Aldridge v. Edmunds
| Decision Date | 01 May 2000 |
| Citation | 561 Pa. 323,750 A.2d 292 |
| Parties | Christopher K. ALDRIDGE and Anne-Marie Aldridge, Administrators of the Estate of Katheryne Elizabeth Aldridge, deceased, Appellants, v. Elizabeth H. EDMUNDS, M.D., Pierantonio Russo, M.D. and St. Christopher's Hospital for Children, Appellees. |
| Court | Pennsylvania Supreme Court |
David C. Federman, Philadelphia, for appellants C. Aldridge, et al.
Allan H. Starr, Philadelphia, Robert Toland, Orlando, FL, for appellee E. Edmunds, M.D.
Richard R. Galli, Francis J. Greek, Philadelphia, for appellee P. Russo, M.D.
Barbara S. Magen, Sheila A. Haren, Philadelphia, for appellee St. Christopher's Hosp.
Before FLAHERTY, C.J., and ZAPPALA, CAPPY, CASTILLE, NIGRO, NEWMAN and SAYLOR, JJ.
The issue presented concerns the use of authoritative texts during the course of an expert witness's direct testimony.
This medical malpractice action arises out of the death of the Appellants' infant daughter, Katheryne Aldridge ("Katheryne"), who was born on September 26, 1990, with a heart defect which remained undiagnosed until July of the following year.1 Other than her small size and weight, Katheryne exhibited no manifest symptoms at birth, but, beginning when she reached four months of age, her parents noticed, among other things, that she was experiencing restlessness and eating difficulties, and she was failing to gain weight. Katheryne also progressively developed chronic respiratory congestion. She was under the care of Appellee Dr. Elizabeth Edmunds, the Aldridges' family physician. By six months of age, Katheryne exhibited severe congestion, and her weight fell below the fifth percentile on a standardized average scale. At such time, Dr. Edmunds noted that Katheryne appeared thin and old for her age and described her symptomology as a failure to thrive. Thereafter, Dr. Edmunds pursued a course of investigation and treatment which included: blood and fluid tests; weekly weight assessments; consultation with a pediatric physician; dietary substitutions; adjustments to caloric intake; and initiation of iron replacement therapy.
On July 20, 1991, Katheryne developed pneumonia, and her parents brought her to St. Joseph's Hospital in Reading. A chest x-ray was taken and an echocardiogram performed, which showed enlargement of the heart and other irregularities. From these and other tests, medical professionals determined that Katheryne was experiencing severe cardiac and respiratory failures and first diagnosed her heart condition. Katheryne was transferred to Appellee St. Christopher's Hospital for Children (the "Hospital") for further cardiac assessment, where, on July 26, 1991, a cardiac catheterization study was performed, confirming the congenital defects. Corrective surgery was scheduled on an urgent basis, and, during this period, Katheryne underwent treatment for a rash in her vaginal area.
Appellee Dr. Pierantonio Russo performed the corrective surgery on July 30, 1991, prior to which femoral catheters were inserted to permit continuous blood pressure monitoring. Although the surgery initially appeared to have been successful, two days later, Katheryne's heart arrested. Despite efforts to resuscitate her and to sustain breathing and circulation, a neurologist found no evidence of brain cortical or subcortical function, and Katheryne was removed from life support on August 2, 1991. Several days later, in the performance of an autopsy, a pathologist found evidence of infection with a fungus known as candida albicans and issued a report indicating as a cause of death "candida albicans sepsis with septic shock."
On January 13, 1992, Appellants commenced the present action, alleging that Dr. Edmunds negligently misdiagnosed Katheryne's condition, that Dr. Russo, the Hospital and others negligently performed surgical techniques,2 and that the alleged failures to provide care within accepted medical standards contributed to Katheryne's death. At trial, Appellants emphasized that Katheryne's mother was a diabetic, a risk factor relative to congenital defects in offspring, and that despite such risk and Katheryne's symptoms (including her failure to thrive and respiration problems), Dr. Edmunds failed to conduct tests which would have disclosed the heart defects and resulted in earlier treatment at substantially lower risk. Appellants also asserted that Hospital personnel inserted the pre-surgical femoral catheter into an area infected with candida albicans, thus introducing the fungus into Katheryne's system. Appellants presented several expert witnesses to support their claims of non-conformance to accepted medical standards.
Appellees maintained that appropriate care had been rendered, denied that Katheryne's death was attributable to a fungal infection, and further asserted that Katheryne had died as a result of her heart defects and known risks associated with the corrective surgical procedure. Of particular relevance to this appeal, Dr. Edmunds maintained that the care she provided was reasonable because, although it was clear in hindsight that Katheryne's failure to thrive was due to her congenital condition, the clinical picture presented at the time of treatment simply did not suggest heart disease. In support of this defense, Dr. Edmunds offered testimony from Dr. William Mebane, a pediatric and family physician, who indicated that congenital heart malformations are an uncommon cause of failure to thrive; whereas, common causes of the syndrome include dietary problems, hormonal problems and psycho/social problems, avenues of Dr. Edmunds' investigation. Over the objection of Appellants' counsel, Dr. Mebane was permitted to support his diagnosis by reference to excerpts from a textbook on pediatrics, FRANK A. OSKI ET AL., PRINCIPLES AND PRACTICE OF PEDIATRICS (J.B. Lippincott Co.1990), which were enlarged, mounted on posterboard and marked as an exhibit. The pertinent testimony from Dr. Mebane proceeded as follows:
Q. In essence, what I want to find out from you, Doctor, whether or not your statement to the Jury that there are multiple causes, some common, some uncommon, some rare for failure to thrive, is there support for that statement in standard reputable authoritative texts in pediatrics, and specifically in the Oski text, that we have referred to?
A. Yes. The Oski text, I think, gives you an overview of the multiple causes of failure to thrive and can help put the different causes into some kind of perspective.
Q. I'm going to display, so we can refer to it as necessary, and so the record is clear, what we have done is taken from the Oski text pages 2033 and 2034.
* * *
Q. Is it fair to state that the authors put together in groups first common causes for failure to thrive? A. Yes. They put together common causes.
Q. And then under common causes, I'm going to skip the area dealing with neglect, and move down to the second most listed common cause, something called non-organic failure to thrive; is that correct?
Q. And underneath none organic [sic] failure to thrive, am I correct that there are a number of sub categories that deal with issues of feeding?
Q. —but is that kind of the next highest category under failure to thrive?
A. It certainly is.
Q. The thing that is shown is uncommon causes for failure to thrive; is that correct, sir?
A. Yes, sir.
Q. And there are—it's about four or five major headings?
A. Uncommon causes of failure to thrive, yes.
Q. And then below that there are rare causes, a number of those listed?
A. That's correct.
Q. And would you tell the Members of the Jury, where on the list congenital heart disease falls and under which category in the author's text that you're referring to?
A. It falls under the group of uncommon causes, under the sub category of increased metabolism. And under that is chronic respiratory insufficiency, congenital heart disease and malignancies.
Q. It is sort of just on the page at the bottom of the uncommon cause list?
A. Yes, sir.
Dr. Mebane's testimony also referenced a second pediatric text, RICHARD E. BEHRMAN ET AL., NELSON TEXTBOOK ON PEDIATRICS (13th ed. W.B. Saunders Co.1987), which was presented to the jury in a similar manner to establish that the failure to thrive syndrome is commonly associated with underfeeding. After the excerpts were described, authenticated and marked as an exhibit, the following interchange occurred:
Q. Is it fair to state that the first sentence [from the excerpts] talks about restlessness, crying and failure to gain weight adequately?
A. Yes, sir.
Q. And a little bit further down, when it's talking about clinical manifestations of underfeeding, does it talk about constipation, failure to sleep, irritability and excessive crying?
A. It does.
Q. And a little further down in the same sentence, does it talk about the infant assuming the appearance of a, quote, old man, end quote?
A. Yes, it does.
Q. And, Doctor, those particular statements, signs and symptoms, were those ones that you observed in your review of these records as pertaining to Katheryne Aldridge at that general point?
A. Yes. This is the description in the chart.
Q. And in the area that we've been talking about as one of the causes for failure to thrive, one of the common causes, this comes under the heading of what?
A. Underfeeding and/or feeding problems.
Q. And what is it that the Nelson text set forth [sic] as the treatment to try to address that concern? And I'll refer you specifically to the second paragraph, it says what?
A. Well, the treatment consists of increasing the fluid and caloric intake, correcting deficiencies, vitamin, mineral...
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