Opinion
G044774 Super. Ct. No. 30-2009-00307004
01-04-2012
Carroll, Kelly, Trotter, Franzen & McKenna, Mark V. Franzen and David P. Pruett for Defendant and Appellant. Rinos & Martin, Dimitrios C. Rinos, Linda B. Martin, and Celeste Brustowicz for Plaintiffs and Respondents.
NOT TO BE PUBLISHED IN OFFICIAL REPORTS
California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions not certified for publication or ordered published, except as specified by rule 8.1115(b). This opinion has not been certified for publication or ordered published for purposes of rule 8.1115.
OPINION
Appeal from a judgment of the Superior Court of Orange County, Ronald L. Bauer, Judge. Affirmed.
Carroll, Kelly, Trotter, Franzen & McKenna, Mark V. Franzen and David P. Pruett for Defendant and Appellant.
Rinos & Martin, Dimitrios C. Rinos, Linda B. Martin, and Celeste Brustowicz for Plaintiffs and Respondents.
A jury determined radiologist Dr. Luke Cheung (Cheung) breached the standard of care in failing to diagnose Lois Shafer's (Lois's) brain hematoma, causing her death. On appeal, Cheung challenges the medical malpractice judgment on the sole ground there was insufficient evidence of causation. We find his contentions lack merit and affirm the judgment.
I
On February 8, 2009, at approximately 9:30 p.m., 85-year-old old Lois fell at home and suffered a head injury. Her husband brought her to Hoag Hospital emergency room (ER).
Lois reported a history of atrial fibrillation (an abnormal rhythm of the heart) that generally increases the risk of stroke and for which she took a blood thinner, Coumadin. While in the ER, Dr. Charles Goldsworthy evaluated Lois. He ordered a computed tomography (CT) scan to determine if there was any intracranial bleeding (the general medical term used for bleeding within the skull; depending on where the blood is located more specific descriptions are used).
Cheung interpreted Lois's CT scan and failed to identify a 7 mm subdural hematoma (a collection of blood on the brain's surface). Consequently, Goldsworthy discharged Lois from the ER at 10:53 p.m. with instructions to resume normal medications and sleep undisturbed. It is undisputed Goldsworthy would not have discharged an elderly patient taking Coumadin if he had been aware she had a subdural hematoma.
Lois returned home and went to bed. The parties dispute whether the evidence proves she also took her regular dosage of Coumadin before going to bed, but it is undisputed blood tests showed her blood clotting ability further decreased during the night. While Lois was asleep, the bleeding continued. The next morning, Lois's husband was unable to awaken her and called the paramedics. After she was transported back to Hoag Hospital, another CT scan revealed the presence of a 2.5 cm (25 mm) subdural hematoma. The blood was compressing Lois's brain, causing neurological damage. It had been over 12 hours since the first CT scan.
In the ER, Lois was given vitamin K and fresh frozen plasma to counteract the Coumadin, and she was rushed into surgery. However, the expansion of the hematoma had caused irreversible and severe brain damage and led to her death.
Lois's husband, Dickson Shafer, and their two adult children, Susan Shafer-Marzo and Jeffrey Shafer (hereafter collectively referred to as the Shafer Family) sued Cheung, Goldsworthy, Hoag Hospital, and Richard Taketa (another radiologist who reviewed the first CT scan and also failed to diagnose the hematoma). Taketa settled with the Shafer Family during the trial. After the close of trial, the court considered and denied Cheung's motion for nonsuit that claimed there was no evidence to prove the necessarily element of causation. The jury found Hoag Hospital and Goldsworthy not liable, and no appeal was taken from that finding. The jury determined Cheung was liable for medical malpractice and awarded the Shafer Family $206,356.31 in damages.
II
A. Nonsuit
Cheung contends the court should have granted his nonsuit motion. He asserts the Shafer Family failed to submit sufficient evidence to meet their burden of proof on the element of causation. Specifically, he argues they "failed to present evidence demonstrating the death was not the natural course of the subdural hemorrhage (see Civ. Code, § 1714.8), as opposed to the failure to make an earlier diagnosis of the hemorrhage." We disagree.
Our standard of review of an order either granting or denying a motion for a nonsuit is a very limited and restricted one, a principle deriving from the nature of the motion itself. As our Supreme Court has said, a nonsuit motion "allows a defendant to test the sufficiency of the plaintiff's evidence before presenting his or her case. Because a successful nonsuit motion precludes submission of plaintiff's case to the jury, courts grant motions for nonsuit only under very limited circumstances. . . . [¶] 'In determining whether plaintiff's evidence is sufficient, the court may not weigh the evidence or consider the credibility of witnesses. Instead, the evidence most favorable to plaintiff must be accepted as true and conflicting evidence must be disregarded. The court must give "to the plaintiff['s] evidence all the value to which it is legally entitled, . . . indulging every legitimate inference which may be drawn from the evidence in plaintiff['s] favor . . . . "' [Citations.] [¶] In an appeal from a judgment of nonsuit, the reviewing court is guided by the same rule requiring evaluation of the evidence in the light most favorable to the plaintiff." (Carson v. Facilities Development Co. (1984) 36 Cal.3d 830, 838-839.)
An essential element of a plaintiff's medical negligence cause of action was causation. (Johnson v. Superior Court (2006) 143 Cal.App.4th 297, 305.) In Espinosa v. Little Co. of Mary Hospital (1995) 31 Cal.App.4th 1304, 1314-1315, the court reversed nonsuit in a medical malpractice action and concluded: "In a medical malpractice action the element of causation is satisfied when a plaintiff produces sufficient evidence 'to allow the jury to infer that in the absence of the defendant's negligence, there was a reasonable medical probability the plaintiff would have obtained a better result. [Citations.]' [Citation.]"
In the case at bench, the Shafer Family contended and the jury concluded Cheung's negligence caused a 12-hour delay in the diagnosis and treatment of Lois's subdural hematoma. We conclude there was substantial evidence by competent expert testimony of a "reasonable medical probability" that in the absence of Cheung's negligence Lois would have obtained a better result. Stated another way, "defendant's acts or omissions were a substantial factor in bringing about the decedent's death." (Bromme v. Pavitt (1992) 5 Cal.App.4th 1487, 1493 (Bromme).)
Several expert witnesses testified on behalf of the Shafer Family. All the witnesses agreed on the following standard of care: If Lois's hematoma had been properly diagnosed she would have been admitted to the hospital, evaluated by other medical staff, and her Coumadin treatment would have been stopped and replaced by vitamin K and fresh frozen plasma to assist in clot formation. As a hospital patient, Lois's vital signs and neurological status would be frequently checked, and if the bleeding continued, expanding the hematoma, then surgery would have been performed as soon as possible.
For example, the Shafer Family's expert William Cable, a board certified neurologist, testified that if Lois had been timely diagnosed there was a reasonable medical probability she would have recovered successfully. Cable stated that if the subdural hematoma had been diagnosed, the first step would have been to "determine if there are any factors that may be contributing to the bleedings such as anticoagulants and then proceed to reverse those . . . ." He stated, at the same time, the treating physician would evaluate the patient's condition, and if it deteriorated, then surgery may be required. Cable testified about the various structures and functions of the brain and he explained that "the brain doesn't like to be squashed. And, as a result of [the] brain being squashed, it will actually stop working. And depending [on] the severity of the pressure on the normal healthy brain, more and more dysfunction occurs. Ultimately, if it's not corrected quickly [the result is] death."
Counsel gave Cable a hypothetical example, involving a patient presenting the same symptoms as Lois, but where the emergency room (ER) physician had been told a 7 mm subdural hematoma was present. The hypothetical asked Cable to compare the treatment Lois received of being sent home to sleep and take more Coumadin, to the hypothetical treatment of being admitted to the hospital and the following facts: The ER physician would have called a neurosurgeon and at the same time began giving vitamin K and plasma to reverse the effects of the Coumadin. The patient would be admitted to the intensive care unit (ICU) or remained in the ER for close and consistent observation of vital signs. Nurses would start lines for fluids and interact with the patient to monitor if the patient was continuing to function normally. At the hospital, a surgical team would have been available within one hour to operate on Lois if necessary.
Based on the hypothetical facts, Cable opined if the patient had been correctly diagnosed and admitted to the hospital under constant observation "everything was favorable for a complete successful recovery from her trauma. Cable explained Lois was initially brought to the ER quickly by her husband, she was examined that night, and her "neurological status was completely normal. The brain scan—the CT brain scan that they performed at the time showed only a very small clot. And realizing those factors, I believe she would have had a very successful outcome, either being normal or very close to normal in her recovery."
Cable explained the "tamponade effect" to the jury. He stated, "[The] tamponade effect is as a blood clot gets larger and larger, at some point it's going to press on the veins and stop further leakage. [¶] We all do this when . . . we give blood. We're asked to put a gauze on the site where the needle has punctured the vein and we apply pressure. That's effectively tamponading the blood flow." Counsel asked about the tamponade effect when a subdural hematoma expands. Cable opined if one's blood is clotting faster "then I wouldn't expect continued growth of the blood clot."
Cable concluded that under the hypothetical facts, the outcome of Lois's condition, to a "reasonable medical probability," would have been a complete recovery or close to a complete recovery because if Lois's bleeding had not stopped with the vitamin K and blood plasma treatment, then Lois would start to show signs of neurological problems while she was being closely monitored in the hospital. If this occurred, she would have been taken to surgery as quickly as possible.
Cable admitted that if Lois was not in the ICU but placed under observation elsewhere in the hospital, there would not be the same intensity of nursing supervision and the surgical response may have been slower, but the outcome for Lois "would still have been favorable. It might not have been quite as good as [if she had been in the ICU]." Cable repeated, "time is an important element here. The further expansion of the blood clot will compress the brain. The greater the degree of compression of the brain, the worse the outcome."
On cross-examination, counsel asked Cable at what point during the night Lois would have exhibited neurological signs or symptoms that would have prompted a neurosurgeon to operate. Cable agreed surgery was not warranted when Lois first came to the hospital. He stated that when the subdural hematoma grows to a point where it is touching the brain the patient will exhibit symptoms and surgery is necessary to prevent irreversible brain damage. Cable stated he could not pinpoint the exact time when Lois would have exhibited symptoms. Counsel asked Cable if an elderly patient would not exhibit symptoms as quickly as a younger patient. Cable agreed that generally older people experience some brain atrophy and typically have more space between their brain and skull. However, Cable opined it would be speculation to say an older person may not exhibit symptoms of a hematoma as quickly as a younger person. He concluded, "that between 10:30 at night when [Lois] went home and when she got back to the hospital the next day we just flat out don't know when the first signs and symptoms of that slow [blood] seepage would have appeared because there was nobody monitoring her[.]" On cross-examination, Cable also conceded the antidotes used to reverse the effect of Coumadin would have taken some time, but in any event, Lois's progress would have been closely monitored in the hospital. He concluded there were several steps that could have been taken that to a reasonable medical probability would have protected Lois's brain.
Mark Langdorf, a board certified emergency medicine expert, explained that when Lois was readmitted to Hoag Hospital, she was given vitamin K and fresh plasma and her clotting time immediately improved. Looking at Lois's medical records, Langdorf explained, "It appears that the vitamin K and the fresh frozen plasma worked faster than I would have expected it to and took her from a state where her blood did not clot well to almost normal clotting." He agreed Lois should never have been sent home given her medical history. Langdorf stated Lois should have been admitted to the hospital for close observation and detection of neurological deterioration.
John Peter Gruen, a board certified neurosurgeon and Director of the Neurotrauma Program at the University of Southern California, Los Angeles County Medical Center, testified on behalf of the Shafer Family on the issue of causation. He opined Lois would have, at some point during the night, required surgery. He stated that once neurological deterioration was identified, Lois would have been taken to surgery and her condition would be the same as when the surgery began. Gruen was optimistic about the outcome of surgery, had it been performed, based on the evidence Lois showed no early signs of deterioration when she first was taken to the hospital. He stated, "[W]hen a patient deteriorates neurologically following a head injury, if there is a hematoma, a bleed, hemorrhage, blood clot, there are stages of deterioration. And she had not reached a stage where she had demonstrated any deterioration. [¶] If something is done as she is entering that deterioration downturn, the patient ends up about as good as they were at the time that you recognized something impeding/bad was going to happen and you intervene and stop it, the patent should be as they were." Gruen testified he had personally treated over 5,000 subdural hematomas over the past 24 years and the standard of care requires a swift response.
On cross-examination, Gruen indicated it would take between four to six hours for the hematoma to increase from 7 mm to 25 mm. He opined that "before" it reached the size of 25 mm, Lois would have exhibited some signs of neurological deterioration. On redirect examination, Gruen clarified that because Lois's brain was bleeding very slowly, she would show signs of some subtle neurologic changes that could be picked up in a hospital setting. Gruen stated "so what I'm saying is if you want to think of it, there's a downward . . . progression of deterioration. And the higher you catch the patient on that curve, if you—wherever you catch them and then intervene and get that . . . [blood] mass out, that pressure is relieved from the brain, [and there is a] greater probability than not [the patient will] stay at that place or they get better."
Cheung asserts he was entitled to nonsuit as a matter of law because the evidence presented by the Shafer Family was insufficient to permit a jury to find in their favor on the element of causation. He asserts they failed to present evidence showing Lois's death was not the natural course of the subdural hemorrhage. In other words, Cheung alleges he cannot be held liable for a result "caused by the natural course" of that "condition" under Civil Code section 1714.8, subdivision (a). We conclude he mischaracterizes the evidence and the applicability of Civil Code section 1714.8.
Civil Code section 1714.8, subdivision (a), provides, "No health care provider shall be liable for professional negligence or malpractice for any occurrence or result solely on the basis that the occurrence or result was caused by the natural course of a disease or condition, or was the natural or expected result of reasonable treatment rendered for the disease or condition. This section shall not be construed so as to limit liability for the failure to inform of the risks of treatment or failure to accept treatment, or for negligent diagnosis or treatment or the negligent failure to diagnose or treat." (Italics added.) Therefore, this section would apply if Cheung made the proper diagnosis, and Lois received the proper treatment, but her death was the natural or expected result for her condition. Such a scenario is simply not what happened in this case.
The Shafer Family presented evidence that if Cheung had made the proper diagnosis, Lois would not have been sent home. Rather, Lois would have received a multi-step course of treatment in the hospital that would have protected her brain and facilitated her recovery. For example, Cable testified if Lois had been correctly diagnosed and given the appropriate treatment for an elderly patient taking anticoagulants, she would have, to a reasonable medical probability, recovered successfully. Cable opined that based on Lois's condition when she was first admitted to the hospital, "she would have had a very successful outcome, either being normal or very close to normal in her recovery." Similarly, Gruen opined that if Lois had been kept under observation in the hospital the early signs of neurological deterioration would have been identified and surgical measures would have intervened to stop a further downturn. These experts agreed that death was not the natural or expected result of reasonable treatment rendered for a properly diagnosed 7 mm hematoma.
Cheung's reliance on the portion of Cable's testimony that Lois died as a natural consequence of her hematoma mischaracterizes the evidence. Lois's death was the consequence of an undiagnosed and untreated 7 mm hematoma that expanded while she was at home into a 25 mm hematoma that crushed her brain. Civil Code section 1714.8 does not absolve Cheung from liability as a matter of law. The trial court properly denied the nonsuit.
B. Substantial Evidence of Causation
Alternatively, Cheung argues substantial evidence does not support the jury's decision his misdiagnosis caused Lois's death because the expert testimony failed to prove causation, and his expert affirmatively demonstrated no causation. We disagree.
"The law is well settled that in a personal injury action causation must be proven within a reasonable medical probability based upon competent expert testimony. Mere possibility alone is insufficient to establish a prima facie case. [Citations.] That there is a distinction between a reasonable medical 'probability' and a medical 'possibility' needs little discussion. There can be many possible 'causes,' indeed, an infinite number of circumstances which can produce an injury or disease. A possible cause only becomes 'probable' when, in the absence of other reasonable causal explanations, it becomes more likely than not that the injury was a result of its action. This is the outer limit of inference upon which an issue may be submitted to the jury. [Citation.]" (Jones v. Ortho Pharmaceutical Corp. (1985) 163 Cal.App.3d 396, 402-403.)
Cheung asserts the case Jennings v. Palomar Pomerado Health Systems, Inc. (2003) 114 Cal.App.4th 1108 (Jennings), is analogous to this case. In Jennings, the court summarized limitations on admissible expert testimony. In that case, plaintiff alleged he developed an abdominal infection outside his peritoneal cavity because defendant left a retractor within the cavity following surgery. In support of this theory, plaintiff offered the testimony of an infectious disease expert, who assumed, although he had no basis upon which to make the assumption, the retractor was contaminated. The expert also failed to explain how the bacteria migrated from the peritoneal cavity into subcutaneous tissue without leaving a trail of infected tissue evidencing the migration; instead, the expert simply concluded in essence that because the retractor was left in place and was probably contaminated, and a nearby area later became infected. He stated, "'[I]t just sort of makes sense. We have that ribbon retractor and [it's] contaminated, he's infected.'" (Id. at p. 1115.)
In Jennings, the trial court sustained defendant's objection to this testimony and the ruling was affirmed on appeal. "Although [the expert] testified the retractor was a cause-in-fact of the infection, his conclusion was unaccompanied by any reasoned explanation supporting his opinion. [Citations.] . . . . That opinion is too conclusory to support a jury verdict on causation. [Citation.]" (Jennings, supra, 114 Cal.App.4th at p. 1120, fn. omitted.) The court concluded, "[The expert's] opinion on the causal linkage between the retained retractor within the peritoneal wall and an infection outside the peritoneal wall was therefore based on an ipso facto explanation." (Id. at p. 1115.) The court noted the expert also suggested two hypothetical scenarios linking the bacterial contaminants on the retractor and the patient's abdominal infection. The court rejected one hypothetical because it did not relate to plaintiff's theory of liability and, therefore, did not assist his case. The court rejected the second hypothetical scenario because the expert conceded it "was speculative" and also did not relate to plaintiff's theory of liability. (Ibid.)
We agree with the Jennings court's conclusion, an expert does "not possess a carte blanche to express any opinion within the area of expertise" and cannot base opinions on assumptions of fact without evidentiary support or on speculative or conjectural facts. (Jennings, supra, 114 Cal.App.4th at p. 1117.) "[W]hen an expert's opinion is purely conclusory because unaccompanied by a reasoned explanation connecting the factual predicates to the ultimate conclusion, that opinion has no evidentiary value because an 'expert opinion is worth no more than the reasons upon which it rests.' [Citation.]" (Ibid.)
However, we disagree with Cheung's theory the Shafer Family's experts in this case did not satisfy the Jennings requirements for admissibility. Cheung maintains Cable offered the same type of ispo facto opinions rejected by Jennings. Cheung categorizes Cable's testimony as offering only broad and vague conclusions about Lois's chances for survival and his opinion the "outcome would have been favorable, either a complete recovery or close to a complete recovery" appears speculative.
Cheung fails to recognize the expert testimony in this misdiagnosis case is very different from the expert testimony in the Jennings case, where the issue was how an infection spread from one area of the body to another. In this case, the predicate fact and conclusion were the same, i.e., there was a fatal undiagnosed brain hematoma. Lois did not die of a bleed elsewhere in her brain.
If we were to accept Cheung's argument an expert opinion about the chances for Lois's survival was inadmissible, then causation could never be proven anytime there is a medical misdiagnosis. There is a well established large body of case authority concerning the misdiagnosis of various cancers that all hold scientific testimony about a patient's hypothetical probability of survival, if he or she had received treatment, is admissible and in fact necessary to assist the jury.
The principles of causation applicable to an action based upon a medical failure to diagnose were addressed in Bromme, supra, 5 Cal.App.4th 1487. In that case, a husband filed suit against a doctor for the wrongful death of his wife, alleging the doctor negligently failed to detect his wife's colon cancer. Several doctors testified about the surgical cure rate for cancer. (Id. at p. 1495.) These experts, who specialized in surgery for cancer, agreed it was a reasonable medical probability the wife's cancer could have been successfully treated had it been detected prior to June 1981, but that after that time, "successful treatment became medically improbable, i.e., the chance of success was less than 50 percent." (Id. at p. 1492.) The trial court barred the jury from considering any negligence after June 1981. The appellate court affirmed this ruling, reasoning that "California does not recognize a cause of action for wrongful death based on medical negligence where the decedent did not have a greater than 50 percent chance of survival had the defendant properly diagnosed and treated the condition." (Id. at pp. 1504-1505, fn. omitted.) This holding, as applied to our case, shows misdiagnosis cases uniquely require qualified expert testimony predicting the chance of survival if there had been proper diagnosis and treatment. Here, the record amply supports the conclusion Cable and Gruen were qualified experts with respect to the standard treatment of and expected recovery for patients suffering from a brain hematoma. Cheung does not challenge their credentials or expert qualifications. As such, the medical expert opinions based on years of experience, offered about Lois's chances of recovery from a diagnosed 7 mm brain hematoma, were absolutely admissible.
It is well settled, "'Proof of causation is particularly difficult in cases where the results complained of are such as might normally be expected to follow from the original disease or injured condition, as is the case when a plaintiff complains of the defendant doctor's failure to cure, rather than of any positive effects of mistreatment. Plaintiffs in such cases are faced with the difficulty of obtaining and presenting expert testimony that if proper treatment had been given, better results would have followed.' [Citation.] [¶] In this type of case where the testimony establishes a probability of a better result (usually the patient's survival) absent a doctor's negligence, a finding for the plaintiff is consistent with existing principles of proximate cause. [Citation; see e.g., Burford v. Baker (1942) 53 Cal.App.2d 301 [where failure to timely diagnose hip injury resulted in bone deformity, proximate cause was established by testimony that prompt treatment would have greatly enhanced the probability of a good result].)" (Dumas v. Cooney (1991) 235 Cal.App.3d 1593, 1603 [malpractice based on delayed diagnosis and treatment of lung cancer].) In this case, the Shafer Family obtained and presented the necessary expert testimony. Cable, an expert specializing in neurology, possessed the medical knowledge and experience to offer evidence that Lois's 7 mm subdural hematoma was potentially life threatening, but with the appropriate treatment, she would have adequately recovered. Lois had a much greater than 50 percent chance of survival. Cable's testimony alone was substantial and supported the jury's verdict.
In addition, we note the jury in this case had the benefit of several other qualified experts. Gruen, the expert neurosurgeon, agreed with Cable as to the proper course of treatment for an elderly patient receiving Coumadin. In forming his opinion, Lois could have fully recovered from her hematoma, Gruen relied on the same factual basis as Cable, i.e., the results of the CT scan, Lois's age and symptoms when she first came to the hospital, and the additional concerns created by Coumadin treatment. Indeed, all the experts, including Cheung's expert (Charles Liu) agreed that if Lois had been diagnosed properly, she would have been hospitalized where staff would have conducted neurological assessments throughout the night. Gruen and Liu agreed Lois likely would have shown signs of neurological deterioration at some point during the night requiring immediate surgery. Liu did not contradict Gruen's opinion that the earlier such surgery is performed, the better the outcome.
Cheung argues Gruen's and Cable's testimony was inadequate because they could not exactly pinpoint the crucial point of time when the subtle neurological deterioration symptoms would appear. The timing of the potential surgery related to Cheung's theory Lois's surgery would not have occurred any sooner and she would have suffered the same outcome even if she had been properly diagnosed. However, in a misdiagnosis case, we find it was sufficient for the experts to offer their professional opinion the standard course of treatment, including surgery, would have occurred much earlier if Lois had been properly diagnosed. The experts explained the medical necessity for early intervention to prevent brain damage and Lois would have received this treatment but for Cheung's misdiagnosis. The experts agreed proper diagnosis and treatment of a 7 mm hematoma to a reasonable medical probability would not have resulted in death because any developing neurological issues would have been detected earlier and treated sooner. To pinpoint the exact time of her downturn if Lois had been hospitalized would require the experts to speculate and assume facts without evidentiary support, the exact type of expert opinion was rejected by the Jennings court.
On a final note, we wish to point out Cheung's expert also did not speculate on the exact point in time surgery would have been required. He simply opined it could have taken approximately four to five hours after admission to the hospital for signs of neurological deterioration from the growing hematoma. Cheung obviously does not suggest this testimony was inadmissible due to vagueness. Moreover, if the jury accepted this prediction, Lois would have shown neurological signs around 3:00 or 4:00 in the morning. Surgery would have been performed between one to two hours later. Under this proposed scenario, Lois's surgery would have occurred many hours earlier than when she actually underwent surgery (Lois arrived by ambulance at 10:30 a.m. and surgery was started approximately two hours later). This testimony appears to be in line with the Shafer Family's expert testimony, that Lois would have received treatment sooner if she had been diagnosed. Ultimately, it was up to the jury to decide, given the various expert opinions on the typical known progression of brain hematomas, if the misdiagnosis was a substantial factor in bringing about Lois's death. And based on this record, we cannot say there was insufficient evidence to support the jury verdict finding Cheung liable. This expert testimony presented by the Shafer Family amply supports the jury's verdict.
III
The judgment is affirmed. Respondent shall recover their costs on appeal. The motion to dismiss the appeal is denied.
O'LEARY, J.
WE CONCUR:
BEDSWORTH, ACTING P. J.