did not plan to refer to medical
research, literature, or studies of any kind when he testified at trial. Dr. Palmer also
conceded that he was not aware of any studies published before 2005 that addressed the
effectiveness of Tamiflu administered in excess of forty hours following the onset of
symptoms. Following Dr. Palmer’s deposition, Plaintiffs attempted to amend the testimony
he provided by submitting a six-page witness correction sheet signed by Dr. Palmer, but
upon Defendants’ motion, the district court struck the document from the record.
{9} Plaintiffs opposed summary judgment, arguing that Dr. Palmer indeed possessed
sufficient experience in emergency medicine, influenza diagnosis, and the administration of
Tamiflu. Attached to their response to Defendants’ motion for summary judgment, Plaintiffs
submitted, among other exhibits, two supplementary affidavits from Dr. Palmer. In the first
affidavit, Palmer attested to his qualifications and opinion about causation in Reid’s case.
In the second affidavit, labeled the “Special Affidavit” by Plaintiffs, Dr. Palmer provided
new information about his post-retirement medical practice in Zimbabwe and in a health
clinic in Albuquerque. In the Special Affidavit, he stated that “[s]hortly after his retirement
he spent two years teaching infectious disease, urgent care[,] and emergency medicine at the
University of Zimbabwe Medical School, . . . which involved a plethora of infectious
diseases including all forms of influenza.”
{10} The Special Affidavit also avowed that from 1998 through 2002, Dr. Palmer
practiced medicine two days per week in the Healthcare for the Homeless Clinic, where he
treated patients with various stages of influenza infections. Dr. Palmer attested that “[t]his
experience started before the modern antiviral treatments for influenza became available and
continued through the introduction of Tamiflu[,] giving him a close observation of the
effectiveness of this antiviral drug which he prescribed regularly.” The Special Affidavit
stated that during his time at the clinic, Dr. Palmer treated hundreds, if not thousands, of
influenza patients, and “was able to carefully observe Tamiflu’s effectiveness based on the
time of its administration from the onset of symptoms.” The Special Affidavit asserted that
“[b]ased on his personal experience in diagnosing, observing, treating[,] and following
influenza patients in the many hundreds, if not thousands, he is thoroughly familiar with this
infectious disease, its consequences, and the effectiveness of the various treatments that have
been administer[ed] for it over the years.”
{11} Defendants subsequently brought motions to strike both affidavits, arguing that they
were “sham” affidavits and that “Dr. Palmer should be bound by his deposition testimony,
not by a self-serving and contradictory affidavit served after the conclusion of discovery.”
Defendants contended that the Special Affidavit qualified as a “sham” because this
additional work experience was not identified on Dr. Palmer’s curriculum vitae produced
during discovery and because it contradicted his deposition testimony that he did not practice
medicine between 1997 and 2004. Plaintiffs responded that the Special Affidavit was meant
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to supplement Dr. Palmer’s deposition testimony and that Defendants had previously agreed
to post-deposition supplementation of discovery. The district court did not rule on either
motion to strike the post-deposition affidavits.
{12} Nonetheless, the district court excluded the testimony of Dr. Palmer, concluding that
he was not “qualified to render opinions o[n] the standard of care in the field of emergency
medicine, including diagnosis and treatment.” It appears from the court’s order that this
decision was based primarily on the court’s finding that “[e]mergency [m]edicine is a
specialized field of medicine in which Dr. Palmer has never been certified, never received
specialized education, nor ever practiced.” Although argued by Defendants as a ground for
exclusion, the court did not note Dr. Palmer’s experience or inexperience with Tamiflu in
its decision to exclude his testimony. The district court then granted summary judgment in
favor of Defendants, stating that based on its Daubert analysis, it agreed with Defendants
that
(1) Plaintiffs do not have competent, admissible expert testimony to support
the elements of duty and negligence against [Defendant], and (2) Plaintiffs
also do not have competent, admissible expert testimony to support their
claim that alleged negligence on the part of the Defendants proximately
caused or contributed to cause the death of Douglas Reid and resulting harm
to . . . Plaintiffs.
See Daubert v. Merrell Dow Pharm., Inc., 509 U.S. 579 (1993). Plaintiffs now appeal.
II. DISCUSSION
{13} At the heart of the summary judgment motion was Plaintiffs’ purported lack of
evidence to support the elements of duty, breach of duty, and causation, that is, whether Reid
would have had a better chance of survival had the proper standard of care been adhered to
by Dr. Helak. Specifically, at issue is whether Dr. Helak should have performed a
differential diagnosis and then administered Tamiflu to Reid. “The testimony of a medical
expert is generally required when a physician’s standard of care is being challenged in a
medical negligence case.” Lopez v. Reddy, 2005-NMCA-054, ¶ 9, 137 N.M. 554, 113 P.3d
377. Here, a medical expert was required to testify regarding the standard of care applicable
to the diagnosis and treatment of influenza, an infectious disease. Once the district court
excluded testimony by Dr. Palmer, Plaintiffs’ only proposed expert witness to prove these
core elements of a negligence cause of action, the court concluded that summary judgment
was necessitated. Plaintiffs assert that it was error to exclude Dr. Palmer’s testimony and
grant summary judgment on the basis identified by the district court.
A. Dr. Palmer’s Absence of Expertise in Emergency Medicine Was Not A Proper
Basis To Disqualify Him As An Expert
{14} “With respect to the admission or exclusion of evidence, we generally apply an abuse
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of discretion standard where the application of an evidentiary rule involves an exercise of
discretion or judgment, but we apply a de novo standard to review any interpretations of law
underlying the evidentiary ruling.” Dewitt v. Rent-A-Center, Inc., 2009-NMSC-032, ¶ 13,
146 N.M. 453, 212 P.3d 341. “In determining whether an expert witness is competent or
qualified to testify, [t]he [district] court has wide discretion . . ., and the court’s
determination of this question will not be disturbed on appeal, unless there has been an abuse
of this discretion.” Lopez, 2005-NMCA-054, ¶ 14 (alterations in the original) (internal
quotation marks and citation omitted). Nonetheless, with regard to the admission of
scientific evidence,
[a]n abuse of discretion . . . can be found when the trial judge’s action was
obviously erroneous, arbitrary, or unwarranted. . . . An abuse of discretion
standard of review . . . is not tantamount to rubber-stamping the trial judge’s
decision. It should not prevent an appellate court from conducting a
meaningful analysis of the admission [of] scientific testimony to ensure that
the trial judge’s decision was in accordance with the Rules of Evidence and
the evidence in the case.
State v. Alberico, 116 N.M. 156, 170, 861 P.2d 192, 206 (1993).
{15} Rule 11-702 NMRA states that “if the expert’s scientific, technical, or other
specialized knowledge will help the trier of fact to understand the evidence or to determine
a fact in issue[, a] witness who is qualified as an expert by knowledge, skill, experience,
training, or education may testify [thereto] in the form of an opinion or otherwise.” Under
Rule 11-702, the trial court must determine whether an expert witness is or is not qualified
to testify and give an opinion about the particular issue. Lopez, 2005-NMCA-054, ¶ 14. The
medical expert has the task of testifying “as to how and why he arrives at an opinion that a
defendant physician’s conduct has been substandard.” Sewell v. Wilson, 97 N.M. 523, 528,
641 P.2d 1070, 1075 (Ct. App. 1982). Thus, “[t]he qualifications of an expert are dependent
on the type of negligence claimed and the medical complexity involved.” Lopez, 2005-
NMCA-054, ¶ 16. We note that “a non-specialist can testify as to the standards of care owed
by a defendant specialist, but only if the non-specialist is qualified and competent to do so.”
Wilson, 97 N.M. at 528, 641 P.2d at 1075. “[T]he mere fact that a medical witness is not a
specialist goes to the weight, not to admissibility, of the witness’[s] expert testimony.” Id.
{16} At issue in this case is whether Dr. Palmer possessed the knowledge, skill, training,
or education to be qualified and competent to testify about whether Reid would have had a
better chance at survival had Dr. Helak adhered to the applicable standard of care. More
specifically, based upon Plaintiffs’ theory of the case, Dr. Palmer must have been qualified
to testify about the standard practice for administering Tamiflu, as well as the likelihood that
Tamiflu would have saved Reid’s life. Here, the district court determined that Dr. Palmer
was unqualified to testify because he lacked experience and expertise in emergency
medicine, yet it neglected to incorporate into its ruling consideration of Dr. Palmer’s many
years of experience in infectious disease treatment or to consider the information separately
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asserted by way of post-deposition affidavits or even to rule upon Defendants’ motions that
the affidavits be stricken.
{17} Initially, we conclude that the district court erred in basing its exclusion on the
exclusive rationale the district court identified, as we reason that Dr. Palmer’s lack of
expertise in emergency medicine does not alone establish a permissible ground for
disqualification as an expert under the circumstance of this case. At issue, generally, is the
standard of care for treating influenza. Evidence indicates that Dr. Palmer was an infectious
disease specialist who taught about and specialized in treating infectious diseases for twenty-
nine years at the University of New Mexico Medical School. The courses he taught to
medical students included instruction on the diagnosis and treatment of influenza. Not as
a specialist in emergency medicine but as a specialist in infectious disease, Dr. Palmer’s
background afforded him experience and expertise in diagnosing and treating influenza. The
standard for diagnosing and treating influenza is not particular to emergency medicine, and
cannot be construed on such a narrow basis. Plaintiffs’ influenza-related claim should be
addressed by an expert who has sufficient experience in both influenza diagnosis and
treatment that is pertinent to the facts of this case. Accordingly, Dr. Palmer’s lack of
specialization in emergency medicine does not automatically disqualify him as an expert
witness. Rather, it goes to the weight a jury could give his testimony if determined
otherwise to be admissible. The district court therefore abused its discretion by determining
that Dr. Palmer was not qualified as an expert on this erroneous and arbitrary basis.
{18} We discern that the decisive issue with regard to Dr. Palmer’s capacity to provide
expertise here turns on his experience or education with regard to administering Tamiflu, a
newer drug used in the treatment of influenza. As well, we recognize that we could affirm
the district court’s exclusion of Dr. Palmer’s testimony if the court correctly determined that
he lacked the qualifications to offer opinions on the appropriate use of Tamiflu. Cordova
v. World Fin. Corp., 2009-NMSC-021, ¶ 18, 146 N.M. 256, 208 P.3d 901 (explaining that
appellate courts may affirm a district court’s decision if it is right for any reason, so long as
doing so would not be unfair to the appellant). However, Dr. Palmer’s Special Affidavit
asserted that he had considerable experience in prescribing Tamiflu and in observing its
effects on influenza. While Defendants moved to strike the Special Affidavit on various
grounds, the district court never ruled on those motions. Consequently, the Special Affidavit
was part of the record upon which the district court based its determination to exclude Dr.
Palmer’s testimony, and the district court’s exclusion was therefore equally improper in light
of the Special Affidavit.
{19} Defendants suggest that we can determine whether the Special Affidavit was properly
before the district court, but we decline that invitation. It is for the district court in the first
instance to rule on motions and, if it has not done so, there is no ruling for us to review. We
express no opinion about how the district court should rule on Defendants’ motions to strike.
On remand, the district court may resolve the still-pending motions to strike, and the parties
may renew or submit any motions, evidentiary or otherwise, they deem to be appropriate in
light of that or our ruling. We therefore reverse and remand because, given the record before
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it, including the Special Affidavit, the district court abused its discretion in excluding Dr.
Palmer’s testimony.
B. Summary Judgment Was Improper
{20} “Summary judgment is appropriate where there are no genuine issues of material fact
and the movant is entitled to judgment as a matter of law.” Self v. United Parcel Serv., Inc.,
1998-NMSC-046, ¶ 6, 126 N.M. 396, 970 P.2d 582. “On appeal from the grant of summary
judgment, we ordinarily review the whole record in the light most favorable to the party
opposing summary judgment to determine if there is any evidence that places a genuine issue
of material fact in dispute.” City of Albuquerque v. BPLW Architects & Eng’rs, Inc., 2009-
NMCA-081, ¶ 7, 146 N.M. 717, 213 P.3d 1146. “However, if no material issues of fact are
in dispute and an appeal presents only a question of law, we apply de novo review and are
not required to view the appeal in the light most favorable to the party opposing summary
judgment.” Id.
{21} The district court based its order of summary judgment entirely on its exclusion of
Dr. Palmer, stating that “Plaintiffs do not have competent, admissible expert testimony to
support the elements of duty and negligence [and proximate cause.]” Since we hold that the
district court abused its discretion in excluding Dr. Palmer, Plaintiffs may now have the
ability to prove those elements of their claim. As such, we reverse the district court’s order
of summary judgment.
III. CONCLUSION
{22} For the reasons stated above, we conclude that the district court erred in excluding
Dr. Palmer’s testimony. We reverse the court’s order excluding Dr. Palmer and its order of
summary judgment and remand the case to the district court. As our holding is dispositive,
we do not address Plaintiffs’ other arguments on appeal.
{23} IT IS SO ORDERED.
____________________________________
J. MILES HANISEE, Judge
WE CONCUR:
____________________________________
RODERICK T. KENNEDY, Chief Judge
____________________________________
CYNTHIA A. FRY, Judge
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