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Ruffin v. Boler
Citation: Not availableDocket: 1-06-3437 Rel
Court: Appellate Court of Illinois; June 25, 2008; Illinois; State Appellate Court
Original Court Document: View Document
The case involves Tanisha Ruffin, represented by her mother Sonya R. Sanders, suing Dr. Leo Boler, Jr. for medical malpractice related to injuries sustained during her birth. The incident occurred on July 20, 1996, when Tanisha was born at Mount Sinai Hospital, where Dr. Boler was the attending obstetrician. The birth involved shoulder dystocia, a condition where the baby's shoulder becomes lodged against the mother's pelvic bone, leading to Tanisha suffering from an injury to the brachial plexus, resulting in Erb's palsy in her left arm. The plaintiffs alleged that Dr. Boler caused the injury by using excessive lateral traction during the delivery, while Dr. Boler contended that the injury was due to the natural forces of labor. To support his defense, Dr. Boler presented expert testimony from Dr. Michele Grimm, a biomedical engineer, which was permitted after a Frye hearing. Ultimately, the jury ruled in favor of Dr. Boler. After the trial, the plaintiffs sought a new trial, arguing that Dr. Grimm's testimony should have been excluded and that Dr. Boler improperly introduced opinions from non-testifying doctors and unverified medical texts. Judge Bill Taylor, who presided over the motion for a new trial after Judge Morrissey's retirement, agreed with the plaintiffs and granted the new trial. Dr. Boler then petitioned for leave to appeal, which was granted, leading to the reversal and remand of the trial court's decision. The background provided details about the rapid labor experienced by Ms. Sanders and Dr. Boler’s practices during delivery, including the techniques used to address shoulder dystocia. Dr. Boler asserted that he adhered to the standard of care during the delivery of Tanisha by avoiding excessive lateral traction, attributing her injury to the natural forces of labor: uterine contractions and maternal pushing. In contrast, Dr. Stuart Edelberg, the plaintiff's expert, contended that Dr. Boler breached the standard of care by applying excessive lateral traction, leading to Tanisha's permanent injury. Dr. Edelberg's opinion was grounded in medical literature, which he claimed indicates that brachial plexus injuries commonly result from shoulder dystocia. During testimony, Dr. Edelberg referenced essential textbooks that did not provide instances of doctors admitting to applying excessive lateral traction. The trial court limited the jury's consideration of Dr. Edelberg's literature references to evaluating the weight of his opinions. Dr. Edelberg highlighted his expertise, noting collaborative critiques with Dr. Allen from Johns Hopkins on shoulder dystocia. On cross-examination, Dr. Edelberg was questioned about his previous letters to the editor that disagreed with articles by Drs. Sandmire and DeMott, who attributed brachial plexus injuries to natural labor forces rather than traction. The plaintiffs objected to this line of questioning, but the court allowed it, emphasizing the need for reliable authority in impeachment. Further inquiries involved Dr. Edelberg's letters that challenged other prominent opinions on the causes of brachial plexus injuries, with the court maintaining a focus on the credibility of the referenced literature. Defense counsel's approach to cross-examining Dr. Edelberg was deemed unusual, as it involved referencing letters written by the doctor that expressed disagreement with other authorities in the field, without first establishing those authorities' recognition. Plaintiffs' counsel contended that this implied Dr. Grimm, a defense expert, was an accepted authority. The plaintiffs moved for a mistrial based on perceived prejudicial testimony, but the court denied this motion, opting instead to strike the contested testimony and instructing the jury to disregard references to the letters and opinions mentioned by defense counsel. During cross-examination, Dr. Edelberg acknowledged both supportive and opposing literature regarding his view that brachial plexus injuries are traction-related. He critiqued the publication 'Precis' for containing errors yet considered it a reliable source for handling shoulder dystocia. He disagreed with specific claims in 'Precis' regarding the clarity of events leading to brachial plexus trauma but agreed with its assertion that other factors may contribute to such injuries. Similarly, while recognizing 'Williams Obstetrics' as reliable, he noted sections he disagreed with, affirming certain statements regarding the potential for brachial nerve stretching during delivery. After Dr. Edelberg's testimony concluded, the court reiterated that the matters discussed in sidebar about learned treatises were adequately addressed in subsequent cross-examination, rendering the struck testimony moot and contributing to the decision to deny the mistrial motion. Plaintiffs challenged the authority of 'Precis' and 'Williams,' and the counsel's motion for a mistrial was denied. Dr. Thomas Carver, an obstetrician/gynecologist testifying for Dr. Boler, affirmed that Dr. Boler met the standard of care regarding Tanisha's shoulder dystocia, asserting her injury was not due to excessive lateral traction as medical records did not support such a claim. Dr. Carver noted that the cause of Tanisha's injury was unknown, but maternal labor forces could lead to a brachial plexus injury prior to recognizing shoulder dystocia. Dr. Boler sought to present testimony from Dr. Michele Grimm, leading to a Frye hearing to assess the admissibility of her novel scientific evidence. Dr. Grimm, a biomedical engineer and associate professor, testified about her research, which included developing a two-dimensional mathematical model to analyze forces during childbirth. This research resulted in three publications in a peer-reviewed journal, detailing their findings on shoulder dystocia. The team created a more intricate three-dimensional model using MADYMO, a software program that applies Newton's laws of equilibrium and conservation of momentum to simulate interactions in biomedical contexts. Their studies indicated that maternal forces exert greater contact force on the infant's shoulder than physician-applied traction, with maternal forces contributing to more brachial plexus stretching. Dr. Grimm acknowledged that the model relies on standard assumptions within the biomedical community, often using surrogates in research. The MADYMO model utilized a goat's neck to replicate a fetus's neck due to difficulties in obtaining data from human fetuses, with Dr. Grimm citing its acceptance in literature as a reliable juvenile neck estimate. To assess the brachial plexus properties, she referenced rabbit tibial nerves and developed the fetus model from a crash dummy based on the 95th percentile of anthropometric measurements for nine-month-old infants. This research was recognized at Society of Maternal Fetal Medicine conferences and referenced in prominent medical publications. Dr. Grimm asserted that her model is grounded in established engineering and obstetrics methodologies, validated against existing literature regarding expected versus measured forces. Despite facing criticism from peers, the trial court deemed Dr. Grimm qualified to testify under the Frye standard, affirming her scientific methods were relevant to the case's conclusions. During her trial testimony, Dr. Grimm clarified her credentials as a Ph.D. in biomedical engineering, emphasizing her knowledge of human anatomy. She identified three forces in childbirth: internal uterine forces, maternal pushing, and physician-applied forces. Dr. Grimm concluded, with reasonable certainty, that the vacuum extractor used by Dr. Boler did not contribute to the injury of Tanisha, attributing the injury instead to maternal forces during rapid labor, which she indicated were the primary cause. The jury ruled in favor of Dr. Boler, leading to a judgment based on that verdict. Following the trial, plaintiffs sought a new trial, contending that Dr. Grimm's testimony should have been excluded and that the defense improperly referenced medical literature and textbooks not established as authoritative during the trial, with the motion heard by Judge Taylor after Judge Morrissey's retirement. Plaintiffs argued for barring Dr. Grimm from testifying due to a prior ruling by another Cook County judge in a related medical malpractice case. They characterized her as a 'mechanical engineer' whose model relied on a 'crash dummy' of a nine-year-old, claiming her methods were unreliable and not generally accepted under the Frye standard for admissibility. The trial court granted the plaintiffs' motion for a new trial, citing concerns about the inability to cross-examine medical experts and improper bolstering of testimony by the defendant's expert. On appeal, Dr. Boler contended that the trial court erred in granting the new trial, which generally is reviewed for abuse of discretion. The appellate review highlighted that Judge Taylor, succeeding Judge Morrissey, relied on trial transcripts to assess the alleged errors, concluding that the Frye analysis and the impeachment of Dr. Edelberg were improperly handled, warranting a new trial. The standard for reviewing the Frye analysis is de novo, while the impeachment issue may not fall under the abuse of discretion if it did not involve a discretionary ruling. Dr. Boler defended the admissibility of Dr. Grimm's testimony, noting that the question of a biomedical engineer's causation opinion in medical malpractice has not been previously addressed in Illinois case law. Before expert testimony can be admitted at trial, the proponent must establish three key criteria: the witness's assistance to the trier of fact, the witness's qualifications, and that the testimony is based on adequate facts, data, or opinions. Expert testimony is permissible if the expert possesses relevant qualifications and the testimony aids in understanding the evidence. For novel scientific methodologies, the proponent must demonstrate general acceptance in the scientific community, as outlined in the Frye standard. The trial court's admission of expert testimony is subject to an abuse of discretion review, whereas the Frye analysis is reviewed de novo. In this case, Dr. Boler supports the admission of Dr. Grimm's testimony, asserting her qualifications and adherence to the Frye standard. The plaintiffs argue against Dr. Grimm's ability to testify on causation, claiming that an expert in medical malpractice must be a licensed medical doctor familiar with the relevant medical practices. This "same school of medicine" rule, established in Dolan v. Galluzzo, requires experts to be licensed in the field they address regarding standard of care. However, the court finds that this rule does not apply here, as Dr. Grimm's testimony focused on causation rather than the standard of care related to Dr. Boler. The court references Greenberg v. Michael Reese Hospital to support its conclusion that the Dolan rule is not applicable in this context, as Dr. Grimm's testimony did not involve explaining a medical judgment. Dr. Grimm's testimony is focused on an independent cause defense in a medical malpractice case, where the plaintiff must prove causation to a reasonable degree of medical certainty. In such cases, medical expert testimony is required to establish the standard of care and deviations from it. While plaintiffs must demonstrate that the alleged negligence caused the injury, defendants have flexibility in how they challenge causation evidence. They are not limited to medical experts when asserting an independent cause defense. For instance, in a hypothetical scenario involving a car accident and subsequent surgery, a medical malpractice claim could be made against a surgeon, but the surgeon could argue that the injury was caused by the accident rather than negligence. In this case, the surgeon might need an expert in biomechanics, rather than a medical doctor, to support her defense regarding the cause of injury. Dr. Grimm's testimony aimed to show that the injury sustained by Tanisha resulted from a cause other than Dr. Boler's alleged negligence. Since Dr. Grimm's testimony does not address Dr. Boler's standard of care, her qualifications as a non-medical doctor do not preclude her testimony, as established in relevant case law. It is acknowledged that Tanisha suffered a brachial plexus injury during birth, and the nature of the injury is well-documented. The dispute centers on whether Dr. Boler's actions during Tanisha's delivery caused her injury by breaching the standard of care through excessive traction, or if the injury resulted from the natural forces of labor. Expert medical testimony, provided by Dr. Edelberg, supports the former theory, while Dr. Boler counters with testimony from Dr. Grimm, an expert in biomedical engineering, to support the latter theory. The plaintiffs do not contest Dr. Grimm's qualifications, which include a Ph.D. in biomedical engineering, extensive research on childbirth forces, and published work in reputable journals. Her testimony is deemed necessary due to the complexity of the forces involved in labor, which exceed common jury knowledge. Dr. Grimm's input aims to demonstrate evidence that negates causation, aligning with the Leonardi case precedent. The court, led by Judge Morrissey, determined that Dr. Grimm's expertise would aid the jury in understanding the natural forces at play during shoulder dystocia. The admissibility of her testimony was evaluated under the Frye standard, which requires that scientific evidence is generally accepted within its field. Since Dr. Grimm's methodology had not been previously established as accepted, a Frye hearing was conducted. Dr. Boler asserted that her principles are based on widely recognized theories, such as Newton's laws and the use of established engineering software (MADYMO), asserting that these methods are standard in the biomedical engineering community. Plaintiffs challenge Dr. Grimm's methodology, arguing it lacks general acceptance due to its reliance on assumptions from a computer model and animal studies, including a model fetus based on a crash dummy. They assert that Dr. Boler provides no substantial evidence, apart from Dr. Grimm's own testimony, to support the claim that biomedical engineering practices are accepted in evaluating fetal reactions during childbirth. The document references **Mitchell v. Palos Community Hospital**, where the court evaluated the admissibility of expert testimony regarding the timing of an infant's neurological injury related to placental abruption. In that case, the defendants presented Dr. Jeffery Phelan, whose method of assessing injury through nucleated red blood cells (NRBCs) was deemed generally accepted in the medical community based on his published work in prestigious journals. The court affirmed that a proponent of evidence can demonstrate general acceptance through scientific literature, prior rulings, practical applications, and expert testimony. Although the plaintiffs argue Dr. Phelan's studies are new and untested, the court noted that newness does not automatically disqualify evidence from being admissible. This principle suggests that the reliability of scientific tests can still be recognized, even if there is no absolute certainty or complete consensus among experts. Dr. Grimm's articles on labor forces and shoulder dystocia, published in the **American Journal of Obstetrics and Gynecology** since 2000, indicate her work has been in the field long enough to warrant consideration, despite being a matter of first impression in Illinois courts. Dr. Grimm's research is recognized in two medical textbooks, and the plaintiffs failed to provide direct evidence disputing her methods, focusing instead on questioning her methodology during cross-examination. Evidence from the Frye hearing supports Dr. Grimm's assertion that her model is generally accepted in the engineering and obstetric communities. The court's review of Judge Morrissey's Frye analysis is not limited to the Frye hearing evidence; it can include external legal and scientific sources. The plaintiffs pointed out that Dr. Grimm was barred from testifying in a separate Cook County case. However, Dr. Boler highlighted a federal court ruling that deemed Dr. Grimm's methods reliable and admissible in a shoulder dystocia malpractice case, applying the Daubert standard, which assesses if expert opinions are grounded in scientific knowledge and accepted in the relevant scientific community. The federal court dismissed challenges to Dr. Grimm's testimony, which mirrored those raised by the plaintiffs here, and acknowledged her acceptance and recognition within the medical and biomechanical fields. Dr. Grimm has received awards for her research on fetal brachial plexus strain and has presented internationally. Her methodologies are based on accepted scientific practices. The court affirmed that under the Frye standard, the trial court's role is to assess the general consensus regarding the reliability of a scientific technique rather than its validity. Consequently, Dr. Grimm's methodology is deemed generally accepted, validating Judge Morrissey's admission of her testimony at trial. Judge Taylor's decision to grant a new trial based on this was determined to be erroneous. Furthermore, Judge Taylor identified reversible error related to the impeachment of Dr. Edelberg during cross-examination concerning non-authoritative letters to the editor and texts. Judge Morrissey had already struck much of this contested testimony and instructed the jury accordingly. Judge Morrissey affirmed that Dr. Edelberg was appropriately cross-examined regarding relevant medical texts, specifically Precis and Williams, despite some material being previously stricken. Justice Schaefer emphasized the significance of expert testimony in achieving justice, arguing that preventing cross-examination on recognized authoritative sources only protects uninformed experts. An expert’s credibility stems from their knowledge, which is rooted in established literature rather than personal opinion. Acknowledging authoritative texts should be encouraged, even amid disagreements on specific content. Dr. Edelberg, albeit with some reluctance, recognized both Precis and Williams as authoritative in obstetrics, fulfilling the criteria for reliability necessary for expert testimony. The court found no error in the cross-examination based on these texts. Furthermore, any potential error from questioning Dr. Edelberg about letters to the editor was deemed harmless, as similar topics were adequately addressed through the cross-examination using Precis and Williams. The court reiterated that a trial court's ruling to strike remarks and instruct the jury to disregard them generally mitigates any prejudicial effects. Any errors related to the improper impeachment of Dr. Edelberg were remedied by Judge Morrissey’s actions, and no prejudice remained due to subsequent proper cross-examination. Therefore, a new trial based on these alleged errors is not justified. Judge Taylor's decision to order a retrial was an abuse of discretion. The order from the circuit court of Cook County granting a new trial is reversed, and the case is remanded with instructions to reinstate the jury's verdict for Dr. Boler. The ruling was delivered by Justice Garcia, with Judges Cahill and Wolfson concurring. The case is identified as Tanisha Ruffin, by her mother Sonya R. Sanders, and Sonya R. Sanders individually, Plaintiffs-Appellees, v. Leo Boler, Jr., Defendant-Appellant, No. 1-06-3437, Appellate Court of Illinois, First District, First Division, filed on June 25, 2008.