Appeal from the Superior Court of the District of Columbia (CA-3421-01) (Hon. Frederick H. Weisberg, Trial Judge).
The opinion of the court was delivered by: Blackburne-rigsby, Associate Judge
Before GLICKMAN and BLACKBURNE-RIGSBY, Associate Judges, and SCHWELB, Senior Judge.
Appellant, Dr. Ngozika J. Nwaneri, seeks reversal of the trial court's denial of a Motion for Judgment as a Matter of Law, or in the alternative, for a new trial. Appellant contends that Dr. Steven P. Woratyla, appellee's expert, failed to provide a sufficient foundational basis for his knowledge of the national standard of care in performing below-the-knee surgery on claudicant patients,*fn1 or to provide a basis for his expert opinion that appellant deviated from the national standard of care. Contrary to appellee's assertions, Dr. Woratyla's expertise in the field of vascular surgery, standing alone, without specific testimony or evidence in the record establishing the basis for his knowledge of the national standard of care for claudicant patients, was insufficient to lay the proper evidentiary foundation to allow Dr. Woratyla to give expert opinion testimony that appellant deviated from the standard of care.
While we recognize that this is a close case, we are constrained to hold that the trial court erred in denying appellant's Motion for Judgment as a Matter of Law. Appellee failed to establish that his expert witness had knowledge of, or that his testimony was grounded in, a national standard of care regarding treatment of claudicant patients -- a prerequisite for medical malpractice actions brought in this jurisdiction. However, because we find that appellee's trial counsel may have reasonably concluded that he did not need to go further in providing a sufficient basis for his opinion when the trial court overruled appellant's foundational objections, we remand to the trial court for a new trial.
I. Factual and Procedural Background
Mr. Sandidge, filed a medical malpractice and informed consent claim against appellant, Dr. Nwaneri, in the District of Columbia Superior Court on May 4, 2001. Mr. Sandidge alleged in his Complaint that Dr. Nwaneri breached the applicable standard of care in performing the surgery, causing Mr. Sandidge to suffer injuries and require additional surgeries on his right knee. He also alleged that Dr. Nwaneri failed to obtain his informed consent in performing composite graft knee surgery.
A jury trial commenced and Mr. Sandidge's sole expert witness, Dr. Woratyla, purported to testify as to the national standard of care applicable to composite graft surgery of the type that was performed on Mr. Sandidge by Dr. Nwaneri. The jury returned a verdict in Mr. Sandidge's favor on his medical malpractice claim and awarded damages in the amount of $300,000.00, but rejected his informed consent claim. Dr. Nwaneri thereafter moved for Judgment as a Matter of Law, or in the alternative, for a new trial, contending that the verdict should have been set aside and judgment entered in his favor because Dr. Woratyla failed to provide any basis for his knowledge of, or opinions as to, the national standard of care for performing composite graft knee surgery on claudicant patients. The trial court disagreed and denied Dr. Nwaneri's motion, finding that it was "without merit" and that, "in context," it was clear that Dr. Woratyla's national standard of care testimony was based on his education, training, and experience in the field of vascular surgery.
The pertinent facts revealed at trial are as follows. Dr. Nwaneri provided medical care to Mr. Sandidge, who was sixty-four years old at the time, between April 1998 and September 1998 in the District of Columbia. During the time that Mr. Sandidge was under Dr. Nwaneri's care, he suffered from pain in both legs as he walked, caused by a condition known as claudication, or inflammation in the veins. When Mr. Sandidge was first treated by Dr. Nwaneri, his condition was more serious in his right leg than in his left leg, but Mr. Sandidge was not in imminent danger of losing a limb.
On May 6, 1998, Mr. Sandidge was admitted to Greater Southeast Community Hospital ("Greater Southeast") in Washington, D.C., where Dr. Nwaneri performed surgery to alleviate blocked blood vessels above and below his right knee -- which was the source of the inflammation in Mr. Sandidge's right leg. This surgery entailed an arterial bypass above Mr. Sandidge's right knee using synthetic graft material, and a second bypass below his knee using a composite graft, which is part vein and part synthetic. Following surgery, Mr. Sandidge developed thrombophlebitis (inflammation of a vein that occurs when a blood clot forms) in his right leg, along with swelling, pain, and draining from the wound in his right knee. As a result of these complications, Mr. Sandidge was re-admitted to Greater Southeast on May 19, 1998.
Mr. Sandidge was admitted to Greater Southeast a third time on June 22, 1998, after complaining of complications. On June 23, 1998, Dr. Nwaneri performed a second surgery to replace the composite grafts below Mr. Sandidge's right knee in an effort to relieve a blood clot that had formed since Mr. Sandidge's first surgery. On July 1, 1998, just one week after Dr. Nwaneri performed the second graft surgery, Mr. Sandidge was taken back to the operating room at Greater Southeast for a third surgery after developing a hematoma in his right leg (a painful collection of clotted blood in a localized area of the body, usually a muscle). Mr. Sandidge was discharged from the hospital on July 18, 1998, after having had a total of three knee surgeries performed by Dr. Nwaneri.
Dr. Woratyla's Trial Testimony
Mr. Sandidge relied solely upon the expert testimony of Dr. Woratyla, a board-certified general and vascular surgeon, to establish that Dr. Nwaneri breached the national standard of care in performing aggressive composite graft surgery on his knee when less invasive options were available.
In October 1998, after undergoing three surgeries on his right knee, Mr. Sandidge was still experiencing intense pain, swelling, and acute distress in his right leg. As a result, Mr. Sandidge sought treatment in the emergency room at the Malcolm Grow Medical Center located on Andrews Air Force Base in Maryland. It was at this time that Mr. Sandidge became a patient of Dr. Woratyla, who was then on staff as a vascular surgeon. Mr. Sandidge was suffering from an infection on the inside of his right leg, in addition to the pain, numbness, and swelling he had been experiencing. As a result of these continued complications in his right leg, Dr. Woratyla performed a right leg bypass surgery on Mr. Sandidge to relieve his pain and swelling on October 5, 1998, and later performed two additional surgeries to alleviate subsequent complications. According to Dr. Woratyla, at the time that he performed bypass surgery on Mr. Sandidge, his condition had progressed to "limb threatening"*fn2 because if the right leg bypass operation was to fail, Mr. Sandidge would lose his leg. Dr. Woratyla testified that "if through some happenstance this graft [became] occluded, or it's damaged in an accident, there [was] no other option . . . for Mr. Sandidge." Much of Dr. Woratyla's testimony will be discussed in detail in our analysis, which can be found in section II of this opinion.*fn3
After the jury returned a $300,000.00 verdict in favor of Mr. Sandidge on his negligence claim, Dr. Nwaneri moved for Judgment as a Matter of Law, or in the alternative, for a new trial. In his motion, Dr. Nwaneri claimed that Mr. Sandidge's "sole expert witness failed to explicitly state how he derived the national standard of care in the areas of vascular surgery about which he offered opinions."
The trial court denied Dr. Nwaneri's motion, finding that it was without merit. Specifically, the trial court determined:
Plaintiff's [Mr. Sandidge] expert was qualified as an expert in vascular surgery without objection. Every opinion offered was asked and answered in terms of what the national standard of care required and whether Defendant's conduct violated the national standard of care. This was certainly true with regard to the witnesses' testimony that a below-the-knee bypass was contraindicated for a claudicant such as Plaintiff, who was not at risk of losing his limb, and his testimony that the use of a composite graft . . . below-the-knee violated the national standard of care.
Appellant, Dr. Nwaneri, argues that Dr. Woratyla failed to identify an "independent basis" for his knowledge of a national standard of care, or his opinion testimony regarding the use of a composite graft on a claudicant who was not in imminent danger of losing a limb. According to Dr. Nwaneri, the questions asked by Mr. Sandidge's trial counsel to Dr. Woratyla simply assumed the existence of a national standard or asked Dr. Woratyla to state the standard without providing a reference point or basis for that standard. We agree.
We review a Motion for Judgment as a Matter of Law de novo. See Snyder v. George Wash. Univ., 890 A.2d 237 (D.C. 2006). "A [Motion for Judgment as a Matter of Law] is proper only if there is no evidentiary foundation, including all rational inferences from the evidence, by which a reasonable juror could find for the party opposing the motion, considering all the evidence in the light most favorable to that party." Majeska v. District of Columbia, 812 A.2d 948, 950 (D.C. 2002) (citation omitted).
In a medical malpractice action, the plaintiff carries the burden of establishing, through expert testimony, "the applicable standard of care, deviation from that standard, and a causal relationship between the deviation and the injury." Travers v. District of Columbia, 672 A.2d 566, 568 (D.C. 1996). In the District of Columbia, the applicable standard of care in a medical malpractice action is "a national standard, not just a local custom." Id. In order to establish a national standard, "the plaintiff must establish through expert testimony the course of action that a reasonably prudent doctor with the defendant's specialty would have taken under the same or similar circumstances." Strickland v. Pinder, 899 A.2d 770, 773 (D.C. 2006) (quoting Meek v. Shepard, 484 A.2d 579, 581 (D.C. 1984) (citing Morrison v. MacNamara, 407 A.2d 555, 560-65 (D.C. 1979))).
The "purpose of expert testimony is to avoid jury findings based on mere conjecture or speculation." Washington v. Washington Hosp. Ctr., 579 A.2d 177, 181 (D.C. 1990) (citations omitted). Therefore, we have consistently held that "[t]he personal opinion of the testifying expert as to what he or she would do in a particular case, without reference to a standard of care, is insufficient to prove the applicable standard of care." Strickland, supra, 899 A.2d at 770 (internal quotation marks and citations omitted). Instead, the testifying expert must establish that a particular course of treatment is followed nationally either through "reference to a published standard, [discussion] of the described course of treatment with practitioners outside the District . . . at seminars or conventions, or through presentation of relevant data." Id. (internal citations omitted) (quoting Hawes v. Chua, 769 A.2d 797, 806 (D.C. 2001)); see also Travers, supra, 672 A.2d at 568-69; Snyder, supra, 890 A.2d at 241 n.3.
A Legally Sufficient Foundation Was Not Laid for Dr. Woratyla's National Standard of Care Testimony.
In an effort to determine whether the trial judge erred in allowing Dr. Woratyla's expert testimony regarding the national standard of care in treating claudicants who are not in danger of losing a limb, a summary of our four leading cases on this issue is appropriate. We begin our analysis with Travers, where we concluded that the testimony offered by the medical expert in support of his opinion regarding treatment with aspirin after a splenectomy amounted to his personal opinion. See Travers, supra, 672 A.2d at 569. We expressed our concern that "the only evidence that the expert had been exposed to the practice of medicine outside the District was his six-month employment with the Department of Defense in 1961 as a 'civilian officer' at Fort Meade in Maryland." Id.at 569 n.2. We affirmed the trial court's grant of judgment in favor of ...