Estate of Anderson v. Prasad

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ESTATE OF STEVEN ANDERSON, by its Executor DEBRA ANDERSON, Individually, Plaintiff-Appellant, v. PRAVEEN PRASAD, M.D., and IOWA SURGERY CENTER, P.C., Defendants-Appellees.

No. 22-0479

Court of Appeals of Iowa

April 26, 2023

Appeal from the Iowa District Court for Polk County, William P Kelly, Judge.

The Estate of Steven Anderson appeals from an adverse judgment in this medical malpractice case against Praveen Prasad and the Iowa Surgery Center. AFFIRMED.

Jim Duff and Thomas J. Duff of Duff Law Firm, P.L.C., West Des Moines, for appellant.

Cathy S. Trent-Vilim and Frederick T. Harris of Lamson Dugan &Murray LLP, West Des Moines, for appellees.

Heard by Bower, C.J., and Ahlers and Buller, JJ.

BOWER CHIEF JUDGE

The Estate of Steven Anderson ("Estate") appeals from an adverse judgment in this medical malpractice case against Praveen Prasad, M.D., and the Iowa Surgery Center, P.C. claiming the district court abused its discretion in allowing Dr. Prasad to testify regarding the standard of care when he was not designated as an expert under Iowa Code section 668.11 (2019). Finding no error of law or abuse of the court's discretion in ruling on evidentiary matters, we affirm.

I. Background Facts and Proceedings.

Steven Anderson went to the hospital complaining of abdominal pain on Friday, August 18, 2017. He was jaundiced. Medical personnel determined Anderson had a gallstone blocking his common bile duct and an infection. On August 19, Dr. Verma, a gastroenterologist, performed an endoscopic retrograde cholangiopancreatogram (ERCP) and was able to break some particles off the large stone in the duct and remove them.^[1] But, the duct remained blocked, and a stent was inserted to allow the bile (and pus) to drain to the intestines.^[2]

On Monday, August 21, Dr. Prasad, a general surgeon employed by Iowa Surgery Center, performed a laparoscopic cholecystectomy, that is, gallbladder removal surgery.^[3] Anderson died from complications on September 5.

The Estate filed suit against Dr. Prasad and the Iowa Surgery Center (collectively, the "defendants"), alleging Dr. Prasad was negligent in performing the gallbladder removal, which caused Anderson's death. Both sides designated experts pursuant to section 668.11; the Estate named Dr. Samuel Feinberg, and the defendants designated Dr. Paul Severson as their medical expert on standard of care.^[4]

Dr. Prasad denied the following statements sent as requests for admissions:

• "during Plaintiff-decedent [Steven] Anderson's August 21, 2017 cholecystectomy procedure Defendant Prasad violated the standard of care of a general surgeon";

• "the ligation of a patient's right hepatic artery during a cholecystectomy violates the standard of care for a general surgeon";

• "the failure to identify the ligation of a patient's right hepatic artery during a cholecystectomy violates the standard of care for a general surgeon";

• "the stapling of a patient's common bile duct during a cholecystectomy violates the standard of care for a general surgeon";

• "the failure to identify the stapling of a patient's common bile duct during a cholecystectomy violates the standard of care for a general surgeon";

• "the ligation of Plaintiff-decedent [Steven] Anderson's right hepatic artery and stapling of Plaintiff-decedent [Steven] Anderson's common bile duct-which occurred during Plaintiff-decedent Stephen Anderson's August 21, 2017 cholecystectomy procedure-caused Plaintiff-decedent [Steven] Anderson's death."

The parties filed motions in limine about the scope of Dr. Prasad's testimony. The court concluded Dr. Prasad "may testify as to the medical facts regarding his care of Mr. Anderson during the laparoscopic surgery and that what he was doing was appropriate based on his opinions associated with treating his patient, Mr. Anderson."

At trial, the Estate's expert, Dr. Feinberg, testified Dr. Prasad violated the standard of care during Anderson's gallbladder removal surgery, which caused Anderson's death. Dr. Feinberg explained,

What you're trying to do is, when you're doing the surgery, is get in the right area so that you can dissect out the structures so that you see the cystic duct and cystic artery. The whole object of the surgery is protect the common bile duct, protect the common hepatic duct. See only two structures that go to the gallbladder. You can safely remove it.

Dr. Feinberg testified Dr. Prasad clipped the right hepatic artery thinking it was the cystic artery.

Q. And I think they used the word they "felt" it was the cystic artery.^[5] When you're in surgeries, do you just feel that things might be something without exploring more?

A. Well, especially with inflammation and you haven't gotten the anatomy down, no. The answer would be you want to see exactly what you're cutting.

Dr. Feinberg testified Dr. Prasad's "failure to appreciate the anatomy" was a violation of the standard of care; "The whole object of the cholangiogram is to orient you so that you know exactly where you are."

Q. I'll ask another question here, Doctor. Dr. Prasad was- what sort of a procedure as far as the cholecystectomy-what type of cholecystectomy was he trying to do?

A. He was trying to remove a subtotal or two-thirds, three-quarters of the gallbladder so that he would be safe to not injure the common hepatic duct or the hepatic artery.

Q. So he's just trying to do a partial removal?

A. That is correct.

Q. He's trying to do a partial removal. What did he actually remove?

A. He removed the total gallbladder with the cystic duct.

Q. Does that violate the standard of care?

A. If his object was to remove the gallbladder itself, then no. If he's only trying to remove part of the gallbladder and ends up removing the whole gallbladder, then yes.

Dr. Severson testified for the defense that Anderson had Mirizzi syndrome, "a very unusual condition" where the "patient [is] infected in the bile ducts due to obstruction of a stone and develop[s] what we call ascending cholangitis-that's an infection where pus gets in the bile duct-it's an extremely dangerous infection."^[6] Dr. Severson testified there are four stages of Mirizzi syndrome. In stage four, a stone that has been trapped in the common bile duct ulcerates through the wall of the duct. In Dr. Severson's opinion, Anderson was Mirizzi stage four.

Dr. Severson testified the interoperative cholangiogram was done "to try to delineate the anatomy," which was difficult because "there was so much fibrous scarring." He stated, "The Mirizzi syndrome has created such dense scar tissue in the hepatocystic triangle that it's impossible to dissect. That is the definition of Mirizzi syndrome." A second interoperative cholangiogram was necessary-which happens "[v]ery rarely." But Dr. Prasad "needed to be absolutely sure about what the anatomy showed and where they could safely divide the infundibulum."

Dr. Severson took issue with Dr. Feinberg's interpretation of the cholangiogram:

Q. Do you have an understanding of where Dr. Feinberg thinks the dye first comes out? Or where the Kumar clamp is, let's start there.

A. He thinks it was-he says that this clamp was across the common hepatic duct and the dye was directly injected into the common hepatic duct.

Q. How would it be directly injected if the needle is down in the cystic duct?

A. It's impossible. There's no-the Kumar only has one needle that always comes out right here (indicating). It can only squirt out here (indicating). It can't squirt out here (indicating). That's the nature of the Kumar clamp.

Q. So if we played this one more time, when we had our eyes up on the end of the Kumar clamp, are we going to see dye coming out the end of that Kumar clamp and flowing in as Dr. Feinberg describes?

A. Well, if he were somehow correct, which he couldn't be because there's no-you can always see the needle. That's why needles are metal. You can always see them. There's no needle up here and there never is a Kumar clamp. They always come out here indicating). You would have dye coming in like this and it would come backwards (indicating).

Q. And does it?

A. That's what he says he saw. No, that's not the way it works.

Dr. Severson testified this three-hour surgery involved "great difficulties, many maneuvers, lots of steps and techniques trying to identify the anatomy and safely perform the surgery."

Q. And do you have an opinion as to whether those steps and techniques were appropriate?

A. Yes.

Q. And why? What is that opinion?

A. The opinion is that those were the appropriate steps.

Q. And why?

A. Well, if you can't have a critical view of safety achieved because the area that we're supposed to start the dissection in, the triangle or the hepatocystic triangle-and that's impossible because it's all fused and it's scarred in-then the infundibular technique is very good and the recommended way for surgeons to be able to continue the operation and safely go around the infundibulum. Around the infundibulum, there really should be no major structures that can get the surgeon into trouble.

Dr. Severson stated Dr. Prasad performed a different surgery than originally planned, referring to it as a “bailout procedure,” that is, “we just have to try to do our best and get out of the operating room today without trying to injure anything serious." He stated the performance of a partial gallbladder removal "allows the doctor to take out the majority of the gallbladder, hopefully control the infection and the sepsis, and get the majority of the stones out. And you try to get the patient to survive the syndrome."

Q. Was it appropriate for him to get those two cholangiograms?

A. Yes, it was very appropriate.

Q. And was it appropriate for Dr. Prasad to-was it appropriate to think that there was a

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