Brandt v. Csaki

• Citation: 937 S.W.2d 268
• Decision Date: 19 November 1996
• Docket Number: No. WD,WD
• Parties: Martha BRANDT, Appellant, v. Bela CSAKI, Respondent. 51050.
• Court: Court of Appeal of Missouri (US)

Page 268

937 S.W.2d 268

Martha BRANDT, Appellant, v. Bela CSAKI, Respondent.

No. WD 51050.

Missouri Court of Appeals Western District.

Nov. 19, 1996.

Motion for Rehearing and/or Transfer to

Supreme Court Denied Dec. 24, 1996.

Application to Transfer Denied

Feb. 25, 1997.

Margaret M. O'Leary, Chicago, Illinois, Catherine A. Donnelly, Gregory W. Vleisides, Vleisides, Donnelly & O'Leary, Kansas City, for appellant.

Thomas W. Wagstaff, Gregory J. Minana, Blackwell, Sanders, Matheny, Weary & Lombardi, Kansas City, for respondent.

Before EDWIN H. SMITH, P.J., and BRECKENRIDGE and ELLIS, JJ.

BRECKENRIDGE, Judge.

Martha Brandt appeals from the trial court's judgment following a jury verdict for Dr. Bela Csaki in Ms. Brandt's medical malpractice action. Ms. Brandt claims that she suffered nerve injuries as a result of Dr. Csaki's failure to timely diagnose and treat an injury caused by a diagnostic test Dr. Csaki ordered. Ms. Brandt raises seven points on appeal. She claims that the trial court erred by (1) denying her motion for a directed verdict; (2) denying her motion for a judgment notwithstanding the verdict (JNOV) or, in the alternative, a new trial; (3) allowing her to be impeached with a prior abandoned claim against the doctor who performed the diagnostic test; (4) allowing Dr. Csaki to make adverse reference in closing argument to her failure to call her husband to testify; (5) admitting evidence of Dr. Csaki's successful treatment of the saddle embolus; (6) allowing Dr. Csaki to use an illustration; and (7) admitting Dr. Csaki's testimony concerning his nerve sheath hemorrhage theory.

Because Ms. Brandt had the burden of proof at trial, the trial court did not err in denying her motion for a directed verdict. The trial court also properly denied Ms. Brandt's JNOV or new trial motion because the jury may not have been persuaded by her evidence and, contrary to her argument, Dr. Csaki was not required to present substantial evidence in support of his defense. Further, there was no manifest injustice resulting from the trial court's admission of the evidence challenged by Ms. Brandt in her Points IV through VII. Since Ms. Brandt is not entitled to relief on any of her seven points relied on, the judgment of the trial court is affirmed.

The evidence viewed in a light most favorable to the judgment reveals that while at home, on February 9, 1990, Ms. Brandt experienced severe pain in her groin and legs, as well as numbness and tingling in her feet. Due to her condition, Ms. Brandt was admitted to the Medical Center of Independence, where Dr. Csaki examined her. Dr. Csaki diagnosed Ms. Brandt's problem as a saddle embolus, which is a blood clot located where the aorta bifurcates to become the iliac arteries that become the femoral arteries supplying the legs with blood. To confirm his diagnosis, Dr. Csaki ordered an angiogram for Ms. Brandt which was performed by Dr. Robert Schwegler.

An angiogram is a procedure where a needle is stuck into an artery to insert a catheter. Radiopaque contrast material is then pumped into the artery through the catheter to create a road map of the arteries. Any blockage is apparent in an X-ray of the arterial system. Dr. Schwegler performed the angiogram through the left axillary artery, a major artery in the upper arm near the arm pit. During the angiogram, Ms. Brandt felt a sharp pain like "an electric shock go through the top part of [her] body." Ms. Brandt was in such pain during the angiogram that Dr. Csaki was summoned to the radiology department to authorize medication for her pain.

After Dr. Schwegler performed the angiogram and confirmed Dr. Csaki's diagnosis, Dr. Csaki operated and successfully removed several small blood clots from the lower aorta in Ms. Brandt's groin. During recovery, Ms. Brandt initially had minimal bruising and swelling at the puncture site of the angiogram. On February 16, 1990, she began to experience numbness and tingling in her left arm, along with bruising and swelling down to the elbow area. At approximately 8:00 a.m. on that date, Dr. Kunz, a radiologist, examined Ms. Brandt in response to her complaints of tingling and numbness. Dr. Kunz ordered periodic measuring of her arm to see if the swelling was stable and monitoring of her complaints. He noted on her chart that he "would expect this to resolve."

On February 17, Ms. Brandt began experiencing significant pain, numbness and loss of motor functions in her hand. After being informed of this condition, Dr. Csaki ordered a Doppler ultrasound to diagnose Ms. Brandt's problems. The ultrasound revealed a small pseudoaneurysm in the artery where the angiogram had been performed. A pseudoaneurysm is a soft blood clot and is a known risk of the angiogram procedure. The pseudoaneurysm was caused by the puncture of the artery during the angiogram. Dr. Csaki determined that Ms. Brandt needed to have the pseudoaneurysm surgically removed.

The surgery could not be performed immediately, however, because Ms. Brandt was on a blood thinning medication, Coumadin. Dr. Csaki prescribed Vitamin K to reverse the blood thinner, but it took three days to take effect. Although, there were quicker methods available to reverse the effect of the blood thinner, they would have increased the risk of blood clots, which could have been life threatening. Dr. Csaki determined that these other options posed too high a risk, considering that Ms. Brandt had a bad mitral value in her heart, artrial fibrillation and, as an individual who has already had an embolus, was at an increased risk of having a recurrence. As a result, the removal of the pseudoaneurysm did not occur until February 20. Two months later, Ms. Brandt was diagnosed with permanent nerve injury to her left arm, although the extent of the injury at the time of trial was disputed.

Ms. Brandt originally brought a medical malpractice action against Dr. Schwegler, the Medical Center of Independence and Dr. Csaki for causing her nerve damage. Her first amended petition named only Dr. Csaki, however, alleging that his delay in diagnosing and removing the pseudoaneurysm negligently caused her injury.

Trial commenced on February 14, 1995. Ms. Brandt presented her theory that Dr. Csaki was negligent in failing to diagnosis and treat her when he was notified of the loss of motor function in Ms. Brandt's arm on February 17, 1990. Her expert testified that the pseudoaneurysm at the site of the angiogram compressed the nerves in her arm, and immediate relief of the pressure was imperative because the longer the nerve was compressed, the greater the likelihood of permanent injury. She claimed Dr. Csaki deviated from the standards of care of his profession by failing to diagnose an emergency situation when he was notified of the loss of motor functions, and that the delay in treatment caused permanent nerve damage.

In his defense, Dr. Csaki introduced evidence that Ms. Brandt's nerve injury was the result of a hemorrhage within the sheath covering the median nerve, which was caused when the nerve was struck during the angiogram, and was not the result of pressure on the nerve caused by the pseudoaneurysm. Dr. Csaki and his expert, Dr. Robert Williams, testified that, to a reasonable degree of medical certainty, any alleged delay in diagnosing and removing the pseudoaneurysm from Ms. Brandt's arm was not the cause of her injury. According to their testimony, Ms. Brandt's nerve had been completely and irreversibly injured by the time the angiogram was completed.

In addition, Dr. Csaki and his expert testified that he timely diagnosed the pseudoaneurysm. In their view, the symptoms originally exhibited by Ms. Brandt were consistent with normal reactions to an angiogram, and did not indicate any unusual circumstance until February 17. At that time, Dr. Csaki ordered the Doppler ultrasound, which was performed the next morning and revealed the pseudoaneurysm. Dr. Williams testified that Dr. Csaki exercised correct judgment "in not operating as an emergency, and letting her Coumadin drift down to a reasonable level where he could operate without risk of undue bleeding, knowing there was a risk to the arm, but that being overshadowed by the risk of a new blood clot that would be catastrophic."

During the trial, Ms. Brandt moved for a directed verdict, which the trial court denied. After the jury entered a verdict in favor of Dr. Csaki, Ms. Brandt filed a motion for a JNOV or, in the alternative, a new trial, arguing that the jury's verdict was against the weight of the evidence. The trial court overruled Ms. Brandt's motion and she filed a timely appeal.

In her first point on appeal, Ms. Brandt contends that the trial court erred by denying her motion for a directed verdict because the evidence established that her injury was caused by Dr. Csaki's failure to properly and timely diagnose and treat her nerve compression. She argues that any defense theory of the cause of her injury was unsupported by competent and substantial evidence.

An appeal of the denial of a motion for a directed verdict involves only questions of law. Hammer v. Waterhouse, 895 S.W.2d 95, 99 (Mo.App.1995). A directed verdict should only be granted if reasonable persons could not differ as to the outcome of the case. Id. A verdict is generally not directed in favor of the party with the burden of proof "no matter how overwhelming that party's evidence may be or how minuscule the other party's evidence may be; a directed verdict in favor of the party having the burden of proof (usually the plaintiff) is never based upon [that party's] evidence." Brandt v. Pelican, 856 S.W.2d 658, 664 (Mo. banc 1993). The rationale underlying this principle is that the party with the benefit of the burden of proof does not have to present any evidence at all, and can rely solely on the jury disbelieving the other party's evidence. Id. at 664-65.

The exception to this rule is when there are no questions...