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ÔÔ€ÔÝ  ÝÑ  ÑÒ € ÒÒ ° ÒÒ € ÒÒ „ ÒÑ\R AØ'\ÑÑ\R AØ'\ÑÑ€ÑÑ7€šÔXXdêdÈ7ÑÑ  ÑÑ  ÑÞ ÞÌJANICE€M.€FRAKES,€surviving€spouse,à à)Ìof€GARY€D.€FRAKES,à àà àà à)Ìà àà àà àà àà àà à)Ìà àPlaintiff/Appellant,à àà àà à)Ìà àà àà àà àà àà à)à àAppeal€No.Ìà àà àà àà àà àà à)à à01„A„01„9702„CV„00069ÌVS.à àà àà àà àà àà à)Ìà àà àà àà àà àà à)à àDavidson€CircuitÌÙ€€ÙßR€!" A1-j|‘¼` ç `€€@ÿRßà àà àà àà àà àà à)à àNo.€94C„2155ÌCARDIOLOGY€CONSULTANTS,€P.C.,à à)Ìand€HARRY€L.€PAGE,€JR.,€M.D.€à àà à)à àà àà àà àà àà àÌà àà àà àà àà àà à)Ìà àDefendants/Appellees.à àà à)ÌÌÌà@ àCOURT€OF€APPEALS€OF€TENNESSEEÌà@ àMIDDLE€SECTION€AT€NASHVILLEÌÌÌAPPEALED€FROM€THE€CIRCUIT€COURT€OF€DAVIDSON€COUNTYÌAT€NASHVILLE,€TENNESSEEÌÌTHE€HONORABLE€WALTER€C.€KURTZ,€JUDGEÌÌÌÌÌRANDALL€L.€KINNARDÌKINNARD,€CLAYTON€&€BEVERIDGEÌ127€Woodmont€BoulevardÌNashville,€Tennessee€37205Ìà àAttorney€for€Plaintiff/AppellantÌÌC.€J.€GIDEON,€JR.ÌSHIRLEY€A.€IRWINÌGIDEON€&€WISEMANÌNationsBank€Plaza,€Suite€1900Ì414€Union€StreetÌNashville,€Tennessee€37219„1782Ìà àAttorneys€for€Defendants/AppelleesÌÌÌÌÌà@ àAFFIRMED€AND€REMANDEDÌÌÌÌÌà àà àà àà àà àà àà àBEN€H.€CANTRELL,€JUDGEÌÌÌNOT€PARTICIPATING:ÌSAMUEL€L.€LEWISÌÌSEPARATE€CONCURRING€OPINION:ÌWILLIAM€C.€KOCH,€JR.ÌÌÓÓÓ  Óà@ àò òòòÔ€„ÔO€P€I€N€I€O€Nó óóóÔ€XÔÌÌà àà àThe€jury€returned€a€verdict€for€the€defendant€doctor€in€this€medicalÏmalpractice€case.€€The€sole€issue€on€appeal€concerns€a€printed€table€which€theÏtrial€court€permitted€to€be€sent€back€to€the€jury€during€its€deliberations,€evenÏthough€it€was€not€formally€admitted€into€evidence€until€after€the€jury€retired.€€WeÏfind€that€it€was€not€error€to€admit€the€table,€and€we€affirm€the€jury€verdict.ÌÌà@ àò òI.ó óÌÌà à€€€In€August€of€1993,€forty„four€year€old€Gary€Frakes,€a€resident€of€Dickson,ÏTennessee,€began€suffering€from€chest€pain€and€dizziness€while€on€the€job€at€theÏFord€Glass€Plant.€€He€was€given€an€EKG€at€the€plant€and€the€result€was€normal.€ÍHis€symptoms,€which€included€left„sided€shoulder€and€facial€pain,€persistedÏintermittently€for€about€four€days,€and€he€went€to€his€family€doctor.€€Dr.€DanielÏDrinnen€examined€and€tested€Mr.€Frakes€on€August€25,€1993.€€Though€a€restingÏEKG€produced€a€normal€result,€Dr.€Drinnen€suspected€a€cardiac€problem,€andÏrecommended€that€Mr.€Frakes€be€admitted€to€Goodlark€Hospital€in€Dickson€forÏobservation.ÌÌà àà àThe€patient€preferred€St.€Thomas€Hospital€in€Nashville,€and€Dr.ÏDrinnen€accordingly€referred€him€to€a€cardiologist€associated€with€that€hospital,Ïthe€defendant€Dr.€Harry€Page.€€Mr.€and€Mrs.€Frakes€drove€the€same€day€toÏNashville,€where€the€defendant€obtained€a€medical€history,€examined€the€patient,Ïand€ordered€a€chest€x„ray,€a€resting€EKG€and€an€exercise€(treadmill)€EKG.ÌÌà àà àThe€x„ray€and€the€resting€EKG€were€normal€but€the€treadmill€testÏwas€stopped€by€the€technician€before€it€was€completed€because€of€the€patientððsÏcomplaints€of€severe€chest€pain.€€The€defendant€examined€the€EKG€strips€andÏconcluded€that€there€was€not€sufficient€medical€justification€to€admit€Mr.€Frakes€toÏthe€hospital.€€He€reassured€the€patient€that€he€was€not€having€a€heart€attack,€andÏsent€him€home€with€instructions€to€return€the€next€day€for€a€thallium€stress€test.ÌÌà àà àAfter€a€stressful€drive€home€through€a€rainstorm,€Mr.€Frakes€beganÏsuffering€chest€pains€again.€€About€three€hours€after€he€arrived€home,€and€as€heÍwas€resting€in€a€reclining€chair,€his€heart€stopped.€€He€could€not€be€resuscitated.€ÏThe€autopsy€report€listed€the€cause€of€death€as€cardiopulmonary€arrest€due€toÏatherosclerotic€coronary€artery€disease.€Ì€Ìà àà àOn€July€6,€1994€Mr.€Frakesðð€widow€filed€suit€against€Dr.€Page€andÏhis€professional€association,€Cardiology€Consultants€P.C.€€The€complaint€allegedÏthat€in€light€of€the€decedentððs€medical€history,€his€obvious€cardiac€symptoms€andÏthe€test€results,€the€standard€of€care€required€Dr.€Page€to€admit€Mr.€Frakes€to€theÏhospital,€where€timely€intervention€would€have€saved€his€life.€€The€jury€found€thatÏDr.€Page€had€not€violated€the€relevant€standard€of€care,€and€returned€a€verdict€forÏthe€defense.€€This€appeal€followed.€ÌÌà@ àò òII.ó óÌÌà àà àA€physician€treating€a€patient€must€possess€and€exercise€the€degreeÏof€skill€and€learning€possessed€and€exercised€under€similar€circumstances€byÏother€members€of€his€profession.òò€€Perkins€v.€Park€View€Hospitalóó,€61€Tenn.€App.Ï458,€456€S.W.2d€276€(1970).€€In€doing€so,€he€is€required€to€use€his€best€judgment,Ïor€he€may€be€held€liable€for€failure€to€do€so.òò€€Wooten€v.€Curry,óó€362€S.W.2d€820Ï(Tenn.€1961).€ÌÌà àà àHowever€the€fact€of€injury€does€not€raise€a€presumption€that€theÏdefendant€is€guilty€of€malpractice.€€Tenn.€Code€Ann.€ðð€29„26„115(d).€òò€Johnson€v.ÏLawrenceóó,€720€S.W.2d€50,€56€(Tenn.€App.€1986).€€Such€a€presumption€does€notÏeven€arise€where€the€injury€occurs€as€the€result€of€an€error€in€judgment€on€the€partÏof€the€physician,€as€long€as€the€judgment€was,€though€mistaken€in€the€particularÏinstance,€consistent€with€the€applicable€standard€of€care.€òò€Hurst€v.€Doughertyóó,€800ÏS.W.2d€183€(Tenn.€App.€1990).ÌÌà àà àHow€then€may€a€plaintiff€prevail€in€a€medical€malpractice€action?€ÏThe€plaintiff€must€prove€through€expert€testimony€(1)€the€appropriate€standard€ofÏacceptable€professional€practice€(2)€that€the€defendantððs€actions€or€omissionsÏdeviated€from€that€standard,€and€(3)€that€as€a€result€of€this€deviation,€the€plaintiffÏsuffered€an€injury€which€would€not€otherwise€have€occurred.€€Tenn.€Code€Ann.€ððÏ29„26„115.ÌÌà àà àIn€the€present€case,€the€defendant€does€not€seriously€dispute€that€inÏhindsight€his€judgment€of€the€significance€of€Mr.€Frakes€symptoms€was€incorrect.€ÏHe€even€admits€that€if€Mr.€Frakes€had€been€hospitalized€at€St.€Thomas€on€AugustÏ25€instead€of€being€told€to€return€home,€he€would€probably€have€lived€through€theÏnight.€However€the€question€the€jury€was€required€to€answer€was€whether€inÏmaking€his€judgment€(without€the€benefit€of€hindsight)€Dr.€Page€deviated€from€theÏrecognized€standard€of€acceptable€professional€practice.ÌÌà àà àThe€jury€found€that€he€did€not.€€On€appeal,€the€plaintiff€argues€thatÏthe€jury€based€its€conclusion€upon€a€piece€of€evidence€that€should€not€have€beenÏadmitted,€and€should€not€have€been€present€in€the€jury€room€during€theirÏdeliberations.€We€overrule€the€plaintiffððs€contention,€and€we€affirm€the€jury€verdictÏbecause€we€believe€the€trial€court€did€not€abuse€its€discretion€in€admitting€theÏtable,€and€that€even€if€it€did,€the€error€was€harmless.ÌÌà@ àò òIII.ó óÌÌà àà àMrs.€Frakes€called€Dr.€Richard€S.€Crampton,€a€Virginia€cardiologist,Ïas€her€expert€witness.€€Dr.€Crampton€testified€that€the€standard€of€care€required€aÏpatient€showing€the€symptoms€and€test€results€demonstrated€by€Mr.€Frakes€to€beÏhospitalized€immediately.€€Emphasizing€Mr.€Frakesðð€failure€to€complete€theÏexercise€EKG,€and€the€evidence€on€the€test€strip,€Dr.€Crampton€stated,€ð ð.€.€.€whenÏyou€have€the€combination€of€exercise„induced€chest€pain€with€ST„segmentÏdepression,€it€is€virtually€diagnostic.€It€means€you€have€coronary€artery€disease,Ïand€it€is€symptomatic€and€dangerous.€Thereððs€the€risk€of€heart€attack€and€the€riskÏof€sudden€death.ðð€Ì€Ìà à€à àOn€cross„examination,€Dr.€Pageððs€attorney€questioned€Dr.€CramptonÏextensively€about€the€test€strip€from€the€exercise€EKG.€€To€do€so,€he€had€markedÍfor€identification€as€Exhibit€14€an€enlarged€copy€of€a€table€entitled€ð ðExercise€TestÏParameters€Associated€With€Poor€Prognosis€and/or€Increased€Severity€of€CADððÏ(CAD€meaning€coronary€artery€disease).€€Dr.€Crampton€acknowledged€that€heÏwas€familiar€with€the€table;€that€it€was€included€in€a€brochure€produced€by€theÏAmerican€College€of€Cardiology€and€the€American€Heart€Association,€and€that€itÏrepresented€a€consensus€statement€on€the€interpretation€of€exercise€treadmillÏtests.€€€€ÌÌà àà àThe€defendantððs€attorney€asked€Dr.€Crampton€about€each€of€theÏparameters€listed€on€the€table,€including€the€onset,€magnitude€and€post„exerciseÏduration€of€ST„segment€depression,€and€got€Dr.€Crampton€to€acknowledge€thatÏthe€exercise€test€strip€did€not€contain€any€results€that€could€be€consideredÏabnormal€by€the€standards€found€on€the€table.€€Dr.€Crampton€insisted€that€theÏearly€termination€of€the€test€prevented€Mr.€Frakes€from€reaching€his€maximumÏheart€rate,€and€that€this€in€turn€prevented€his€ST„segment€depression€fromÏreaching€a€diagnostic€level.€€However,€he€conceded€that€before€the€test€wasÏterminated,€Mr.€Frakes€had€completed€Stage€2€of€the€standard€protocol€for€theÏconduct€of€exercise€stress€tests€(the€Bruce€Protocol).€€He€also€acknowledged€thatÏMr.€Frakes€died€as€a€result€of€sudden€cardiac€arrest,€not€of€heart€attack.€TheÏplaintiffððs€attorney€did€not€ask€Dr.€Crampton€any€questions€on€re„direct.ÌÌà àà àThe€plaintiff€then€called€Dr.€Page€and€questioned€him€about€hisÏtreatment€of€Mr.€Frakes.€€On€cross„examination€Dr.€Page€stated€that€the€above„mentioned€guidelines€represented€the€accepted€standard€of€professional€practiceÏfor€cardiologists€at€the€time€of€the€testing€on€Mr.€Frakes.€€The€attorney€led€himÏthrough€the€same€steps€in€the€interpretation€of€the€exercise€EKG€as€he€had€withÏDr.€Crampton,€with€Dr.€Page€responding€at€each€stage€that€the€data€on€the€testÏstrip€did€not€reach€the€diagnostic€levels€set€out€in€the€table.€ÌÌà àà àThe€plaintiff€also€called€a€forensic€pathologist,€Dr.€Gerald€T.€Gowitt,Ïfor€questioning€of€his€review€of€the€autopsy€report.€€On€cross„examination,€Dr.ÏGowitt€testified€that€the€autopsy€showed€that€Mr.€Frakes€died€from€sudden€cardiacÏarrest,€a€ð ðheart€rhythm€disturbance€precipitated€by€blockage€in€the€coronaryÏarteries.ðð€€Mr.€Frakesðð€heart€was€otherwise€healthy,€and€there€was€no€evidenceÏthat€he€had€suffered€a€heart€attack.Ì€€€Ìà àà àAfter€completing€his€case„in„chief,€Mrs.€Frakesðð€attorney€moved€inÏlimine€that€the€defendant€not€be€permitted€to€use€the€enlarged€table€in€hisÏquestioning€of€his€own€expert.€€The€basis€of€the€motion€was€Rule€618€of€theÏTennessee€Rules€of€Evidence,€which€states€that€learned€treatises€may€be€used€forÏimpeachment€purposes,€but€not€as€substantive€evidence.€€The€court€denied€theÏmotion.€€ÌÌà àà àDuring€his€portion€of€the€proof,€the€defendant€called€anotherÏcardiologist,€Dr.€Phillip€C.€Watkins.€€Dr.€Watkins€also€testified€that€the€guidelines€inÏExhibit€14€represented€the€recognized€standard€of€care€for€the€interpretation€ofÏexercise€stress€tests.€€Like€the€other€experts,€he€was€questioned€about€theÏexercise€test€strips€in€light€of€those€guidelines,€and€he€too€testified€that€none€of€theÏtest€results€could€be€considered€abnormal.€€He€also€stated€that€completion€ofÏStage€2€of€the€Bruce€Protocol€meant€that€enough€stress€had€been€placed€uponÏthe€patientððs€heart€to€make€the€test€results€reliable,€and€he€concluded€that€Dr.ÏPage€had€not€violated€the€standard€of€care€by€choosing€not€to€hospitalize€Mr.ÏFrakes.ÌÌà àà àAt€the€conclusion€of€the€defendantððs€proof,€the€plaintiffððs€attorneyÏmoved€that€Exhibit€14€not€go€back€to€the€jury,€on€the€basis€that€it€was€a€hearsayÏdocument€that€had€not€been€formally€admitted.€€The€court€rejected€the€motion,Ïstating€that€all€the€experts€had€adopted€the€document€as€a€correct€statement€of€theÏstandard€of€care,€and€that€it€would€serve€as€a€useful€tool€for€the€jury.€€TheÏdefendantððs€attorney€then€moved€for€admission€of€the€document,€ð ðif€I€forgot€to€doÏit,ðð€and€his€motion€was€granted.ÌÌà@ àò òIV.ó óÌÌà àà àThe€appellant€presents€three€grounds€for€his€challenge€to€theÏadmission€of€Exhibit€14:€€that€it€is€a€hearsay€document;€that€it€was€used€for€anÏimpermissible€purpose,€and€that€the€timing€of€the€motion€for€admission€unfairlyÏprevented€him€from€offering€any€meaningful€counter„proof.€€We€will€examine€eachÏof€these€arguments€in€turn.€ÌÌà àà àThe€appellant€points€out€that€the€guidelines€table€was€prepared€byÏan€unknown€number€of€unknown€doctors€who€were€not€present€and€were€notÏsubject€to€cross„examination€at€trial.€€As€such,€when€presented€to€prove€the€truthÏof€the€matter€it€addresses,€it€constitutes€hearsay.€€See€Tennessee€Rule€ofÏEvidence€801.ÌÌà àà àThe€appellant€acknowledges€that€even€though€it€is€hearsay,€theÏRules€of€Evidence€permit€the€use€of€the€table€for€a€limited€purpose:ÌÒ 0 ÒÒ „ ÒÒ 0 ÒÒ  ÒÓÓà àò òRule€618.€Impeachment€of€expert€byÏlearned€treatises.€ó ó„„€To€the€extent€called€to€the€attentionÏof€an€expert€witness€upon€cross„examination€or€reliedÏupon€by€the€witness€in€direct€examination,€statementsÏcontained€in€published€treatises,€periodicals,€or€pamphletsÏon€a€subject€of€history,€medicine,€or€other€science€or€art,Ïestablished€as€a€reliable€authority€by€the€testimony€orÏadmission€of€the€witness,€by€other€expert€testimony,€or€byÏjudicial€notice,€may€be€used€to€impeach€the€expertÏwitnessððs€credibility,€but€may€not€be€received€asÏsubstantive€evidence.€ÌÌÒ € ÒÒ  ÒÒ € ÒÒ „ ÒÓÓÌà àà àThere€is€no€doubt€that€the€appellee€used€the€table€very€effectively€toÏimpeach€Dr.€Crampton,€first€through€his€own€testimony,€and€then€through€theÏtestimony€of€Dr.€Page€and€Dr.€Watkins.€€The€table€was€also€used€to€organize€theÏexpert€testimony€to€assist€the€trier€of€fact€to€more€easily€understand€a€highlyÏtechnical€subject.€€See€Tennessee€Rules€of€Evidence€702€and€703.ÌÌà àà àBeyond€that,€the€appellee€argues€that€the€document€could€no€longerÏbe€considered€hearsay€after€Dr.€Page€and€Dr.€Watkins€had€each€adopted€it€byÏasserting€in€their€respective€testimony€that€it€represented€the€standard€of€care€forÏcardiologists.€We€hesitate€to€give€an€unqualified€endorsement€to€the€concept€thatÏa€hearsay€document€can€be€transmuted€into€non„hearsay€by€virtue€of€its€adoptionÏby€a€witness.€We€note,€however,€that€the€table€was€used€for€a€legitimate€purpose,Ïthat€its€contents€were€extensively€explored€in€the€questioning€of€three€witnesses,Ïand€that€this€is€not€a€situation€where€a€jury€is€improperly€exposed€to€unexaminedÏhearsay.€€As€the€trial€judge€pointed€out€in€ruling€on€the€motion€to€admit€theÏdocument,€the€result€was€exactly€the€same€as€if€one€of€the€experts€had€beenÏasked€to€go€to€the€board€and€list€the€standards€to€be€applied€in€interpreting€theÏstress€test.€€By€the€end€of€the€trial€the€exhibit€was€simply€a€statement€of€what€atÏleast€two€experts€testified€was€the€standard€of€care€with€respect€to€reading€the€testÏresults.ÌÌà àà àThe€appellee€argues€that€the€table€was€admissible€as€an€exceptionÏto€the€hearsay€rule€under€the€Tennessee€Rules€of€Evidence:€€€€€ÌÒ 0 ÒÒ „ ÒÒ 0 ÒÒ  ÒÓÓà àò òRule€803.€Hearsay€exceptions.€„„€ó óTheÏfollowing€are€not€excluded€by€the€hearsay€rule:ÌÌ(1.1)€.€.€.Ì.€.€.Ì(17)€ò òMarket€Reports€and€CommercialÏPublications.„„ó ó€Market€quotations,€tabulations,€lists,Ïdirectories,€or€other€published€compilations,€generallyÏused€and€relied€upon€by€the€public€or€by€persons€inÏparticular€occupations.ÌÒ € ÒÒ  ÒÒ € ÒÒ „ ÒÓÓÌÌà àà àThe€guidelines€table€is€neither€a€market€report€nor€a€commercialÏpublication,€and€despite€the€fact€that€€all€the€expert€witnesses€agreed€thatÏcardiologists€relied€upon€it€we€do€not€agree€that€it€is€the€type€of€list€that€comesÏwithin€paragraph€17€of€Rule€803.€€We€rely€instead€on€the€fact€that€two€of€the€threeÏexperts€testified€that€it€represented€the€standard€of€care€for€the€profession.€TheÏthird€(Dr.€Crampton)€implied€that€the€table€was€neither€totally€accurate€norÏcomplete,€but€he€acknowledged€that€it€embodied€the€consensus€standard€amongÏcardiologists.ÌÌà àà àThe€admissability€of€evidence€is€within€the€sound€discretion€of€theÏtrial€court.€òò€Inman€v.€Aluminum€Co.€Of€Americaóó€697€S.W.€2d€350€(Tenn.€AppÏ1985);òò€Austin€v.€City€of€Memphisóó,€684€S.W.2d€624€(Tenn.€App€1984).€€TheÍcolloquy€between€the€trial€court€and€counsel€for€both€parties€indicates€that€theÏtable€was€admitted€because€the€court€believed€that€it€had€been€thoroughlyÏexplored,€that€all€the€expert€witnesses€had€conceded€that€it€was€relevant€inÏdetermining€the€standard€of€care,€and€that€it€would€aid€the€jury€in€understanding€aÏdifficult€subject.€€After€thoroughly€reviewing€the€record€in€this€case,€we€concludeÏthat€the€trial€court€did€not€abuse€its€discretion€in€admitting€Exhibit€14.€ÌÌà àà àWe€agree€with€the€appellant€that€the€timing€of€the€motion€forÏadmission€of€the€table€was€unfortunate.€€It€appears€to€us,€however,€that€theÏappellant€was€not€prejudiced€by€the€fact€that€the€exhibit€was€not€admitted€untilÏafter€oral€argument.€€For€example,€the€appellant€did€not€have€to€know€that€theÏtable€would€be€admitted€in€order€to€understand€the€need€to€repair€the€damageÏcaused€by€the€cross„examination€of€Dr.€Crampton.€€The€same€could€be€said€forÏthe€need€to€address€the€contents€of€the€table€in€oral€argument.ÌÌà àà àWhile€we€obviously€cannot€endorse€the€practice€of€admittingÏevidence€after€the€proof€has€been€closed,€creating€an€absolute€prohibition€onÏsuch€an€action€would€limit€the€courtððs€discretion€to€correct€the€oversight€of€anÏadvocate€who€has€had€an€exhibit€marked€for€identification,€and€inadvertentlyÏfailed€to€take€the€next€step.€Whether€the€timing€of€the€appelleeððs€motion€was€dueÏto€inadvertence,€or€the€result€of€a€calculated€ð ðambushðð€as€the€appellant€claims,€weÍstill€believe€that€the€trial€court€acted€within€the€bounds€of€its€discretion€in€admittingÏthe€table.ÌÌò òà@ àV.ó óÌÌà àà àThe€judgment€of€the€trial€court€is€affirmed.€€Remand€this€cause€to€theÏCircuit€Court€of€Davidson€County€for€further€proceedings€consistent€with€thisÏopinion.€Tax€the€costs€on€appeal€to€the€appellant.ÌÌÓÓÌÌà àà àà àà àà àà à________________________________Ìà àà àà àà àà àà àBEN€H.€CANTRELL,€JUDGEÌÑ Ü ÑÑ X ÑÑ  Ñà@ à