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Eisenhauer v. The Henry County Health Center

Supreme Court of Iowa

October 25, 2019

LARRY D. EISENHAUER, Conservator, ex rel. CONSERVATORSHIP OF T.D., Appellant,

          Appeal from the Iowa District Court for Henry County, Mark Kruse, Judge.

         Plaintiff appeals district court's entry of the jury verdict dismissing a medical malpractice case.

          Jeffrey L. Goodman, Nicole L. Keller, and Daniel Peacock (until withdrawal) of Goodman Law, P.C., West Des Moines, and Michael J. Moreland of Harrison, Moreland, Webber & Simplot, P.C., Ottumwa, for appellant.

          Jennifer E. Rinden, Robert D. Houghton, and Nancy J. Penner of Shuttleworth & Ingersoll, P.L.C., Cedar Rapids, for appellee Henry County Health Center.

          Robert V.P. Waterman Jr., Mikkie R. Schiltz, and Alexander C. Barnett of Lane & Waterman, LLP, Davenport, for appellees James Widmer and Family Medicine of Mt. Pleasant, P.C.


         This medical malpractice case concerns plaintiff's suit against defendants for negligent acts or omissions during plaintiff's birth. Defendants encountered the medical emergency of shoulder dystocia after plaintiff's shoulder became stuck on his mother's pelvis. Defendants performed maneuvers to resolve the stuck shoulder, but plaintiff was born with a permanent injury to his left arm preventing normal use and function. The jury returned a defense verdict and the district court dismissed plaintiff's claims. On direct appeal, we first consider whether the district court committed reversible error in the specifications of negligence it submitted to the jury. We also consider whether the district court abused its discretion when it prohibited plaintiff from offering evidence of defendants' continuing medical education credits. Next, we are asked to determine whether the district court properly admitted expert opinion testimony. Lastly, we determine whether limiting the jury's access to evidence during deliberations was within the district court's discretion.

         For reasons expressed below, we conclude the plaintiff's proffered instructions were sufficiently encompassed by the instructions submitted or, in the alternative, were not supported by substantial evidence. We further conclude the district court did not abuse its discretion in prohibiting the plaintiff from introducing continuing medical education records to show a breach in the standard of care. However, although it was an abuse of discretion for the district court to prohibit the use of continuing medical education records as impeachment evidence, the error was harmless. Next, we determine defendants' expert opinion testimony was properly disclosed and did not reflect an opinion in anticipation of litigation. We further determine the district court did not abuse its discretion in limiting the jury's access to video evidence during deliberation; it was a judgment call for the district court to make.

         I. Background Facts and Proceedings.

         T.D. was born on August 31, 2007, at the Henry County Health Center (HCHC). Dr. Widmer, employed by Family Medicine of Mt. Pleasant, P.C., [1] was the physician in charge of T.D.'s prenatal care and delivery. Many of the facts surrounding T.D.'s birth are not disputed. During the delivery, T.D.'s head delivered but his left shoulder became stuck on his mother's pelvis. This situation, a shoulder dystocia, is a medical emergency because the infant's delay in birth may cause severe brain damage or death if not resolved in six minutes or less. Dr. Widmer and the nurses performed maneuvers that resolved the shoulder dystocia in one minute and ten seconds. However, T.D. was born with a permanent injury to his left brachial plexus preventing normal use and function of his arm. T.D.'s delivery was captured on a twenty-one minute birth video recorded by T.D.'s aunt.

         T.D., through a conservator, [2] filed a medical malpractice action on March 10, 2016, in Henry County alleging defendants were negligent during labor and delivery, causing injury. Nearly a year and a half later, T.D. filed a motion for leave to amend and substitute his original petition. Defendants resisted, citing concerns that T.D. was raising new claims of negligent training and credentialing for the first time less than sixty days before trial. On October 13, 2017, after an evidentiary hearing, the district court determined T.D.'s proposed amendment "that adds a new claim of negligent training does 'substantially change the issues or defenses of the case.' Allowing the amendment would prejudice the defense in this case." It ruled,

The primary issues in this case remain as to what the applicable standard of care was on the date in question and whether there was a violation of this standard with a causal relationship to the injury.
To the extent there may be any reference in the [a]mended [p]etition that relates to a theory of recovery based on negligent training or credentialing, the amendment is denied.

         The district court later granted defendants' motion in limine relating to, among other things, any reference to either HCHC's training and credentialing process or Dr. Widmer's training as a family practice physician, including his Continuing Medical Education (CME) records.

         Trial commenced on November 7, 2017, and concluded on November 17. Both parties offered expert testimony to support their respective positions. T.D. offered the birth video into evidence without objection. At the close of his case-in-chief, T.D. sought to admit Dr. Widmer's CME records and made on offer of proof. The district court affirmed its prior ruling and prohibited T.D. from offering evidence of the CME records.

During direct examination by defendants, Dr. Widmer testified:
Q. Do you have an opinion as to whether the maneuvers you used were in conformity with the standard of care?
MR. GOODMAN: Undisclosed opinion.
THE COURT: Overruled.
A. I believe I did.

         On the sixth day of trial, during redirect examination, Dr. Widmer referred to a single page of handwritten notes. He testified to creating the notes when he reviewed the birth video and stated his notes would assist in recalling the times he heard fetal heart rates without the need to watch the entire birth video. Defendants later moved to admit the notes as demonstrative evidence.

         During deliberations, the jury asked to view the birth video, which was not submitted to the jury for deliberations. The district court complied with the request and played the video for the jury once in its entirety. Over plaintiff's objections, the birth video was not sent back to the jury room during deliberations but could be viewed an additional time upon request by the jury. Such a request was made and the video was again played in its entirety. Subsequently, the jury returned a verdict for defendants, finding neither HCHC's nurses nor Dr. Widmer were negligent. Consequently, the jury did not reach the question of causation or damages.

         The district court, based upon the jury's verdict, entered an order dismissing T.D.'s claims. T.D. appealed the district court order, and we retained the appeal.

         II. Standard of Review.

         The standard of review for jury instructions is for prejudicial error by the district court. Thavenet v. Davis, 589 N.W.2d 233, 236 (Iowa 1999) (en banc). Therefore, a district court's refusal to give a requested jury instruction is reviewed for correction of errors at law. See Alcala v. Marriott Int'l, Inc., 880 N.W.2d 699, 707 (Iowa 2016). "Instructions must be considered as a whole, and if the jury has not been misled there is no reversible error." Thavenet, 589 N.W.2d at 236. "In considering whether the instruction is supported by substantial evidence, we give the evidence the most favorable construction it will bear in favor of supporting the instruction." Asher v. OB-Gyn Specialists, P.C., 846 N.W.2d 492, 496-97 (Iowa 2014), overruled by Alcala, 880 N.W.2d at 707-08, 708 n.3.

         A district court's decision to admit relevant evidence is reviewed for an abuse of discretion. See Mohammed v. Otoadese, 738 N.W.2d 628, 631 (Iowa 2007). "An abuse of discretion occurs when 'the court exercise[s] [its] discretion on grounds or for reasons clearly untenable or to an extent clearly unreasonable.'" Graber v. City of Ankeny, 616 N.W.2d 633, 638 (Iowa 2000) (en banc) (alteration in original) (quoting Waits v. United Fire & Cas. Co., 572 N.W.2d 565, 569 (Iowa 1997)). Grounds or reasons are clearly untenable if they are not supported by substantial evidence or if they are based on an erroneous application of law. Id. "A party may claim error in a ruling to admit or exclude evidence only if the error affects a substantial right of the party . . . ." Iowa R. Evid. 5.103(a).

         We review whether a district court properly admitted expert testimony for abuse of discretion. See Hansen v. Cent. Iowa Hosp. Corp., 686 N.W.2d 476, 479 (Iowa 2004).

         Similarly, "[s]ubmission of exhibits to the jury is a matter resting in [the] trial court's discretion." Brooks v. Holtz, 661 N.W.2d 526, 532 (Iowa 2003) (alteration in original) (quoting Heth v. Iowa City, 206 N.W.2d 299, 303 (Iowa 1973)).

         III. Analysis.

         A. Specifications of Negligence.

         We first consider whether there was reversible error in the district court's specifications of negligence. In a medical malpractice action, "a plaintiff must produce evidence that (1) establishes the applicable standard of care, (2) demonstrates a violation of this standard, and (3) develops a causal relationship between the violation and the injury sustained." Oswald v. LeGrand, 453 N.W.2d 634, 635 (Iowa 1990). The questions respecting the violation of a standard of care and the causal relationship are ordinarily for the trier of fact. See Speed v. State, 240 N.W.2d 901, 904 (Iowa 1976).

         A plaintiff is required to identify the specific acts or omissions relied upon to generate questions for the trier of fact. See Herbst v. State, 616 N.W.2d 582, 585 (2000) (en banc). As we explained in Herbst, "Jury instructions should be formulated so as to require the jury to focus on each specification of negligence that finds support in the evidence." Id. (quoting Bigalk v. Bigalk, 540 N.W.2d 247, 249 (Iowa 1995)). Put another way, a party is entitled to have its legal theory submitted to the jury if that theory is supported by substantial evidence. See Ludman v. Davenport Assumption High Sch., 895 N.W.2d 902, 919-20 (Iowa 2017).

         Of course, whether a jury instruction sufficiently encompasses each specification of negligence alleged by a plaintiff is determined by the facts of the particular case. See Herbst, 616 N.W.2d at 586. Iowa law requires a court give a requested instruction as long as the instruction is a correct statement of law, is applicable to the case, and is not otherwise embodied elsewhere in the instructions. See Ludman, 895 N.W.2d at 919; Porter v. Iowa Power & Light Co., 217 N.W.2d 221, 234 (Iowa 1974). This principle, however, does not require a court give instructions that provide undue emphasis to any particular aspect of the case, Burkhalter v. Burkhalter, 841 N.W.2d 93, 106 (Iowa 2013), or that duplicate specifications adequately encompassed elsewhere in the instructions, Porter, 217 N.W.2d at 233-34.

         T.D. challenges the manner in which the district court instructed the jury on his specific claims of negligence. Regarding Dr. Widmer, T.D. proposed the following instruction with six subparts:

Dr. Widmer was negligent by failing to meet the standard of care in the following way: a. Repeatedly directing [mother] to push after shoulder dystocia was identified and traction failed to deliver the stuck shoulder; or
b. Applying improper traction to [T.D.]'s head or neck during the delivery;
c. Failing to properly and effectively supervise, direct, or coordinate the efforts of the delivery team;
d. Mistakenly concluding that [T.D.] was experiencing bradycardia and as a result, delivering [T.D.] hastily and without due care;
e. Failing to follow the HCHC policy on Shoulder Dystocia, or Vacuum Extraction, or Pitocin;
f. Failing to properly and effectively use maternal and fetal maneuvers to safely deliver [T.D.] after shoulder dystocia occurred, including, but not limited to: McRoberts maneuver, suprapubic pressure, Wood's screw, reverse Wood['s] screw (Rubin's), delivering the posterior arm, and Gaskin's maneuver;

         The district court whittled down T.D.'s proposed specifications about Dr. Widmer and instructed the jury on the following specifications of negligence:

         Dr. Widmer was negligent by failing to meet the standard of care in one or more of the following ways:

(a) in failing to direct or coordinate proper maneuvers to deliver the baby after the recognition of shoulder dystocia;
(b) by applying excessive or improper traction in an effort to deliver him after the recognition of shoulder dystocia;

         Regarding the nurses, T.D. proposed the following instruction with five subparts:

Either nurse or both Rebecca Fraise, R.N. and Yvonne Sloan, R.N. were negligent by failing to meet the standard of care in the following way:
a. Repeatedly directing [mother] to push after shoulder dystocia was identified and traction failed to deliver the stuck shoulder;
b. Failing to follow the HCHC policy on Shoulder Dystocia or Pitocin;
c. Failing to properly and effectively perform the McRoberts maneuver and suprapubic pressure, to safely deliver [T.D.] ...

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