Raul Swain And Kathleen Schons, Res. V. Swedish Health Services, App.

IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON
RAUL SWAIN and KATHLEEN
SCHONS, individually and as guardians
of minor child JAXOM SWAIN-SCHONS
Respondents,
SWEDISH HEALTH SERVICES d/b/a
SWEDISH MEDICAL CENTER, and
MICHAEL C. SHANNON, M.D.,
Appellants.
No. 71616-6-1
DIVISION ONE
UNPUBLISHED OPINION
FILED: June 15, 2015
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Trickey, J. — Generally all relevant evidence is admissible, except as
limited by constitution, statute, or other evidentiary rule. 	ER 401. 	The decision to
exclude or allow testimony in rebuttal in a medical malpractice case depends in
part on whether the proponent intentionally violated discovery rules and whether
there was any prejudice in permitting such testimony. Here, the plaintiffs disclosed
a treating physician as a witness and submitted her report months before trial to
the defendants. 	Because the defendants were already aware of the physician's
conclusions from her 	report, 	there was 	no prejudice. 	Her testimony merely
corroborated her report, which was also admitted into evidence.
Nor did the trial court abuse its discretion in the remaining evidentiary
rulings the defendants raise in this appeal. Affirmed.
FACTS
This is a medical malpractice case arising out of medical care Dr. Michael
Shannon and Swedish Medical Center (collectively, Shannon) provided to Jaxom
Swain-Schons.

No. 71616-6-1/2
On August 14, 2011, Jaxom, then 20 months old, experienced a febrile
seizure. 	Paramedics arrived and Jaxom appeared to be stabilized. 	After the
paramedics left, Jaxom had a second seizure. 	The parents took him to Swedish
Mill Creek Emergency Department. 	While there, 	Jaxom 	had 	another febrile
seizure. 	The nurses at Mill Creek were unable to install an intravenous (IV). The
clinic decided to transfer Jaxom to Swedish First Hill (Swedish) Pediatric Intensive
Care Unit in Seattle.
Swedish 	sent 	its pediatric transport team, 	consisting 	of a 	nurse, 	Dr.
Shannon, and a respiratory therapist to Mill Creek. 	On arrival there, the transport
nurse placed a peripheral IV in one ofJaxom's hands and readied him for transport.
During the ambulance ride to Swedish, the peripheral IV failed.
At the hospital, 	after several unsuccessful attempts to place another
peripheral IV in Jaxom, a decision was made to install a central line by placing a
femoral central venous catheter. 	Dr. Shannon performed the installation.
Jaxom was discharged the following 	day. 	On August 18, his parents
returned 	to Swedish 	because 	Jaxom 	was 	complaining of neck 	pain and 	a
headache, 	and was walking funny at times with a wide gate. 	Physicians at
Swedish informed Jaxom's parents that the symptoms were probably a result of
the anti-seizure medication and should dissipate within a few days.
Jaxom continued to experience these symptoms and 	began 	behaving
abnormally. 	His body would sometimes stiffen and he experienced episodes of
pain causing him to cry uncontrollably. 	In December, a neurologist saw Jaxom,
but did not find any cause for Jaxom's symptoms.

No. 71616-6-1/3
On February 29, 2012, the parents noticed a small bump on Jaxom's neck,
near his collarbone. 	Jaxom's pediatrician prescribed antibiotics. 	Later that day,
the cyst had moved and the parents took Jaxom to the Everett emergency clinic.
X rays revealed two long metal wires in his body.
Jaxom was transferred by ambulance to Seattle Children's Hospital. 	Dr.
George Drugas, a pediatric surgeon at Children's Hospital, removed a guidewire
from Jaxom's body on March 1, 2012.
Jaxom and his parents filed suit. 	The jury returned a verdict of $500,000
for Jaxom and $250,000 each for his parents. Shannon timely appeals.
ANALYSIS
Shannon 	contends 	the 	trial 	court 	made 	multiple 	evidentiary 	errors.
Specifically, Shannon contends that the trial court erred by permitting one of
Jaxom's treating physicians to testify in rebuttal, excluding his expert metallurgist
from testifying regarding reports of product failure, admitting evidence regarding
the length of his shift rotation, and a checklist used by another hospital for similar
procedures.
Evidentiary decisions are within the sound discretion of the trial court. 	A
trial court abuses its discretion when its decision is manifestly unreasonable or
based on untenable grounds. 	Silas v. Hi Tec Erectors, 168 Wn.2d 664, 668-69,
230 P.3d 583 (2010).
Rebuttal Testimony
During the plaintiffs' case-in-chief, the plaintiffs informed the court that Dr.
Teresa Chapman, a radiologist at Children's Hospital, might be called as a rebuttal

No. 71616-6-1/4
witness depending on the testimony of Dr. Timothy Larson, the defense's expert
radiologist. The defense argued that Dr. Chapman was merely a treating physician
and should not be called on rebuttal. 	The following colloquy occurred:
THE COURT: 	It seems, if what Dr. Chapman is going to say, is she
looked at these x-rays and they were not coiled, they were straight
wires, that would then rebut presumably your Dr. Larson who is going
to say he looked at the fluoroscopy of the x-ray or something and
saw coiled architecture.
[DEFENSE COUNSEL]: 	Right
THE COURT: 	Right now we don't have anybody that has actually
testified that anybody saw coiled architecture.
[DEFENSE COUNSEL]: Well, nobody has testified, that's right. We
only have the records.
That is why I think you are perfectly entitled to call her in their
case in chief. They should. 	She is obviously available. 	He told you
she was. 	She should come in and testify. 	And we will listen to what
she says and why, and then when we have Dr. Larson aboard, he
will testify as he did in his deposition.
So if you look at the test of rebuttal, that wouldn't be rebuttal
under these circumstances.
THE COURT: 	It would be rebuttal if nobody has testified yet it is
coiled, right? So then she is going - your witness is going to say, we
looked at the x-ray, it is coiled. She is going to come in afterwards
and say, no, I looked at the x-ray and it was not coiled. 	That is
rebuttal.
[DEFENSE COUNSEL]: Well, but that is true, technically that would
be rebuttal. But the rule on rebuttal, as I understand it, it is something
that can't be reasonably anticipated.
We have known from the get-go what the two theories of the
case are. 	They know and they had Dr. Drugas talk today about it
being a straight wire. 	That is what he said. 	And he said he looked
at the fluoroscopy. 	So they have had that on there.
Nowwe have Dr. Larson coming in, he says, no, I have looked
at it and it is coiled.
Ijust think if they really want to get Dr. Chapman's testimony,
and she is a factual witness, she only read, she only read the plane
films.™
1 Report of Proceedings (RP) (12/11/13) at 179-181.
4

No. 71616-6-1/5
Dr. Chapman, a radiologist at Seattle Children's Hospital, testified regarding
her reading of the X rays. She testified that the X rays taken from the Everett clinic
indicated that there was a wire protruding upward, "tenting the skin."2 She further
stated:
And then this is the smooth linear course of this radio density, this
wire, which courses up into the head. 	It is just a nice example when
you magnifies these up the margins of the wire are very smooth,
which, again, this is why I am calling them wires. 	This is what wires
look like. 	They are radio dense with very smooth margins.[3]
The plaintiffs then inquired what Dr. Chapman thought regarding the defense's
theory that the objects were not wires, but the coiled portion separated from the
guidewire. 	Defense counsel objected.
After 	an 	unreported 	sidebar discussion, 	plaintiffs' 	counsel 	asked 	the
following question:
Dr. Chapman, since learning about the defense theory of this coiled
portion coming off, have you examined a guidewire to see the coiled
portion separated from the central wire?[4]
Dr. 	Chapman answered affirmatively. 	The plaintiffs then asked 	if what Dr.
Chapman had seen on the X rays taken was just a coil and not a guidewire. 	She
responded:
It is not possible. I have actually seen what a coil looks like under a
radiograph. It has a different texture to it. It literally looks like a Slinky
kind of coil. 	It is radio dense but not quite as dense as this and it
does not have smooth margins. 	Nor would it act firmly. 	These have
some strength to them. 	A coil is flimsy and would be wavy, might
even collapse. Certainly couldn't lift skin up like what we are seeing
on the radiograph. These are wires.[5]
2 RP (12/18/13) at 68.
3 RP (12/18/13) at 73.
4 RP (12/18/13) at 74.
5 RP (12/18/13) at 74.

No. 71616-6-1/6
Dr. Chapman's answer is consistent with her report dated February 29, 2012,
wherein she stated: "There are 2 thin metallic densities in the chest, consistent
with wires, as seen on the comparison study."6
Her testimony is likewise in accord with the written report by Dr. John Ho,
who along with Dr. Drugas removed one of the two wires from Jaxom:
There is a retained guidewire coursing the sigmoid sinus on the right
side down the internal jugular vein through the superior vena cava
and ending in the right atrium. 	The wire has been retrieved with a
trilobedm ensnare. 	Follow up venogram shows no evidence of
extravasation. 	The wire was removed entirely.171
This court reviews decisions regarding 	rebuttal testimony for abuse of
discretion. 	State v. White. 74 Wn.2d 386, 394-95, 444 P.2d 661 (1968). 	Such
abuse occurs only when no reasonable person would take the adopted view.
Vasauez v. Martin. 46 Wn. App 480,483, 731 P.2d 510(1986). Rebuttal testimony
may be somewhat cumulative.
Ascertaining whether the rebuttal evidence is in reply to new matters
established by the defense, however, is a difficult matter at times.
Frequently true rebuttal evidence will, in some degree, overlap or
coalesce with the evidence 	in chief. 	Therefore, 	the question 	of
admissibility of evidence on rebuttal rests largely on the trial court's
discretion, and error in denying or allowing it can be predicated only
upon a manifest abuse of that discretion.
White. 74 Wn.2d at 395.
Here, Dr. Chapman's testimony directly rebutted Dr. Larson's testimony.
Dr. Chapman testified that based on her review of the images and her expertise,
the wires were straight, not uncoiled, and that uncoiled wires would not have
6 Exhibit (Ex.) 6-00009.
7 Ex. 6-00014.

No. 71616-6-1/7
behaved in the manner that these wires did inside Jaxom's body. 	She described
the object as "radio dense with very smooth margins" and that only a wire would
be firm enough to tent the skin as was done here.8
There was no prejudice or surprise to the defendants. 	Dr. Chapman was
disclosed as a possible primary witness in April 2013. 	Her name was on the
medical records from Children's Hospital, which the defendants had received even
earlier.
Shannon cites Kremer v. Audette. 35 Wn. App. 643, 648, 668 P.2d 1315
(1983), for the proposition that a plaintiff is not permitted "to present. . . evidence
cumulatively at the end of [a] defendant's case."9 	But in the trial court's view, Dr.
Chapman's rebuttal testimony was proper because no one had yet testified to the
object inside of Jaxom as being a coil rather than a wire. 	Defense counsel agreed
that no one had testified but argued that the record so indicated. 	There was no
abuse of discretion.
Defense counsel argued that Dr. Chapman derived her opinion not from her
treatment but from experiments run afterwards. 	But Dr. Chapman's opinion that
the objects in Jaxom's body were wires is clearly stated in her report while she was
a treating physician. Even if the evidence is cumulative to what was in the admitted
reports, 	the admission 	of cumulative evidence is a matter within the court's
discretion. 	Christensen v. Munsen, 123 Wn.2d 234, 241, 867 P.3d 626 (1994).
Atreating physician may testify as to both fact and medical opinion. Carson
v. Fine, 123 Wn.2d 206, 215-16, 867 P.2d 610 (1994). Here, unlike the cases cited
8 RP (12/18/13) at 73.
9Appellant's Reply Br. at 5.

No. 71616-6-1/8
by Shannon, there was no undue surprise or prejudice. 	Dr. Chapman's testimony
regarding any secondary action she might have taken after reviewing defense
testimony (that what remained in Jaxom was a coil and not a guidewire) was
consistent with the evidence that defense knew existed, i.e., wires were left in
Jaxom.
ER703
Defense retained metallurgist Keith Cline as an expert witness. 	In voir dire
outside the presence of the jury, defense counsel asked Cline about MAUDE
(Manufacturer and User Facility Device Experience) reports concerning Cook
guidewires. 	Cline testified that as a metallurgical engineer, he had reviewed
MAUDE reports, provided by defense counsel, to obtain background on the history
of the wire device. 	None of the cases in the MAUDE reports were exactly like the
present case.
In cross-examination on voir dire, Cline testified that he did not rely on the
MAUDE reports for the specific failure of the guidewire in this case. 	In response
to questioning from the court, Cline noted that there were no instances where the
inner coil separated from the outer coil in the MAUDE reports.
Plaintiffs moved to restrict the MAUDE reports based on federal law and ER
703. 	The court asked the lawyers to limit their arguments to whether or not the
reports should be excluded under ER 703. ER 703 provides:
The facts or data in the particular case upon which an expert
bases an opinion or inference may be those perceived by or made
known to the expert at or before the hearing. If of a type reasonably
relied upon by experts in the particular field in forming opinions or
inferences upon the subject, the facts or data need not be admissible
in evidence.
8

No. 71616-6-1/9
The trial court granted the motion to exclude the MAUDE reports based on
ER 703 for the following reasons:
My impression of him on the stand was he didn't even know
about a 	MAUDE report until he 	was 	presented 	it from 	defense
counsel. 	It is possible that he said, well, you do research and you try
to find out anything you can about product failures. 	He said I think
probably other metallurgists probably do that too.
I think the rule is clear that it's not enough that the particular
expert relied on this [sic] facts or data that were given to him by
defense counsel, but the proponent of the testimony must show the
experts in the witness's field in general reasonably relied on such
material in their own work for purposes other than litigation. That is
the thing I don't think has been established, that other metallurgists
rely on MAUDE reports for purposes other than litigation. 	Ifeel that
that has not been, that standard has not been met.
And it bothers me as well that there is really no other reporting
here. 	I don't know how he can rely on them when there is no
reporting here that has a failure similar where we are talking about
the inner core separating from the outer core.
He does have reports that say something was cut with a
needle or scalpel or itwas cut and the ends were frayed. 	But I don't
know how that informs his decision on whether or not - 	I don't know
why I am forgetting that word, the places where they are soldered
together -- welds - that the welds had failed.[10]
This court reviews the trial court's exclusion of this testimony to determine
whether the 	exclusion was 	manifestly unreasonable or based on 	untenable
grounds or reasons. State v. Roberts. 142 Wn.2d 471, 520, 14 P.3d 713 (2000).
Because ER 703 is concerned with the trustworthiness of the resulting
opinion, it is not sufficient to showthat the particular expert in question customarily
relies on the facts and data in question. A proponent of the testimony must show
that experts in the witness's field, in general, reasonably rely on such material in
10 RP (12/16/13) at 70.

No. 71616-6-1/10
their own work, for reasons other than litigation. 	In re Detention of Marshall. 156
Wn.2d 150, 161, 125 P.3d 111 (2005).
The trial court's decision found that the reports were not reasonably relied
upon 	by experts and thus insufficient to support the expert's opinion. 	In 	re
Detention of McGarv, 175 Wn. App. 328, 341, 306 P.3d 1005. review denied, 178
Wn.2d 1020, 312 P.3d 651 (2013). The trial court did not abuse its discretion.
Checklist and Length of On-Call Shift
Shannon also argues that the trial court erred in denying his motion to
exclude the testimony regarding 	both the length of his on-call shift and that
Children's Hospital used a checklist when performing this type of procedure.
Shannon contend that this testimony was irrelevant and prejudicial.
In ruling against this motion, the trial court stated:
The 	fact 	that 	Dr. Shannon 	didn't 	use 	a 	checklist -- 	Dr.
[Kenneth] Schenkman is an expert and isn't that the reason he is
being called is to say this is what Dr. Shannon didn't do, and in fact,
my expert opinion, if he had done X, Y and Z he could have avoided
this mistake. That is tantamount to a checklist. That is his opinion
about how to avoid leaving objects in a patient, presumably.1111
The trial court noted that defense could elicit from Dr. Schenkman that a checklist
is not required and, therefore, not using a checklist does not violate the standard
of care. The court further noted, "That doesn't mean he can't opine that would
have been one way to mitigate the problem, is what I am saying. That is why I am
denying the motion."12 	For similar reasons, the court permitted defense to admit
evidence that Dr. Shannon had worked a 48-hour shift and was in his 41st hour.
11 RP (12/9/13) at 91-92.
12 RP (12/9/13) at 92.
10

No. 71616-6-1/11
Generally 	all 	relevant 	evidence 	is 	admissible, 	except 	as 	limited 	by
constitution, statute, or other evidentiary rule. 	ER 402. 	Evidence is relevant if it
has a "tendency to make the existence of any fact that is of consequence to the
determination of the action more probable or less probable than it would be without
the evidence." ER 401. Thus, in a medical malpractice suit, physicians may testify
as to their professional conduct that is repeatedly and consistently performed when
treating persons with similar symptoms so long as it is relevant.
The plaintiffs' expert, 	Dr. Kenneth Schenkman, a 	pediatric critical care
doctor at Children's Hospital, reviewed the care provided by Dr. Shannon. 	Dr.
Schenkman stated that Children's Hospital used a checklist in response to a
question from counsel about how physicians at Children's Hospital ensure that a
guidewire is removed after a procedure.
Here, the testimony was proffered to counteract the defense's theory that
an experienced doctor, such as Dr. Shannon, would not have left a guidewire in a
patient. 	While this statement might be true in ordinary circumstances, the length
of Dr. Shannon's shift (41 st hour of a 48-hour on-call shift) and not using a checklist
could explain why no one discovered the guidewire in Jaxom until months later.
On cross-examination, defense counsel inquired about the checklist. 	Dr.
Schenkman specifically stated that he was not telling the jury that the standard of
care required Dr. Shannon to use a checklist. 	Dr. Schenkman also stated there
were no rules about the amount of time physicians can work. On redirect, plaintiffs'
counsel 	elicited 	that Children's 	Hospital 	does 	not 	have 48-hour shifts. 	Dr.
Schenkman testified that the checklist was just a tool to help avoid errors.
11

No. 71616-6-1/12
The 	trial court did 	not 	abuse 	its discretion 	in admitting 	this 	relevant
testimony.
Because we find that the trial court did not abuse its discretion in the
evidentiary rulings challenged on 	appeal, we 	need 	not 	address the plaintiffs'
argument that the physician was liable as a matter of law. We affirm the judgment.
I /ttkey 	iJ
WE CONCUR:
A*l>< 	'M.	d^j,
12