82 Hawai'i 486, Takayama v. Kaiser Foundation Hosp.

• Decision Date: 30 August 1996
• Docket Number: No. 19237,19237
• Citation: 923 P.2d 903,82 Hawaii 486
• Parties: 82 Hawai'i 486 Darlene K. TAKAYAMA, Plaintiff-Appellant, and Richard H. Takayama, Plaintiff, v. KAISER FOUNDATION HOSPITAL; Kaiser-Permanente Medical Care Program; Hawai'i Permanente Medical Group, Inc.; Kaiser Foundation Health Plan, Inc.; Bernard Robinson, M.D., Defendants-Appellees, and John Does 1-10; Jane Does 1-10; Doe Corporations 1-10; Doe Partnerships 1-10; Doe Trusts 1-10; Doe "Non-Profit" Organizations 1-10; and Roe Governmental Agencies 1-10, Defendants.
• Court: Hawaii Supreme Court

Page 903

923 P.2d 903

82 Hawai'i 486

Darlene K. TAKAYAMA, Plaintiff-Appellant and Richard H. Takayama, Plaintiff, v. KAISER FOUNDATION HOSPITAL; Kaiser-Permanente Medical Care Program; Hawai'i Permanente Medical Group, Inc. Kaiser Foundation Health Plan, Inc. Bernard Robinson, M.D. Defendants-Appellees, and John Does 1-10; Jane Does 1-10; Doe Corporations 1-10; Doe Partnerships 1-10; Doe Trusts 1-10; Doe "Non-Profit" Organizations 1-10; and Roe Governmental Agencies 1-10, Defendants.

No. 19237.

Supreme Court of Hawai'i.

Aug. 30, 1996.

Jan M. Weinberg and Roy J. Bell of Weinberg & Bell, Honolulu, for plaintiff-appellant Darlene K. Takayama.

George W. Playdon, Jr. and M. Lorena Uy of Reinwald, O'Connor, Marrack, Hoskins & Playdon, Honolulu, for defendants-appellees Kaiser Foundation Hospital, Kaiser-Permanente Medical Care Program, Hawaii Permanente Medical Group, Inc., Kaiser Foundation Health Plan, Inc. and Bernard Robinson, M.D.

Before MOON, C.J., and KLEIN, LEVINSON, NAKAYAMA and RAMIL, JJ.

MOON, Chief Justice.

Following a jury trial in this medical malpractice case, plaintiff-appellant Darlene K. Takayama appeals from the judgment entered in favor of defendants-appellees Kaiser Foundation Hospital, Kaiser-Permanente Medical Care Program, Hawai'i Permanente Medical Group, Kaiser Foundation Health Plan and Bernard Robinson, M.D. [hereinafter, collectively, Kaiser]. On appeal, Takayama argues that the trial court: (1) abused its discretion in granting Kaiser's motion in limine regarding rebuttal evidence and in refusing to permit Takayama to present certain rebuttal evidence; (2) abused its discretion in denying Takayama's motion in limine to exclude evidence or argument by Kaiser on the issue of causation of Takayama's injuries; (3) erred in denying Takayama's motion for a directed verdict on the issue of causation of Takayama's injuries; and (4) erred in denying Takayama's motion for judgment notwithstanding the verdict and/or for a new trial. For the following reasons, we affirm.

I. BACKGROUND

In 1985, at the age of thirty-eight, Takayama began experiencing recurrent headaches, increasing stiffness and pain in her neck, and difficulty swallowing. She sought medical advice and treatment at Kaiser. After being initially treated by another Kaiser physician, Takayama was treated by Meredith Olds, M.D., ¹ a Kaiser neurosurgeon. On November 25, 1985, Dr. Olds diagnosed Takayama as suffering from Diffuse Idiopathic Skeletal Hyperostosis, or DISH, a congenital condition that causes excess bone to develop on the outer surface of the spine. Dr. Olds noted that Takayama's neck was very restricted in motion and suspected that Takayama would eventually need to undergo a cervical decompression procedure.

In November 1986, Dr. Olds consulted with Dr. Robinson, the chief of the neuroscience department at Kaiser, on Takayama's case. Dr. Robinson examined Takayama and determined that, in addition to the DISH condition, Takayama was also suffering from one of the most severe cases he had seen to that date of a condition called "OPLL," or Ossified Posterior Longitudinal Ligament.

OPLL is a relatively rare disease process whereby the posterior longitudinal ligament, a normally thin, leathery structure that runs along the inside of the spinal canal, slowly "ossifies," or turns to bone, thereby occupying more space in the spinal canal and causing "stenosis," a narrowing of the spinal canal, which, in turn, may cause compression of the spinal cord.

Because of the severity of Takayama's OPLL condition, Dr. Robinson surmised that, without an operation to alleviate the spinal compression caused by the OPLL, Takayama would be at dire risk of death or severe neurologic compromise from as little as a simple slip and fall or some other minor trauma.

Taking into account Takayama's physical and medical condition and history, including diabetes mellitus, ² bipolar manic-depressive disorder, ³ high blood pressure, ⁴ and obesity, ⁵ Dr. Robinson formulated a two-stage surgical plan to treat Takayama's OPLL condition consisting of two separate surgical procedures. The first procedure, a "posterior fusion and bone graft," would strengthen and stabilize Takayama's neck by the grafting of bone tissue harvested from Takayama's rib onto Takayama's vertebrae at the C2, C3, and C4 levels. The second procedure, a series of "anterior cervical corpectomies," was to be performed several weeks after the first procedure and would involve: (1) removal of the vertebral bodies of multiple levels of Takayama's spine; (2) removal of the abnormal bone growth on the external anterior surface of the spine due to the DISH condition; (3) removal of the OPLL development inside the spinal canal; and (4) the grafting of bone harvested from Takayama's leg onto the anterior external surface of Takayama's spinal column to strengthen the spine. Dr. Robinson described the first procedure as a "staging" procedure for the second procedure and, of the two surgeries that were to be performed on Takayama, considered the first procedure to be far safer than the second.

On August 11, 1987, Takayama underwent the first procedure. After she was anesthetized, Dr. Robinson placed Takayama in a prone position on her stomach with her head secured in a Mayfield head clamp, a device that holds the head stable for surgery by the insertion of three pins through the scalp and slightly into the skull. As Dr. Robinson exposed Takayama's spinal column, John Graham, M.D., another Kaiser neurosurgeon assisting Dr. Robinson, harvested the rib bone for the graft.

Dr. Robinson prepared the C3, C4, and C5 vertebrae for the grafting procedure by "roughing up" the surface of the vertebrae with a power drill. He drilled six "laminotomies," or holes, one each on the left and right sides of Takayama's three problem vertebrae. Drs. Robinson and Graham then passed eighteen-gauge stainless steel sublaminar wires through the laminotomies and between the vertebral laminal surface and the underlying "dura," the outer protective sheeting tissue of the spinal canal, to form loops. The sublaminar wire loops were then used to secure the bone graft to the vertebrae to facilitate bone fusion and to add strength to the spine.

Dr. Robinson testified, both in his deposition and at trial, that the first procedure went well. However, in the recovery room shortly after the completion of the surgery, Dr. Robinson discovered that (1) Takayama was quadriparetic ⁶ in that she was significantly weak in all four of her limbs and (2) the Mayfield head clamp used to stabilize Takayama's head had slipped, causing a laceration on Takayama's scalp approximately a centimeter long.

After attempting to restore function to Takayama's limbs with medication, Dr. Robinson ordered Takayama back into the operating room, where she was again anesthetized. To save time, Dr. Robinson secured Takayama's head with a horseshoe clamp instead of a Mayfield head clamp. Dr. Robinson then exposed the spinal column and removed the sublaminar wires. After removal of the wires, Dr. Robinson secured the bone grafts to the spine with a flap of muscle tissue.

Takayama's condition improved after the second surgery, although she remained quadriparetic. Takayama remained hospitalized at Kaiser for the next seven months. Subsequent examination indicated that the muscle tissue flap technique, employed by Dr. Robinson in the second surgery, was successful in securing the bone grafts to Takayama's spine and that the grafts eventually fused to the vertebrae. Without the sublaminar wiring, however, the fusion process took longer.

On December 1, 1987, Takayama underwent the second half of Dr. Robinson's surgical plan. This complex and difficult procedure involved extracting a lower incisor tooth, splitting Takayama's jaw down the midline, cutting around her tongue and the base of her mouth, removing a portion of her thyroid gland, and opening the back of her throat in order to expose the uppermost portion of the spine. The entire procedure lasted more than twenty-four hours and involved four surgeons and a physician's assistant working in shifts. Takayama remained quadriparetic after the second surgery.

After complying with the requirements of Hawai'i Revised Statutes (HRS) chapter 671, Takayama filed a complaint against Kaiser in the First Circuit Court on August 6, 1991, alleging, inter alia, ⁷ medical negligence on the part of Dr. Robinson in Takayama's treatment. After discovery was completed and a series of pretrial motions were resolved, ⁸ a jury trial began on January 3, 1995.

Takayama's principal theory of medical negligence was that Dr. Robinson breached the applicable standard of care by utilizing a sublaminar wiring staging procedure on Takayama when Takayama's spinal canal was severely stenosed. As part of its case-in-chief at trial, Takayama called Henry Bohlman, M.D., a prominent orthopedic surgeon, as an expert witness. Dr. Bohlman opined that, because Takayama's OPLL condition was so severe and her spinal canal so stenosed, there was no room to insert sublaminar wiring into Takayama's spinal canal. Dr. Bohlman testified:

Q. [By Takayama's counsel] Then do you have an opinion within--to a degree of reasonable medical probability as to whether or not the insertion of sublaminal wires by Dr. Robinson in the first surgery on August 11, 1987 complied with the standard of care?

A. Yes.

Q. And what is your opinion?

A. I think that was absolutely below the standard of care based on what was obvious on the studies before the surgery.

I mean, there just was absolutely no room to put any instruments or wire of any type into the spinal canal where the spinal cord was flattened down to six millimeters. I mean, you have to realize that the normal spinal canal is usually eighteen millimeters or about three quarters of an inch, and this was only six millimeters of room with the spinal cord squished and that's only about a...