Smith v. Andrews

• Citation: 959 A.2d 597,289 Conn. 61
• Decision Date: 21 October 2008
• Docket Number: No. 17745.,17745.
• Court: Supreme Court of Connecticut
• Parties: Michael SMITH et al. v. Raymond ANDREWS et al.

959 A.2d 597

289 Conn. 61

Michael SMITH et al. v. Raymond ANDREWS et al.

No. 17745.

Supreme Court of Connecticut.

Argued February 6, 2008.

Decided October 21, 2008.

Steven D. Ecker, with whom, on the brief, were James T. Cowdery, Hartford, Russell Berkowitz and Danielle DiBerardini-Albrecht, Stamford, for the appellants (plaintiffs).

James B. Rosenblum, with whom was James Newfield, for the appellees (named defendant et al.).

KATZ, PALMER, VERTEFEUILLE, ZARELLA and SCHALLER, Js.

SCHALLER, J.

In this medical malpractice action, the named plaintiff, Michael Smith,¹ appeals from the trial court's judgment,² rendered after a jury verdict in favor of the defendants, Raymond Andrews, an anesthesiologist, and Medical Anesthesiology Associates, P.C. (Medical Anesthesiology).³ The plaintiff claims that: (1) the trial court improperly admitted evidence of a local standard of care with respect to the method of intubation performed on the plaintiff prior to surgery; (2) the trial court improperly permitted defense counsel to ask a prejudicial and confusing hypothetical question as to the standard of care that misled the jury; (3) defense counsel engaged in various improprieties during trial; and (4) the trial court improperly awarded various trial costs to the defendants. We affirm the judgment of the trial court as to the first three issues; we affirm in part and reverse in part the judgment of the trial court awarding costs to the defendants.

The jury reasonably could have found the following facts. On August 6, 2001, the plaintiff underwent disk surgery to alleviate neck injuries related to a slip and fall incident. Abraham Mintz and Gerard Girasole, orthopedic surgeons, performed the surgery at St. Vincent's Hospital (St Vincent's) in Bridgeport.⁴ Prior to surgery, Andrews and Alana Rotondi,⁵ a nurse anesthetist, intubated the plaintiff utilizing a standard endotracheal intubation by laryngoscopy.⁶ During the surgical process, the plaintiff suffered a severe spinal cord injury. Despite subsequent surgeries, the plaintiff is a paraplegic.

The plaintiff instituted the present action alleging that his injuries were caused by the negligence of the defendants. The controversy centers on whether the method of endotracheal intubation used by the defendants complied with the applicable national standard of care used to anesthetize a patient in the plaintiff's condition or whether the standard of care required the defendants to use an awake fiber-optic intubation method. The primary factual issue at trial revolved around the plaintiff's condition—that is whether there was a medical distinction between a patient with "instability" in his spine and a patient with an "unstable" spine. During trial, each side offered conflicting expert testimony regarding the plaintiff's condition and the corresponding standard of care.

At the close of evidence, the trial court charged the jury that the applicable standard of care to determine whether the defendants were liable is a national standard of care.⁷ After three days of deliberation, the jury returned a verdict for the defendants. In its answer to an interrogatory, the jury indicated that it found that the defendants did not breach the standard of care. Subsequently, the plaintiff filed a motion to set aside the verdict and for a new trial, which the trial court denied. This appeal followed.

I

We first address the plaintiff's claim that the trial court improperly admitted evidence of a local standard of care for anesthesiologists regarding the methods of intubation practiced at St. Vincent's. The plaintiff argues that such evidence is irrelevant because the law requires the defendants' conduct to be evaluated in terms of a national standard of care. We conclude that the evidence establishing the standard of care at St. Vincent's was relevant to support the defendants' contention that the use of standard endotracheal intubation complied with the applicable national standard of care for a patient in the plaintiff's condition. The trial court properly admitted the evidence.

The following additional facts and procedural history are necessary for our resolution of this claim. In their evaluation of the plaintiff's preoperative condition, the treating surgeons, Mintz and Girasole, diagnosed the plaintiff as having "instability" in his spine.⁸ As noted, prior to surgery, the defendants intubated the plaintiff utilizing standard endotracheal intubation.

To avoid confusion, we start out by simplifying the parties' claims. The plaintiff argues that the terms "instability" and "unstable" are synonymous—both mean that the spine is unstable—and that the standard of care for a patient with an unstable spine requires fiber-optic intubation. The defendants agree that the standard of care for a patient with an unstable spine requires fiber-optic intubation.⁹ The defendants dispute however, that the plaintiff's spine was unstable. Instead, the defendants contend that instability is medically distinguishable from unstable.¹⁰ Therefore, the defendants argue, the standard of care for a patient with cervical instability permits endotracheal intubation.¹¹ Despite the apparent congruence of instability and unstable, both Mintz and Girasole¹² testified that these terms represent two different degrees of injury—that is, an unstable spine is an acute, more serious condition such as a traumatic injury, whereas a spine with instability is a chronic, less serious condition in which the spine is basically stable. The record reveals no instance in which the plaintiff disputed that the standard of care for a patient with a stable spine permits endotracheal intubation.

The plaintiff contends that no medical distinction exists between an unstable spine and a spine with instability. According to the plaintiff, therefore, fiber-optic intubation was the only relevant standard of care. Roger Kaye, a neurosurgeon who testified as an expert for the plaintiff, stated that the defendants were "trying to draw a distinction between [two] words where [he found] no distinction." Similarly, Floyd Heller, the plaintiff's anesthesiology expert, testified that the two terms represented the same condition. In fact, only the witnesses affiliated with St. Vincent's distinguished between the terms instability and unstable in their practice.

We begin our analysis with the standard of review. The trial court's ruling is governed by an abuse of discretion standard. "The trial court's ruling on the admissibility of evidence is entitled to great deference.... [T]he trial court has broad discretion in ruling on the admissibility ... of evidence ... [and its] ruling on evidentiary matters will be overturned only upon a showing of a clear abuse of the court's discretion.... We will make every reasonable presumption in favor of upholding the trial court's ruling, and only upset it for a manifest abuse of discretion." (Internal quotation marks omitted.) Jacobs v. General Electric Co., 275 Conn. 395, 406, 880 A.2d 151(2005). Furthermore, "[b]efore a party is entitled to a new trial because of an erroneous evidentiary ruling, he or she has the burden of demonstrating that the error was harmful.... The harmless error standard in a civil case is whether the improper ruling would likely affect the result.... When judging the likely effect of such a trial court ruling, the reviewing court is constrained to make its determination on the basis of the printed record before it.... In the absence of a showing that the [excluded] evidence would have affected the final result, its [included] is harmless." (Internal quotation marks omitted.) Desrosiers v. Henne, 283 Conn. 361, 366, 926 A.2d 1024 (2007).

General Statutes § 52-184c(a) governs the standard of care for liability in medical malpractice cases.¹³ In Logan v. Greenwich Hospital Association, 191 Conn. 282, 301, 465 A.2d 294 (1983), we considered whether the standard of care should be limited geographically and concluded that the historical distinction between a statewide and national standard of care was no longer warranted because "[u]nder contemporary conditions there is little reason to retain this vestige of former times when there was a substantial basis for believing that the rural doctor should not be held to the standards of the urban doctor, since the latter had greater access to new theories and had more opportunity to refine his method of practice.... We are not aware of any differences in the educational background and training of physicians practicing in Connecticut compared with those in other states. Medical literature of significance is normally disseminated throughout this country and not confined to a particular state." (Citation omitted; internal quotation marks omitted.) Id., at 301-302, 465 A.2d 294. In malpractice cases, "[t]he requirement of expert testimony ... serves to assist lay people, such as members of the jury and the presiding judge, to understand the applicable [national] standard of care and to evaluate the defendant's actions in light of that standard." (Internal quotation marks omitted.) Grayson v. Wofsey, Rosen, Kweskin & Kuriansky, 231 Conn. 168, 188-89, 646 A.2d 195 (1994). In light of Logan, we conclude that expert testimony establishing a standard of care at a particular hospital is relevant only if it comports with an accepted, applicable national standard of care.¹⁴ See Baxter v. Cardiology Associates of New Haven, 46 Conn.App. 377, 390-91, 699 A.2d 271 (affirming trial court's exclusion, on relevancy grounds, of evidence related to procedures followed by hospital personnel for obtaining blood, and stating that evidence "would be relevant only if it was later supported by expert testimony that a cardiologist would rely on a resident to order blood on an expeditious basis"), cert. denied, 243 Conn. 933, 702 A.2d 640 (1997); Koontz v. Ferber, 870 S.W.2d 885, 892 (Mo.App.1993) ("[hospital] rules and regulations are not admissible to establish...