Washington Hospital Center v. Butler

• Decision Date: 29 September 1967
• Docket Number: No. 20368,20369.,20368
• Citation: 127 US App. DC 379,384 F.2d 331
• Parties: WASHINGTON HOSPITAL CENTER, Appellant, v. Robert BUTLER, Administrator of the Estate of Beatrice H. Butler, Deceased, Appellee. James E. WISSLER et al., Appellants, v. Robert BUTLER, Administrator of the Estate of Beatrice H. Butler, Deceased, Appellee.
• Court: U.S. Court of Appeals — District of Columbia Circuit

127 US App. DC 379, 384 F.2d 331 (1967)

WASHINGTON HOSPITAL CENTER, Appellant, v. Robert BUTLER, Administrator of the Estate of Beatrice H. Butler, Deceased, Appellee.

James E. WISSLER et al., Appellants, v. Robert BUTLER, Administrator of the Estate of Beatrice H. Butler, Deceased, Appellee.

Nos. 20368, 20369.

United States Court of Appeals District of Columbia Circuit.

Argued May 3, 1967.

Decided September 29, 1967.

COPYRIGHT MATERIAL OMITTED

Mr. Thomas Penfield Jackson, Washington, D. C., with whom Mr. John L. Laskey, Washington, D. C., was on the brief, for appellant in No. 20368.

Mr. Walter J. Murphy, Jr., Washington, D. C., for appellants in No. 20369.

Mr. Alfred M. Schwartz, Washington, D. C., for appellee.

Before EDGERTON, Senior Circuit Judge, and McGOWAN and ROBINSON, Circuit Judges.

SPOTTSWOOD W. ROBINSON, III, Circuit Judge:

These appeals emanate from a judgment¹ on a verdict for appellee, as administrator of the estate of his wife. Beatrice H. Butler, against appellants,² a hospital and a partnership of radiologists maintaining a laboratory in the hospital premises,³ in an action charging negligence contributing to a fall by and resulting injuries to Mrs. Butler during the course of diagnostic X-irradiation in the laboratory shortly before her death,⁴

Mrs. Butler, who had been receiving treatment from her personal physician for diabetes, became a patient in the hospital on March 23, 1962. The physician's admission note, entered on her hospital chart the following day, recited that she had experienced "recent weakness, dizziness, and near-syncopal episodes for about 8 days." The physician ordered certain diagnostic tests, including an intravenous pyelogram — an X-ray examination of the kidneys during retention of a dye substance previously injected into the blood stream.

The hospital's arrangements for the pyelogram included a requisition prepared by a nurse. The requisition form contained space for a summary of the patient's history, information the form characterized as "very essential." In that space the nurse wrote "diabetes with complications" or "diabetic complications," omitting further reference to the symptoms recorded on the chart.⁵

On March 26, Mrs. Butler was moved by wheelchair to the radiological laboratory for the pyelogram. The requisition, but not the chart, accompanied her. She walked to a dressing room, donned a gown and walked to an X-ray table. With the assistance of a student X-ray technician, she stretched horizontally on the table, and the technician made the first picture. Shortly thereafter, a resident radiologist injected the dye substance into a vein in her arm. The technician, continuing the procedures with Mrs. Butler lying supine on the table, made a series of X-rays, the process consuming 20 to 30 minutes.

The technician then requested Mrs. Butler to slide toward the bottom end of the table and rest her feet on a footboard there, explaining that the table would be turned upright. Asked if she could stand, Mrs. Butler replied that she could, and the turning began. Halfway through the maneuver the technician stopped the table and again inquired whether Mrs. Butler was all right and could stand; again the response was in the affirmative.⁶ The technician then completed the rotation to a vertical position and, leaving Mrs. Butler standing without any sort of artificial support, went behind the radiation shield to take the next picture. At that point, Mrs. Butler toppled forward, striking her face against equipment on the floor, and fracturing her left cheekbone.

The development of the proof at trial was somewhat a departure from the more usual pattern involving the use of experts to delineate the duties owed by hospitals and radiologists to their patients and to opinionate as to whether they were honored.⁷ The mechanical steps in the pyelogram procedure, including the upright X-ray, were competently shown, as was the fact that dizziness is sometimes but not always a by-product of a diabetic condition. But neither side adduced evidence relative to the existence or efficacy of medical practice in the community regarding the kind of information inserted in radiology requisitions or the precautions taken before vertical irradiation is attempted.

Moreover, the liability issues were submitted for the jury's decision on a legal theory atypical of malpractice suits. The trial judge charged in substance that the hospital was accountable for a negligent omission from the requisition of data contained in the chart, and the radiologists for a negligent failure to protect the patient, if a proximate cause of the fall and the patient did not contribute to it. But the jury also was told that for purposes of ascertaining whether there was negligence, all parties' conduct was to be measured by what a reasonable person of ordinary prudence would have done under the same circumstances.⁸

Appellants complain that the jury should not have been authorized to assess fault by application of the test these instructions supplied. They also urge that expert testimony was necessary to establish any responsibility and any breach for which they might be charged. We disagree, and we affirm.

With but few exceptions, none relevant here, society demands that everyone under a duty to use care observe minimally a general standard. Familiarly expressed judicially, the yardstick is that degree of care which a reasonably prudent person would have exercised under the same or similar circumstances.⁹ Beyond this, the law requires those engaging in activities requiring unique knowledge and ability to give a performance commensurate with the undertaking. We have verbalized, in terms of the skill and care customary in the community, the special noncontractual standards which hospitals,¹⁰ physicians¹¹ and radiologists¹² must observe.

Thus it is that expert testimony is usually essential in medical malpractice cases.¹³ With lay jurors unlearned and inexperienced in matters of medical science and technique, there must, when the special tests are to be applied, be explanation in order that they may intelligently determine what the criterion is and whether the defendant's conduct meets it. And it goes without saying that when liability is to be gauged by special rules, juries must be properly instructed accordingly. We recognize fully these principles and the supporting considerations, and we reemphasize our adherence to them.

There are, however, occasions upon which the acts or omissions of medical professionals can be found to fall below even the standard of reasonably prudent care.¹⁴ In that event, there is no reason, certainly if the plaintiff assents,¹⁵ why the rights and liabilities of the parties cannot be adjudicated through an application of that standard to the evidence.¹⁶ Nor is there peculiar need for expert testimony on any issue the resolution of which would not extend the jury beyond the range of ordinary lay knowledge and experience. Even where the special medical standard is invoked as the touchstone of liability, "the proposition that experts alone are qualified to testify as to the manner of treatment of a patient is `sound only when soundly applied,'" and "`there must be, in the nature of things, many instances where the facts alone prove the negligence, and where it is unnecessary to have the opinions of persons skillful in the particular science to show unskillful and negligent treatment.'"¹⁷ And we have differentiated situations "where the question turns on the merits and the performance of scientific treatment," so that "the issue may not be resolved by the jury without the aid of expert opinion,"¹⁸ from "an ordinary case of negligence, where the jury is able to solve the question by applying thereto their own experiences" and "the test is: How would a reasonably prudent man have acted under the circumstances?"¹⁹

We consider the case at bar, while slightly hybrid, to be fully amenable to utilization of these principles. The testimony of experts was not indispensable to sagacious resolution of the great bulk of the factual questions, and in the few instances where it was essential it was supplied. With the technical aspects of the controversy thus elucidated, the jury's ultimate determinations could be fashioned on the basis of what in similar circumstances reasonably prudent men would have done.²⁰

The jury could have found that the hospital contributed to Mrs. Butler's tumble by failing to adequately inform the radiologists of the facts contained in its records suggesting a proneness to black out. While its nurse did insert in the requisition "diabetes with complications" or "diabetic complications", a notation the significance of which laymen would not be expected to comprehend on their own, the jury was at liberty to resort to the uncontradicted expert view expressed at trial that not all, but only some, diabetics are predisposed to loss of consciousness. Since the requisition at most communicated to the radiologists the fact that as a diabetic Mrs. Butler might or might not be so affected, while the chart contained data denoting plainly that she was, the jury could properly conclude that a reasonably prudent person would have been more specific than the hospital,²¹ and that had it been the fall might not have occurred.²²

The jury might appropriately have pursued a similar course in evaluating the conduct of the radiologists. They were on notice not only that Mrs. Butler was a diabetic but also that there were associated complications, and they should have been aware of the medical fact that some diabetics are unsteady afoot. Yet they conducted no examination of the patient on their own, and made no inquiry of the hospital or the attending physician for further information.²³ And there was testimony, given by experts, that anyone — even a normal person, and less dubitably a sick person — might become dizzy on rotation from a supine to an upright position. The jury was...