News: An appeals court rejected a bid from a hospital to overturn a $3.2 million verdict after jurors ruled a staff nurse negligently tore a man’s rectum while administering enemas. The defendant hospital argued the plaintiff failed to prove when and how the perforation occurred.
In January 2014, a man in his early 70s went to the hospital with complaints of diarrhea and vomiting. The patient was later discharged with a prescription for enemas to be administered at home; however, the patient returned to the hospital days later after unsuccessful attempts to administer treatment.
While in the hospital, two nurses administered three enemas over three days. On the fourth day, the patient was rushed to surgery when doctors discovered a massive rectal bleed. Surgeons performed an ileostomy, but the patient developed a necrotizing infection that required multiple medical procedures.
The patient and his wife filed a malpractice lawsuit against the hospital. They were awarded a verdict of more than $3.2 million. The court denied the defendant’s motion for a judgment notwithstanding the jury’s ruling.
On appeal, the hospital argued the patient did not produce enough evidence showing the enema caused the perforation. The tip of the enema was 4.375 cm. The average length of the anal canal is 3.5 to 5 cm. If the patient was on the higher end of the range, the enema could not have reached deep enough to cause the damage.
The appeals court rejected the hospital’s argument, contending the plaintiff’s expert only needed to show the perforation was reasonably probable, not determine past any shadow of a doubt the enema caused the damage.
Background: In January 2014, an elderly patient presented to the hospital with complaints of diarrhea and vomiting. The hospital admitted the man for treatment. A colonoscopy showed the patient’s rectum was “largely intact.” The patient was discharged and prescribed enemas for his wife to administer at home. Several days later, the patient was readmitted after experiencing fainting and dehydration. The patient’s wife could not administer the enemas due to the patient’s irritation and pain. Two nurses administered three enemas to the patient over three days.
On the fourth day, the patient was rushed to the ICU after physicians discovered massive rectal bleeding. During surgery, the surgeon discovered an internal hemorrhoid and a 2 cm tear in the rectum. The surgeon performed an ileostomy to divert feces from the tear. However, the patient developed sepsis and required many medical procedures.
The patient and his wife filed a malpractice lawsuit against the hospital, alleging the perforation was caused by the nurses who administered the enemas. The plaintiffs argued the hospital was vicariously liable for the nurses’ negligence. The defendants claimed the plaintiffs did not produce sufficient evidence to show when the perforation occurred or whether the enema tip was long enough to cause the perforation.
The jury ruled in favor of the plaintiffs, awarding $3.2 million for past and future economic damages and loss of consortium. The defendants appealed, contending the plaintiffs did not show affirmative evidence that either nurse negligently caused the perforation. The hospital also contended the differential diagnosis method the plaintiffs’ expert witness used to form his opinion was improper.
The appeals court upheld the trial court’s decision. The appellate judges found that differential diagnosis has been considered a proper methodology for expert opinions. Judges also ruled the defendant failed to cite any authority for its argument the plaintiffs needed to provide specific evidence of the patient’s actual anatomical measurements. The court believed the argument imposed an unjust requirement on expert testimony and evidence beyond that which is necessary.
The court also addressed the fact there was no perforation in the patient’s rectum in January 2014, and that nothing had been inserted in his anus after his wife’s initial attempt at administering the enema. In addition, both nurses testified the plaintiff was the first and only person to whom they had administered this specific type of enema.
The panel noted the trial court correctly found the hospital’s proposed instruction, which asked jurors to indicate whether the plaintiffs had specifically proved the nurses had caused the tear, went against the jury instructions upon which both parties had agreed.
The appeals court upheld the trial court’s denial of the defendant’s motion for judgment notwithstanding the verdict. The court determined the issue was subject to review. They concluded the plaintiffs met their burden of producing sufficient evidence for the jury to find the enema was physically capable of causing the perforation, as the expert testified the enema was of sufficient size to insert into the rectum and the tip could possibly cause the perforation.
What this means to you: The main issue in this appeal is whether the plaintiff presented sufficient evidence to support a medical malpractice claim. To prevail in a malpractice action, the plaintiff must prove the standard of care, a deviation from that standard of care, and a causal connection between the deviation and the claimed injury.
It is important to note that directed verdicts typically are not favored, and a trial court should direct a verdict only when a jury could not reasonably and legally have reached any other conclusion. In reviewing a motion for a directed verdict, the court must consider the evidence in the light most favorable to the plaintiff. A directed verdict is justified if the evidence is so weak that it would be proper for the court to set aside a verdict rendered for the other party.
Generally, expert testimony is required to establish both the standard of care to which the defendant is held and the breach of that standard. Expert medical opinion usually is required to show the causation of an injury or disease. Usually, the infliction of injuries is not common knowledge to a layperson. However, the mere fact an injury followed a medical procedure is insufficient to establish negligence. Causation is an important element.
The defendant’s appeal focused on causation. All medical malpractice claims, whether involving acts or inactions of a defendant, require a defendant’s conduct to proximately cause the plaintiff’s injuries. The question is whether the defendant’s conduct was a substantial factor in causing the plaintiff’s injury. This causal connection must be more than conjecture. A trier is not concerned with simple possibilities but with reasonable probabilities to make the claim plausible. The causal relation between an injury and its later physical effects may be established by the direct opinion of a physician, by his or her deduction by the process of eliminating causes other than the trauma, or by his or her opinion based on a hypothetical question.
The plaintiffs bear the burden to prove an unbroken sequence of events that tied the patient’s injuries to the defendant’s negligent conduct. However, it is important to note plaintiffs are not required to disprove all other possible theories for the accident, but simply demonstrate it is more than likely the defendant’s negligence caused the accident.
An expert opinion does not need to address the precise language of causation. A conclusion must be more likely than not to be considered reasonably probable. However, whether an expert’s testimony is expressed in terms of a reasonable probability that an event has occurred depends on the entire substance of the expert’s testimony — not the use a particular word or phrase. Also note that an expert is not required to use any specific words to show reasonable probability as long as it is clear his or her opinion is based on reasonable probabilities.
Two aspects of this case stand out from the risk perspective. First, neither nurse involved had administered the medication before. That means each nurse was obligated to either contact the hospital pharmacist to obtain the manufacturer’s instructions for administration, or read the instructions if sent to the patient’s unit. This brand of enema included instructions explaining how to use it without damaging the rectum. Pushing past resistance is not included in the printed instructions. The instructions state to insert gently then squeeze firmly to expel the contents. Despite what is probably the direct cause, there is the second event to consider. If the average length of the human rectum is 3.5 in to 5 in, why would the manufacturer develop a product with a tip longer than the shortest end of the range, thus putting more individuals at risk? It is important to be aware of inherently dangerous devices and procedures.
REFERENCE
- Decided Feb. 8, 2022, in the Connecticut Appellate Court, Case number AC 44241.
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