Wright v. W. Kent Barr

• Decision Date: 23 October 2001
• Docket Number: WD59067
• Citation: 62 S.W.3d 509
• Parties: Virginia Wright and John Wright, Respondents, v. W. Kent Barr, M.D., and Northland Cardiology, P.C., Appellants.
• Court: Missouri Court of Appeals

62 S.W.3d 509

VIRGINIA WRIGHT AND JOHN WRIGHT, Respondents vs W. KENT BARR, M.D., AND NORTHLAND CARDIOLOGY, P.C., Appellants.

WD 59067

COURT OF APPEALS OF MISSOURI, WESTERN DISTRICT

October 23, 2001, Filed

Rehearing Denied December 4, 2001.

APPEAL FROM THE CIRCUIT COURT OF CLAY COUNTY. The Honorable David W. Russell, Judge.

Norman I. Reichel, Jr., Esq., Overland Park, KS for appellants.

James M. Crabtree, Esq., Lenexa, KS for respondents.

Before Thomas H. Newton, P.J., Harold L. Lowenstein, J. and James M. Smart, Jr., J. Thomas H. Newton, Judge, Harold L. Lowenstein, Judge, and James M. Smart, Jr., Judge, concur.

Thomas H. Newton

W. Kent Barr, M.D., and Northland Cardiology, P.C. ("appellants") appeal a jury verdict in favor of Mrs. Virginia Wright and Mr. John Wright ("respondents"). Respondents' petition contained two counts. The first count alleged negligent treatment of Mrs. Wright's atrial fibrillation, which caused her to suffer a stroke, and the second count was a loss of consortium claim brought by Mr. Wright. Appellants were found negligent in failing to have an echocardiogram performed prior to administering an electrocardioversion and in failing to provide anticoagulant medications to ensure that clotting did not exist in Mrs. Wright's heart when electrocardioversion was performed.

Appellants raise six points on appeal. In Point I, they claim that the trial court erred in denying appellants' motion for directed verdict at the completion of respondents' evidence because respondents failed to prove causation and, thus, did not make a submissible case. Next, Points II and III assert that the trial court erred in giving Instruction No. 5, respondents' verdict director, because there was not substantial evidence to support the instruction. In Point IV, appellants argue that the trial court erred in allowing respondents' counsel to engage in numerous improper arguments to the jury. Appellants' fifth point asserts that the trial court erred in allowing the jury to award damages based on an exhibit prepared by respondents' expert because respondents' exhibit was based on matters not in evidence. Finally, appellants urge in their sixth point that the trial court erred in failing to conform the judgment pursuant to § 538.210, which places a cap on noneconomic damages.

We affirm.

Background

In 1991, Virginia Wright suffered a heart attack, which typically occurs when a blood clot severely or totally blocks one of the coronary arteries that supplies blood to the heart muscle. "Thrombolytics," or clot busters, are the only medications currently available that can destroy an existing blood clot, and their use is reserved for the most extreme cases in which a clot is seriously obstructing blood flow to an area of the body, such as with a heart attack, stroke, or pulmonary embolism. To treat the heart attack, Mrs. Wright was given the clot buster "tissue plasminogen activator" ("t-PA"), and she subsequently developed damage to her kidneys. It was unclear whether the damage was caused by a blood clot going to her kidney, or if she had hemorrhaged.

In 1996, Mrs. Wright suffered a stroke. She had suffered from "atrial fibrillation" for many years. Atrial fibrillation is a very common type of "arrhythmia," which is an irregular heartbeat resulting from any change, deviation, or malfunction in the heart's electrical system. Atrial fibrillation got its name because the atria, the heart's upper chambers, quiver instead of contracting normally, resulting in an abnormally fast and highly irregular heartbeat.

Northland Cardiology is a general cardiology practice. The doctors there treat most cardiovascular problems, such as hypertension, congestive heart failure, and arrhythmias. They take care of patients with coronary artery disease and heart attack patients, and they recommend surgeries, procedures, and medications. In addition to atrial fibrillation, Mrs. Wright also suffered from hypertension and diabetes. With her heart problems, Mrs. Wright first became involved with Northland Cardiology by seeing Dr. James Ernest, who retired from the group in 1990. From 1990 through 1996, Mrs. Wright was seen at the Northland Cardiology office several times, and she was also seen at Trinity Lutheran Hospital by doctors from Northland Cardiology on at least two occasions. Dr. W. Kent Barr first became involved with Mrs. Wright's care in 1994 when he performed a stress test on her.

To treat atrial fibrillation, oral calcium channel blockers ("CCBs"), such as cardizem or verapamil, may be used to slow the heart rate. If necessary, a doctor may treat a patient in atrial fibrillation by using paddles to apply an electric shock to the patient and convert the patient's heart rhythm from atrial fibrillation to a normal rhythm, called sinus rhythm. This manner of restoring sinus rhythm is called "electrocardioversion" ("cardioversion"). 1 Prior to her heart attack in 1991, Mrs. Wright had cardioversion performed by a doctor at the VA Hospital in Leavenworth, Kansas. She was given the CCB verapamil, which, according to the attending physician, caused her heart to stop. The doctor performed cardioversion to restart her heart, and she was then transferred to KU Medical Center, where she remained for approximately ten days.

Atrial fibrillation is a powerful risk factor for stroke, making people with atrial fibrillation six times more likely to have a stroke than people without. Because the atria are quivering instead of contracting, the blood flow through the heart slows when a person is in atrial fibrillation. When blood starts pooling in the atria ("stasis"), there is a pronounced risk of blood clots forming. There are two situations in which the blood clots can cause serious problems. First, the clots can be dangerous if they are large enough to block a blood vessel where they have formed ("thrombus"). Second, if either a whole clot or pieces of the clot break off, the clot may travel through the bloodstream and block a blood vessel in another part of the body ("embolism"). Either scenario can result in a heart attack or stroke.

Most strokes are caused by a lack of or restricted blood flow to the brain (an "ischemic stroke"), as opposed to by bleeding within or around the brain (a "hemorrhagic stroke"). An ischemic stroke results when brain does not get enough oxygen-rich blood, usually due to a blood clot that is blocking an artery leading to the brain. The blood clot may have formed in an artery, causing a thrombotic stroke. Alternatively, a blood clot may have lodged in the artery after traveling through the bloodstream from another part of the body, which could cause an embolic stroke. A number of embolic strokes are a complication of stasis in the atria in people who have arrhythmias such as atrial fibrillation. In addition to atrial fibrillation, other risk factors for stroke include hypertension, diabetes, and bleeding disorders. These risk factors were present in Mrs. Wright.

On November 5, 1996, Mrs. Wright went to the emergency room at Liberty Hospital in Liberty, Missouri. Dr. Barr noted that she had a long-standing history of paroxysmal atrial fibrillation, or atrial fibrillation that came and went, and an electrocardiogram confirmed that she was in the irregular rhythm of atrial fibrillation. Dr. Barr placed Mrs. Wright on cardizem to slow her heart rate. Because the risk of stroke associated with atrial fibrillation may be reduced through the use of "anticoagulants" by preventing new blood clots from forming and keeping existing clots from growing larger, Dr. Barr also placed her on intravenous "heparin" with the intention of admitting her to the hospital. Warfarin, sold under the brand name "Coumadin," is the oral anticoagulant most frequently prescribed in cases of atrial fibrillation. While Coumadin takes several days to stop clots from forming, another type of anticoagulant, heparin, stops clotting almost immediately but only lasts for several hours. In addition, Mrs. Wright had already been taking aspirin regularly prior to that day. Aspirin is the most commonly used "antiplatelet." Antiplatelets are a type of anticoagulant that help prevent the formation of blood clots by reducing platelet viscosity and keeping platelets from binding together. Platelets are the body's natural blood-clotters. Dr. Barr recommended continuing her on aspirin due to her past history of problems with Coumadin. On two occasions prior to November 1996, Mrs. Wright suffered from retinal hemorrhaging, or bleeding in the eye, associated with some vision impairment, and, as such, she discontinued using Coumadin. Dr. Barr was also aware of the effect that t-PA had on her kidneys in 1991. Thus, given her history, he felt that the risk of a hemorrhagic stroke outweighed any reduced risk of ischemic stroke by placing her on Coumadin. Consequently, intravenous heparin and aspirin were utilized instead of Coumadin.

Aspirin therapy may be used to effectively prevent many types of strokes. In fact, one study showed the risk of stroke was reduced from 6.3% per year in the placebo group to 3.6% per year for patients on aspirin, whereas the same study indicated a risk reduction from 7.4% per year in the placebo group to 2.3% in patients treated with warfarin. However, anticoagulation with warfarin has been found to be much more effective at reducing the risk of stroke in atrial fibrillation patients. Although aspirin is safer and easier to use that warfarin, aspirin is a poor alternative to anticoagulation with warfarin in atrial fibrillation patients.

Dr. Barr's partner at Northland Cardiology, Dr. Freund, took over Mrs. Wright's care the following day. After 36 hours in the hospital, her heart rate did not return to normal on its own. Guidelines published by the American College of Chest Physicians strongly recommend that oral anticoagulants, such as warfarin or Coumadin, be given for three weeks before elective cardioversion in patients who have...