ÿWPC¡ *éMYLô=Ÿ§yóÙáõÅ2Ad8”£©(ÓƒE£mº½é¥ek6ÀãÐé‹Kr²¤nhX# 0ˆa U Né ^ 7 wC zG ÒÁ 4“ § ¶ m¸ ÆÏ Æ• Æ[ Æ!UNçN57 0D?Eƒ……………………………………………………………b–––––––––––––––––––––––––––––––––––– 0ëžžžž B‰‰ 0¤¦ D3J D-} 0Kªª ASõÆH 0¤ 0D² A«ö˜HP LaserJet 4050 Series PCL 6ÈÈ,,,,ÈÈ0» &Times New Roman(`£ª$¡¡Ñ€.ÑÑ8€½­»»d»»d8ÑÑ ý ÑÓ  Ó(í€"  Z6Times New Roman Regular„q,-s  ˜C:\PROGRA~1\COREL\WORDPE~1\TEMPLATE\CUSTOM~1\REVISE~1.WPTC:\Program Files\Corel\WordPerfect Office 2000\Template\Custom WP Templates\revised standard opinion.wpt9‚±,,C¥k|’§3|xÿU‹ÿÀÀÀLevel 1Level 2Level 3Level 4Level 5‚Level 1Level 2Level 3Level 4Level 5„Level 1Level 2Level 3Level 4Level 5…Level 1Level 2Level 3Level 4Level 5(ÖÃ9 Z‹6Times New Roman Regular (#Ã$òòÚ  Ú0Ú  Úóó Ý ƒR0²$ÝÓ  Óà  àòòÚ  Ú1Ú  ÚóóÔ€ôíò»»ÔÝ  ÝÔ_ÔIt€is€respectfully€suggested€that€Tennessee€might€do€well€to€follow€the€Supreme€Court€of€Montana€wherein€itÐ ° Ðheld:Ð tÄ ÐÌà8  àà ` àWe€agree€with€Ô_ÔBNÔ_Ô€that€the€answer€given€by€Dr.€Ô_ÔSchimpffÔ_Ô€is€not€strong€and€clear.€€This€CourtÐ üL Ðhas€generally€adhered€to€a€test€of€ð ðreasonable€medical€certaintyðð€as€the€basis€for€admissibility€althoughÐ À Ðwe€do€not€require€of€doctors€the€same€strictness€in€testifying€that€was€once€required.€€See€òòÔ_ÔStordahlÔ_Ô€v.Ð „Ô ÐRush€Implement€Companyóó€(1966),€148€Mont.€13,€417€P.2d€95.€€Although€we€still€formally€adhere€toÐ H ˜ Ða€ð ðreasonable€medical€certaintyðð€standard,€the€term€is€not€well€understood€by€the€medical€profession.€Ð  \ ÐLittle,€if€anything,€is€ð ðcertainðð€in€science.€€The€term€was€adopted€in€law€to€assure€that€testimonyÐ Ð  Ðreceived€by€the€fact€finder€was€not€merely€conjectural€but€rather€was€sufficiently€probative€to€beÐ ” ä  Ðreliable.€€We€are€striving€for,€what€in€fact,€is€a€probability€rather€than€a€possibility.€€Our€evidentiaryÐ X ¨  Ðstandards€are€satisfied€if€medical€testimony€is€based€upon€an€opinion€that€it€is€ð ðmore€likely€than€not.ðð€Ð  l  ÐWe€find€that€Dr.€Ô_ÔSchimpffÔ_Ôððs€testimony€regarding€ð ðpermanencyðð€was€sufficient€for€the€jury€to€find€itÐ à 0  Ðprobable€that€Dallasðð€present€symptomatic€condition€would€not€improve€during€his€lifetime.Фô Ð Ð  ÐÌòòDallas€v.€Burlington€Northern,€Inc.óó,€689€P.2d€273,€277€(Mont.€1984).Ð ,|  ÐÌà  àThus€did€Montana€allow€the€ð ðmagic€wordsðð€to€disappear€back€into€the€abyss€of€uncertainty€from€whence€theyÐ ´  Ðcame.- ù-(|G20²$¤¤Ý ƒ£ª!ÝÑ€.ÑÑ8€W%»»dXXdì8ÑÑ ý ÑÓ  ÓÝ  Ýà  àòòÚ  Ú0Ú  ÚóóÔ€ôíò»»Ô d(|3ÉS$££Ý ƒ£ª!ÝÑ€.ÑÑ8€W%»»dXXdì8ÑÑ ý ÑÓ  ÓÝ  ÝVVVV'ÿÿdxd)!ÈÈÈÈdxdx( ±þ$’’ò òFigure€Ú  Ú1Ú  Úó ó^_X`YEþÿ<<CÿÿƒLevel 1Level 2Level 3Level 4Level 5(|3ÉS$¢¢Ý ƒ£ª!ÝÑ€.ÑÑ8€W%»»dXXdì8ÑÑ ý ÑÓ  ÓÝ  Ý($$””ò òÚ  Ú1Ú  Úó óX[Z&OLE 2.0 Box <=8ÿÿÿÿÿÿÿÿÿÿCÿÿ HKKKKÝ ƒ£ª!ÝÑ€.ÑÑ8€W%»»ddÈ8ÑÑ ý ÑÓ  ÓÝ  ÝÔ_ÔÑ  ÑÔ€¼W%»»»ÔÑ8€ )XXdì»»d8ÑÑ  ÑÑ ý Ñà@ü ü ìàÔ‡îKtW%ÔIN€THE€COURT€OF€APPEALS€OF€TENNESSEEˆÐ ° Ðà@kk$ìàAT€NASHVILLEÔ#†¼W%»îîKt#ԈРÖ& ÐÓ  Ó€January€10,€2002€SessionÐ üL ÐÔ‡X )X»¼W%ÔÌò òÔ#†¼W%»XX )#ÔVICKIE€BARA,€òòet€al.óó€v.€CLARKSVILLE€MEMORIAL€HEALTHÐ úJ ÐSYSTEMS,€INC.,€d/b/a€CLARKSVILLE€MEMORIAL€HOSPITAL,€òòET€AL.óóÔ‡X )X»¼W%Ôó óÐ  ^ ÐÌà@@½½ìàò ò€Appeal€from€the€Circuit€Court€for€Montgomery€CountyÐ  ^ Ðà@@øøìàNo.€C12„852€€€€€€James€E.€Walton,€JudgeÐ ú J ÐÌÌà@@ìì*ìàßA€V) °°` d€÷E<½` AßÐ ¾  ÐÌà@@TTìàNo.€€M2001„00682„Ô_ÔCOAÔ_Ô„R3„CV€„€Filed€September€12,€Ô_Ô2002Ô_ÔÐ ¹  ÐÌßA€V) °°` dE<` AßÐ ‘á  Ðó óÌÓ  ÓÔ‡X )XXX )ÔParents€of€deceased€child€sued€Clarksville€Memorial€Hospital€and€Dr.€David€Miller€for€the€death€ofÐ ŒÜ Ðtheir€child.€€They€alleged€this€death€occurred€due€to€Defendantsðð€mis„diagnosis€of€their€daughterððsÐ xÈ Ðinjuries€following€an€automobile€accident€and€subsequent€incorrect€and€negligent€treatmentò ò.ó ó€€TheÐ d´ Ðjury€returned€a€verdict€for€Defendants.€€Plaintiffs€now€appeal€alleging€two€points€of€error€in€the€juryÐ T¤ Ðinstructions;€(1)€that€it€was€error€to€charge€the€jury€that€Plaintiffs€must€prove€causation€to€aÐ @ Ðreasonable€degree€of€medical€certainty€and;€(2)€that€it€was€error€to€charge€the€jury€that€they€must€findÐ ,| Ðthe€childððs€death€to€be€reasonably€foreseeable.€€We€find€that€the€jury€instructions€on€reasonableÐ h Ðdegree€of€medical€certainty€and€foreseeability€were€incorrect€statements€of€the€law,€confusing€to€theÐ T Ðjury,€and€more€probably€than€not,€affected€the€juryððs€verdict.€€We€thus€reverse€the€judgment€andÐ ð@ Ðremand€for€a€new€trial€as€to€Defendant€Miller.€€We€affirm€the€judgment€in€favor€of€ClarksvilleÐ Ü, ÐMemorial€Hospital.€€Ô#†X )XXX )(#ÔÔ#†¼W%»XX )Ö#ÔÔ‡X )X»¼W%ÔÐ È ÐÌÌÓÓò òTenn.€R.€App.€P.€3€Appeal€as€of€Right;€Judgment€of€the€Circuit€Court€Ð ŒÜ ÐReversed€and€Remanded€as€to€Defendant€Dr.€MillerÐ x È ÐAffirmed€and€Remanded€as€to€Defendant€Clarksville€Memorial€Hospital€ó óÐ d!´  ÐÌÌòòÓ  ÓÔ#†¼W%»àX )] #ÔÔ‡X )X.¼W%ÔWilliam€B.€Cain,óó€J.,€delivered€the€opinion€of€the€court,€in€which€òòóóPòòATRICIAóó€J.€CòòOTTRELLóó,€J.€andÐ ($x# ÐòòóóIòòRVINóó€H.€KòòILCREASEóó,€JòòRóó.,€SòòPóó.€J.,€joined.Ð %d $ ÐÌJoe€Bednarz,€Sr.€and€Joe€Bednarz,€Jr.,€Nashville,€Tennessee,€for€the€appellants,€Vickie€Bara€and€JohnÐ ì&<"& ÐPaul€Ô_ÔBaraÔ_Ô.€Ð Ø'(#' ÐÌWayne€L.€Robbins,€Jr.,€Nashville,€Tennessee,€for€the€defendant,€David€S.€Miller,€M.D.Ð °)%) ÐÌRobert€L.€Trentham€and€G.€Brian€Jackson,€Nashville,€Tennessee,€for€the€appellee,€ClarksvilleÐ ˆ+Ø&+ ÐMemorial€Hospital.Ð t,Ä', ÐÓ¦ Óò òOPINIONó óÔ#†¼W%»XX )Õ #ÔÔ‡X )X»¼W%ÔÐ `-°(- ЇòòóóÔ#†¼W%»XX )Ö#ÔÔ‡X )X»¼W%ÔÓ  Óà  àÔ‡X )XXX )ÔSofia€Bara,€deceased,€€was€in€an€auto€accident€on€November€30,€1997.€€She€was€taken€to€theÐ ° Ðemergency€room€at€Clarksville€Memorial€Hospital€where€she€was€examined€by€an€emergency€roomÐ œì Ðphysician.€€The€ER€physician€ordered€a€CT€scan€of€her€abdomen€and€called€in€Defendant,€surgeonÐ ˆØ ÐDr.€David€Miller,€for€consultation€regarding€the€possibility€of€internal€injuries.€€Dr.€Miller€viewedÐ tÄ Ðthe€CT€scan€and€examined€Sofia.€€He€then€admitted€her€to€the€hospital€for€observation€at€around€2:00Ð `° Ða.m.€on€the€night€of€the€accident.€€Ð L œ ÐÌà  àThe€CT€scan€showed€some€fluid€around€her€liver,€but€the€fluid€appeared€to€Dr.€Miller€to€beÐ $ t Ðfatty€tissue,€as€Sofia€was€quite€overweight.€€He€saw€her€again€around€2:00€p.m.€the€followingÐ  ` Ðafternoon,€at€which€time€she€was€drinking€and€asking€for€food;€however,€he€did€not€perform€aÐ ü L  Ðphysical€examination€at€that€time.€€He€spoke€with€her,€and€after€checking€her€vital€signs€and€talkingÐ è 8  Ðwith€her€mother,€he€stated€that€it€would€be€fine€for€her€to€go€home.€€However,€Dr.€Miller€did€notÐ Ô$  Ðdischarge€her€at€that€time,€nor€did€he€provide€any€discharge€instruction.€€Sofia€also€had€anÐ À  Ðorthopaedic€injury€and€still€needed€to€be€seen€by€her€orthopaedic€surgeon€prior€to€any€discharge.€Ð ¬ü  ÐThere€was€a€question€at€trial€as€to€who€actually€discharged€Sofia.Ð ˜è  ÐÌà  àShe€was€discharged€at€around€7:20ò ò€ó óp.m.€on€the€evening€of€November€30,€1997,€and€sentÐ pÀ Ðhome€with€no€discharge€instructions€regarding€a€possible€internal€injury€or€the€potential€for€internalÐ `° Ðbleeding.€€She€continued€to€feel€ill€and,€on€the€night€of€December€1,€was€found€unconscious.€€SheÐ Lœ Ðdied€before€she€could€be€transported€to€the€hospital.€€Her€parents,€Vickie€and€John€Paul€Bara,Ð 8ˆ Ðbrought€suit€against€Dr.€David€Miller€and€Clarksville€Memorial€Hospital€for€malpractice.Ð $t ÐÌà  àThe€case€was€tried€to€a€jury€in€October€2000,€and€the€jury€rendered€a€verdict€finding€no€faultÐ üL Ðon€the€part€of€either€Defendant.€€Plaintiffs€appeal€the€verdict€asserting€that€(1)€the€jury€wasÐ è8 Ðincorrectly€charged€that€Plaintiffs€must€prove€causation€to€a€reasonable€degree€of€medical€certainty,Ð Ô$ Ð(2)€the€jury€was€incorrectly€charged€that€Plaintiffs€had€the€burden€of€proving€by€a€preponderance€ofÐ À Ðthe€evidence€that€the€death€of€Sofia€Bara€was€reasonably€foreseeable,€and€(3)€the€jury€verdict€wasÐ ¬ü Ðagainst€the€weight€of€the€evidence.€€We€agree€that€as€to€Dr.€Miller€the€jury€was€incorrectly€chargedÐ ˜è Ðon€causation€and€foreseeability€and€find€that€these€errors€likely€affected€the€outcome€of€the€trial.€€TheÐ „Ô Ðjudgment€is€reversed€as€to€Dr.€Miller€and€the€case€remanded€for€a€new€trial.Ð pÀ ÐÌò òó óòòÓ  ÓSTANDARD€OF€REVIEWÐ H!˜ ÐóóÓ§ÓÌà  àThe€necessity€of€jury€instructions€based€on€a€clear€and€sound€exposition€of€the€law€in€orderÐ  #p! Ðfor€a€jury€verdict€predicated€upon€those€instructions€to€stand€is€a€long€standing€principle€ofÐ  $\" ÐTennessee€law.€€€ð ðThe€parties€are€entitled€to€a€clear€and€consistent€charge,€as€well€as€a€correct€one,Ð ø$H # Ðthat€justice€may€be€reached.ðð€€òòCitizensðð€Street€Railroad€Co.€v.€Shepherdóó,€64€Ô_ÔS.W.Ô_Ô€710,€711€(Tenn.Ð ä%4!$ Ð1901).€€A€verdict€will€be€reversed€if€it€can€be€shown€that€an€instruction€contains€an€inaccurateÐ Ð& "% Ðstatement€of€the€law€or€is€confusing€and,€considering€the€charge€of€the€court€as€a€whole,€that€the€errorÐ ¼' #& Ðwas€not€harmless,€i.e.€that€the€instruction€more€likely€than€not€affected€the€outcome€of€the€trial.€Ð ¨(ø#' ÐòòCardwell€v.€Goldenóó,€621€S.W.2d€774€(Tenn.€Ct.€App.€1981);€òòHelms€v.€Weaveróó,€770€S.W.2d€552Ð ”)ä$( Ð(Tenn.€Ct.€App.€1989);€òòWhitsett€v.€McCort,óó€1990€Tenn.€App.€Lexis€611,€at€*20€(Tenn.€Ct.€App.Ð €*Ð%) ÐAugust€28,€1990).€€Ð l+¼&* Їà8  àà ` àThe€real€question€on€this€issue,€then,€is€whether€the€error€should€beÐ ° Ðconsidered€harmless.€.€.€.€€Tenn.€R.€App.€Proc.€36(b)€states€that€a€judgment€should€notÐ œì Ðbe€set€aside€unless,€considering€the€whole€record,€the€error€more€probably€than€notÐ ˆØ Ðaffected€the€judgment€or€would€result€in€prejudice€to€the€judicial€process.€€Our€courtsÐ tÄ Ðhave€held€that€in€order€to€amount€to€reversible€error€it€must€appear€that€the€jury€wasÐ `° Ðmislead€by€the€erroneous€charge.ÐL œÐ Ð  ÐÌòòCarney€v.€Coca„Cola€Bottling€Works€of€Tullahomaóó,€856€S.W.2d€147,€150€(Tenn.€Ct.€App.€1993)Ð $ t Ð(citations€omitted).€€This€Court€thoroughly€analyzed€the€reasoning€behind€this€requirement€forÐ  ` Ðaccuracy€in€jury€instructions€in€òòLadd€v.€Honda€Motor€Co.,€LTDóó,€939€S.W.2d€83€(Tenn.€Ct.€App.Ð ü L  Ð1996).Ð è 8  ÐÌà8  àà ` àJuries€have€the€exclusive€duty€to€decide€all€disputed€questions€of€factÐ À  Ðsubmitted€to€them€based€on€the€law€as€explained€by€the€trial€court.€€Thus,€theÐ ¬ü  Ðsoundness€of€every€jury€verdict€rests€on€the€fairness€and€accuracy€of€the€trial€courtððsÐ ˜è  Ðinstruction.€€Since€the€instructions€are€the€sole€source€of€the€legal€principles€neededÐ „Ô  Ðto€guide€the€juryððs€deliberations,€trial€courts€must€give€substantially€accurateÐ pÀ Ðinstructions€concerning€the€law€applicable€to€the€matters€at€issue.Ð\¬Ð Ð  ÐÌà8  àà ` àJury€instructions€need€not€be€perfect€in€every€detail.€€A€single€erroneousÐ 4„ Ðstatement€will€not€necessarily€undermine€otherwise€proper€instructions€that,€on€theÐ  p Ðwhole,€fairly€define€the€issues€and€do€not€mislead€the€jury.Ð \Ð Ð  ÐÌà8  àà ` àInstructions€must€be€viewed€as€a€whole,€and€the€challenged€portion€of€theÐ ä4 Ðinstructions€should€be€considered€in€light€of€its€context.€€An€erroneous€instructionÐ Ð  Ðwill€not€be€considered€reversible€error€if€the€trial€court€explains€or€corrects€it€in€otherÐ ¼  Ðportions€of€the€charge.ШøÐ Ð  ÐÌà8  àà ` àJuries€are€generally€composed€of€persons€who€do€not€have€formal€legalÐ €Ð Ðtraining.€€Accordingly,€a€trial€courtððs€instructions€should€be€couched€in€plain€termsÐ l¼ Ðthat€lay€persons€can€readily€understand.€€It€also€follows€that€appellate€courts€mustÐ X ¨ Ðview€the€challenged€instructions€not€through€the€practiced€eyes€of€a€judge€but€ratherÐ D!” Ðthrough€the€eyes€of€an€average€lay€juror.Ð0"€ Ð Ð  ÐÌòòLaddóó,€939€S.W.2d€at€93„94€(citations€omitted).Ð $X" ÐÌòòóóòòÔ#†X )XXX )o#ÔÔ‡X )XXX )ÔÓ  ÓTHE€ð ðREASONABLE€DEGREE€OF€MEDICAL€CERTAINTYðð€QUAGMIREóóÐ à%0!$ ÐÓ),ÓÌà  àTo€prevail€in€a€medical€malpractice€action,€Plaintiffs€must€present€expert€evidence€(1)Ð ¸'#& Ðestablishing€the€applicable€standard€of€care,€(2)€demonstrating€that€Defendantððs€conduct€fell€belowÐ ¤(ô#' Ðthat€standard€of€care€and,€(3)€that€Defendantððs€conduct€was€a€proximate€cause€of€injuries€whichÐ )à$( Ðâ âwould€not€otherwise€have€occurred.€€Tenn.€Code€Ann.€ðð€29„26„115(a)€(1980);€òòMoon€v.€St.€ThomasÐ |*Ì%) ÐHospitalóó,€983€S.W.2d€225,€229€(Tenn.€1998)€and€òòWhite€v.€Vanderbilt€Universityóó,€21€S.W.3d€215,Ð ° Ð226€(Tenn.€Ct.€App.€1999).Ð œì Ðâ âÌà  àThere€was€ample€medical€expert€testimony€introduced€in€the€case€under€which€a€verdictÐ tÄ Ðeither€for€the€plaintiffs€or€for€the€defendant€Dr.€Miller€would€be€unassailable€on€appeal,€assumingÐ `° Ða€correct€charge€of€the€law€to€the€jury.Ð L œ ÐÌà  àIn€examining€each€of€the€medical€experts,€able€counsel€for€all€parties€did€what€prudenceÐ $ t Ðdemanded€and€when€asking€the€expertsðð€opinion€on€any€issue€intoned€the€standard€incantation€thatÐ  ` Ðthe€doctor€base€his€opinion€upon€ð ða€reasonable€degree€of€medical€certainty.ððÐ ü L  ÐÌà  àThe€continued€usage€of€these€ð ðmagic€wordsðð€has€come€under€intense€academic€scrutiny€overÐ Ô$  Ðthe€past€decade€and€the€near€universal€conclusions€drawn€are€somewhat€startling.€€òòThe€Genesis€andÐ À  ÐEvolution€of€Legal€Uncertainty€About€ððReasonable€Medical€Certaintyóóðð€ðð€òòJeff€L.€Lewinóó,€57€Md.€L.Ð ¬ü  ÐRev.€380€(1998);€òòóóð ðòòDissecting€Missouriððs€Requirement€of€ððReasonable€Medical€Certaintyóóðð€ðð€òòGlennÐ ˜è  ÐE.€Bradfordóó,€57€Journal€of€Missouri€Bar,€136€(May€2001).Ð „Ô  ÐÌà  àIn€his€exhaustive€and€heavily€foot„noted€66€page€article€published€in€1998,€Professor€Jeff€L.Ð \¬ ÐLewin€observes:Ð H˜ ÐÌà8  àThe€universal€use€of€the€phrase€ððreasonable€medical€certainty,ðð€and€the€importanceÐ  p Ðthat€some€courts€attach€to€this€phrase,€cannot€be€explained€by€its€intrinsic€meaning,Ð  \ Ðfor€the€phrase€has€no€readily€apparent€meaning.€€The€very€notion€of€ððreasonableÐ øH Ðcertaintyðð€is€almost€an€oxymoron,€because€the€adjective€ððreasonableðð€qualifies€andÐ ä4 Ðessentially€negates€the€absolute€implications€of€the€noun€ððcertainty.ðð€€Insertion€of€theÐ Ð  Ðadjective€ððmedicalðð€does€not€reduce€the€tension€between€ððreasonableðð€and€ððcertaintyððÐ ¼  Ðfor€the€concept€of€certainty€is€just€as€elusive€in€medicine€as€in€other€scientificÐ ¨ø Ðdisciplines,€and€perhaps€more€so.ДäÐ Ð  ÐÌ57€Md.L.Review€380,€400„401€Jeff€L.€Lewin€1998.Ð l¼ ÐÌà  àAccording€to€Lewin€and€Bradford,€the€phrase€ð ðreasonable€medical€certaintyðð€originated€inÐ D!” ÐIllinois€sometime€between€1915€and€1930€and€spread€to€at€least€22€other€jurisdictions€between€1940Ð 0"€  Ðand€1960.€€Mr.€Bradford€observes:Ð #l! ÐÌà8  àGiven€the€broad€popular€usage€and€acceptance€of€the€concept€of€ððreasonable€medicalÐ ô$D # Ðcertainty,ðð€it€would€be€expected€that€the€courts€have€given€the€phrase€a€precise€andÐ à%0!$ Ðdefinite€meaning.€€On€the€contrary,€appellate€opinions€seem€to€use€the€phraseÐ Ì&"% Ðððreasonable€medical€certaintyðð€as€if€its€meaning€were€self€evident.и'#&Ð Ð  ÐÌ57€Journal€of€Missouri€Bar,€136€(Glenn€E.€Bradford€2001).Ð )à$( Ðâ âÐ |*Ì%) Ðà  àTennessee€seems€to€have€picked€up€this€language€in€òòNashville€C€&€St.€L€Railway€v.€Reevesóó,Ð ° Ðâ â157€S.W.2d€851€(Tenn.€Ct.€App.€1941)€in€a€case€dealing€with€the€admissibility€of€medical€evidenceÐ œì Ðas€to€the€permanency€of€an€injury.€€Ð ˆØ ÐÌà  àDelving€further€into€the€dicta€involving€these€ð ðmagic€wordsðð€as€a€pre„requisite€to€theÐ `° Ðadmissibility€of€expert€testimony€is€not€necessary€to€a€decision€in€this€case.€€We€are€dealing€here€withÐ L œ Ðthe€charge€to€the€jury€in€a€case€where€each€of€the€doctors€used€the€ð ðmagic€wordsðð€and€the€trial€judgeÐ 8 ˆ Ðadmitted€into€evidence€all€of€their€testimony€for€consideration€by€the€jury.Ô_Ô׃×Ý ƒ#ÃÝòòÚ  Ú1Ú  ÚóóÝ  Ý×  ×Ô_ÔÐ $ t ÐÌòòÓ  ÓEXPERT€TESTIMONY€AS€TO€PRE„DEATH€EVENTSóóÐ ü L  ÐÓ(?ÓÌà  àThe€accident€in€issue€was€a€one€car€accident€that€occurred€in€the€evening€hours€of€NovemberÐ Ô$  Ð30,€1997.€€Sofia€Ô_ÔBaraÔ_Ô€was€driving€her€fatherððs€car€accompanied€by€her€brother€Michael€and€others.€Ð À  ÐIt€had€been€raining€and€the€pavement€was€wet.€€She€lost€control€of€the€car€and€struck€a€tree€causingÐ ¬ü  Ðinjury€to€herself€and€minor€injuries€to€the€other€occupants€of€the€car.€€Both€Sofia€and€her€brotherÐ ˜è  ÐMichael€were€wearing€their€seatbelts.€€Sofia€was€taken€to€the€emergency€room€at€ClarksvilleÐ „Ô  ÐMemorial€Hospital€and€first€treated€by€Dr.€Ô_ÔDotyÔ_Ô€who€observed€symptoms€of€pain€in€her€abdomen€andÐ pÀ Ðin€her€left€foot.€€She€also€had€a€seatbelt€mark€with€bruising€in€the€abdominal€area€where€the€seatbeltÐ \¬ Ðhad€been€strapped€around€her.€€Sofia€was€obese€weighing€between€240€and€250€pounds€and€Dr.€Ô_ÔDotyÔ_ÔÐ H˜ Ðordered€a€CAT€scan€to€search€for€internal€injuries.€€The€defendant€Dr.€Miller,€a€general€surgeon,€wasÐ 4„ Ðcalled€into€the€emergency€room€and€examined€the€films€from€the€CT€scan€which€were€unremarkableÐ  p Ðexcept€for€disclosing€some€fluid€in€the€area€of€the€liver.€€Dr.€Miller€conferred€by€telephone€with€theÐ  \ Ðradiologist€Dr.€Doug€Hong.€€Dr.€Hong€in€his€report€on€the€results€of€the€CT€scan€had€referred€to€theÐ øH Ðfluid€he€found€as€ð ðascites.ðð€€He€explained:Ð ä4 Ðâ âÐ Ð  Ðà8  àWhen€we€said€ascites,€doctors€understand€usually€this€means€fluid€in€the€abdomenÐ ° Ðâ âthat€include€blood€or€any€kind€of€fluid,€even€urine€or€true€ascitic€fluid€or€even€bile€allÐ œì Ðlook€alike€on€the€CT€scan,€and€so€thatððs€what€I€meant€on€my€report€when€I€saidÐ ˆØ Ðascites€that€means€fluid€inside€of€the€abdomen.ÐtÄÐ Ð  ÐÌà  àNeither€Dr.€Miller€nor€Dr.€Hong€observed€any€laceration€of€the€liver€discernable€from€the€€Ð L œ ÐCT€scan.€€When€asked€for€the€possible€sources€of€this€free€fluid€Dr.€Hong€answered:Ð 8 ˆ ÐÌà8  àIf€you€„€„€if€we€confine€possible€source€of€fluid€„€„€I€mean€confine€the€injury€as€far€asÐ  ` Ðinjury€is€concerned,€it€could€be€injury€from€liver€or€spleen€or€it€could€be€injury€to€theÐ ü L  Ðgallbladder.€€It€could€be€injury€to€the€intestine.€€Also€it€could€be€injury€to€the€kidneyÐ è 8  Ðor€ureter.ÐÔ$ Ð Ð  ÐÌà  àDr.€Miller€opined€that€the€substance€disclosed€by€the€CT€scan€was€in€fact€fatty€tissue€aroundÐ ¬ü  Ðthe€liver€but€nonetheless€admitted€her€to€the€hospital€around€2:00€a.m.€for€continued€observation.Ð ˜è  ÐÌà  àShe€also€had€an€injury€to€her€foot€and€an€orthopaedic€specialist,€Dr.€Steven€Salyers,€wasÐ pÀ Ðcalled€in€to€treat€her€for€the€foot€injury.€€After€observing€Sofia,€Dr.€Salyers€diagnosed€a€mid„footÐ \¬ Ðinjury€and€ordered€a€CT€scan€to€rule€out€a€more€ominous€dislocation€pattern,€together€with€an€iceÐ H˜ Ðpack€for€her€left€foot€and€crutches€to€hold€down€weight€bearing.€€After€this,€Dr.€Ô_ÔSalyersÔ_Ô€testified:Ð 4„ ÐÌà8  àà ` àI€received€a€phone€call€from€one€of€the€nurses€on€the€floor,€and€she€told€meÐ  \ Ðthat€Dr.€Miller€had€transferred€Miss€Bara€to€my€service.€€And€I€told€her€that€I€did€notÐ øH Ðaccept€that€patient€in€transfer,€that€Dr.€Miller€had€not€spoken€to€me€and€arrangedÐ ä4 Ðahead€of€time€for€me€to€accept€the€patient;€and€that€if€it€was€only€the€orthopaedicÐ Ð  Ðcondition€that€was€being€treated,€that€the€patient€would€not€have€even€been€admittedÐ ¼  Ðto€the€hospital€because€it€was€a€relatively€minor€foot€fracture€that€we€were€going€toÐ ¨ø Ðinvestigate€further€to€rule€out€if€it€was€a€more€significant€injury.€€But€if€the€foot€injuryÐ ”ä Ðhad€been€her€only€injury,€she€would€not€have€been€admitted€to€the€hospital€and€I€didÐ €Ð Ðnot€feel€it€was€appropriate€for€her€to€be€transferred€to€my€service.Ðl¼Ð Ð  Ðà8  àà ` àMy€motivation,€more€than€anything,€probably,€was€I€didnððt€want€to€dictate€theÐ X ¨ Ðdischarge€summary.€€I€didnððt€want€to€do€the€orders.€€And€it€was€a€€„€„€I€did€not€agreeÐ D!” Ðto€accept€that€patient€on€my€service.Ð0"€ Ð Ð  ÐÌà  àSofia€was€seen€again€by€Dr.€Miller€at€about€2:00€in€the€afternoon€when€he€observed€no€visualÐ $X" Ðsigns€of€distress€and€discussed€with€her€mother€possible€discharge€from€the€hospital.€€About€7:00Ð ô$D # Ðp.m.€that€same€afternoon€Sofia€was€discharged€from€the€hospital€and€went€home,€though€the€recordÐ à%0!$ Ðis€unclear€as€to€who€actually€authorized€her€discharge.à p àÔ#†X )XXX ) ,#ÔÔ‡X )XXX )ÔÔ#†¼W%»XX )8#ÔÔ‡X )X»¼W%ÔòòÐ Ì&"% ÐÌà  àóóSofia€Bara€died€about€10:00€p.m.€December€1,€1997€either€at€her€home€or€en€route€to€theÐ ¤(ô#' Ðhospital.Ð )à$( ÐÌòòÐ h+¸&* ЇÓ  ÓTHE€AUTOPSY€RESULTSóóÐ ° ÐÓÑTÓÌà  àDr.€Charles€W.€Harlan,€who€performed€the€autopsy€on€Sofia€Ô_ÔBaraÔ_Ô,€testified€that€the€hospitalÐ ˆØ Ðrecord€indicated€she€came€into€the€hospital€following€an€automobile€accident€shortly€after€midnightÐ tÄ Ðon€November€30€and€was€discharged€from€the€hospital€at€approximately€7:00€p.m.€on€November€30.€Ð `° ÐShe€returned€to€the€hospital€at€approximately€10:00€on€the€evening€of€December€1,€1997,€at€whichÐ L œ Ðtime€she€had€already€died.Ð 8 ˆ ÐÌà  àDr.€Harlan€testified€that€he€found€a€relatively€small€laceration€of€the€liver€and€approximatelyÐ  ` Ð2000€ccððs€of€blood€in€the€peritoneal€cavity€(commonly€called€the€belly).€€He€opined€that€she€bled€toÐ ü L  Ðdeath€internally€from€the€laceration€of€the€liver€during€the€period€between€the€accident€in€the€veryÐ è 8  Ðearly€hours€of€November€30,€1997€and€10:00€p.m.€on€December€1,€1997.Ð Ô$  ÐÌòòÓ  ÓEXPERT€TRIAL€TESTIMONY€ON€MALPRACTICEóóÐ ¬ü  ÐÓYÓÌà  àThere€is€little€to€be€gained,€under€the€circumstances,€in€detailing€the€expert€medical€testimonyÐ „Ô  Ðat€trial€relative€to€standard€of€care,€deviation€from€standard€of€care€and€causation.à x àIt€suffices€to€sayÐ pÀ Ðthat€there€is€expert€medical€testimony€establishing€the€standard€of€care€and€that€Dr.€Miller€deviatedÐ \¬ Ðfrom€that€standard€when,€knowing€that€the€substance€evidenced€by€the€CT€scan€could€be€blood,€heÐ H˜ Ðallowed€Sofia€to€be€discharged€from€the€hospital€too€quickly€and€without€ascertaining,€for€certain,Ð 4„ Ðthat€the€substance€on€the€CT€scan€was€in€fact€fatty€tissue€and€not€blood€and€further,€in€not€givingÐ  p Ðdetailed€discharge€instructions€relative€to€the€possibility€of€internal€bleeding.Ð  \ Ðà  àòòÌà  àóóThere€was€likewise€ample€testimony€for€the€defense€as€to€the€applicable€standard€of€care€andÐ ä4 Ðthat€Dr.€Miller€did€not€deviate€therefrom€and€that€no€action€or€inaction€by€Dr.€Miller€proximatelyÐ Ð  Ðcaused€the€demise€of€Sofia€Bara.Ð ¼  ÐÌà  àThus,€we€have€typical€questions€of€fact€to€be€resolved€by€the€jury€under€proper€instructionsÐ ”ä Ðas€to€the€law€by€the€court.Ð €Ð ÐÌòòTHE€INSTRUCTIONS€GIVEN€BY€THE€TRIAL€COURT€ESSENTIALLY€FOLLOW€THEÐ X ¨ ÐTENNESSEE€PATTERN€CIVIL€JURY€INSTRUCTIONS€WITH€TWO€CRITICAL€EXCEPTIONS,Ð D!” ÐTHE€FIRST€€INVOLVI€NG€ð ðREASONABLE€DEGREE€OF€MEDICAL€CERTAINTYðð€AND€THEÐ 0"€  ÐSECOND€INVOLVING€ð ðFORESEEABILITY€OF€DEATHðð€RATHER€THAN€GENERALÐ #l! ÐFORESEEABILITY€OF€INJURYóó.Ð $X" ÐÌà  àOver€the€objections€of€Plaintiffs,€the€trial€court€charged€the€jury€in€accordance€with€theÐ à%0!$ Ðdefendantððs€special€request€number€nine€which€asserted€ð ðin€order€for€you€to€find€that€the€injuriesÐ Ì&"% Ðand/or€death€of€Ms.€Bara€were€proximately€caused€by€the€negligence€of€any€defendant,€the€plaintiffsÐ ¸'#& Ðmust€have€proven€causation€to€a€reasonable€degree€of€medical€certainty.ððÐ ¤(ô#' ÐÌà  àThe€actual€charge€embodying€this€special€request€provides:€ð ðProof€of€causation€in€a€medicalÐ |*Ì%) Ðmalpractice€case€cannot€rest€on€conjecture.€€The€mere€possibility€of€such€causation€is€not€enough€toÐ h+¸&* Ðsustain€the€plaintiffððs€burden€of€proof.€€In€order€for€you€to€find€that€the€injuries€and/or€death€of€Ms.Ð ° ÐBara€were€proximately€caused€by€the€negligence€of€any€defendant,€the€plaintiffs€must€have€provenÐ œì Ðthat€causation€to€a€reasonable€degree€of€medical€certainty.ððÐ ˆØ ÐÌà  àAssuming€that€such€a€charge€to€the€jury€was€proper,€the€same€glaring€deficiency€confrontsÐ `° Ðthe€jury€as€has€confronted€the€bench€and€bar€for€seventy€years.€€Nobody€undertakes€to€define€theÐ L œ Ðmeaning€of€the€term.€€Prior€to€incorporating€this€special€request€number€nine€into€the€charge,€theÐ 8 ˆ Ðjudge€has€just€finished€charging€the€jury€that€Plaintiffs€have€the€burden€of€proving,€by€aÐ $ t Ðpreponderance€of€the€evidence,€all€facts€necessary€to€prove€fault€on€the€part€of€Defendants.€€Then€theÐ  ` Ðcourt€specifically€defines€preponderance€of€the€evidence€to€mean€ð ðmore€likely€true€than€not.ðð€€ThenÐ ü L  Ðit€has€charged€that€if€the€negligence€of€a€party€was€ð ða€legal€cause€of€the€injury€or€damageðð€that€partyÐ è 8  Ðis€at€fault.€€Thus,€the€two€time€honored€elements€lack€of€ordinary€care€and€legal€(proximate)€causeÐ Ô$  Ðhave€been€correctly€charged€under€a€ð ðpreponderance€of€the€evidenceðð€requirement.€€Then€on€theÐ À  Ðheels€of€these€imminently€correct€instructions€the€jury€is€told€that€ð ðproof€of€causationðð€(cause€in€factÐ ¬ü  Ðòòandóó€proximate€cause?)€must€be€proven,€not€by€a€preponderance€of€the€evidence,€but€ð ðto€a€reasonableÐ ˜è  Ðdegree€of€medical€certainty.ððÐ „Ô  ÐÌà  àThis€is€the€precise€bullet€that€the€trial€court€correctly€dodged€in€òòMiller€v.€Choo€ChooÐ \¬ ÐPartners,€L.P.óó,€73€S.W.3d€897€(Tenn.€Ctòò.€óóApp.€2001).€€When€the€defendant€challenged€the€trialÐ H˜ Ðcourtððs€refusal€to€charge€the€jury€as€to€this€ð ðreasonable€certaintyðð€element,€Judge€Susano,€for€theÐ 4„ Ðmajority€in€the€Eastern€Section€of€the€Court€of€Appeals,€countered:Ð  p ÐÌà8  àà ` àThe€defendantððs€proposed€instruction€regarding€the€requirement€that€expertÐ øH Ðtestimony€on€causation€be€ð ðreasonably€certainðð€embodies€a€correct€principle€of€law.€Ð ä4 ÐHowever,€we€do€not€find€that€it€was€error€not€to€instruct€the€jury€as€to€this€principle.€Ð Ð  ÐThat€an€expertððs€testimony€is€ð ðreasonably€certainðð€is€said€to€be€a€prerequisite€to€theÐ ¼  Ðadmissibility€of€that€testimony.€€òòSee€Lindseyóó,€689€S.W.2d€at€862.€€The€admissibilityÐ ¨ø Ðof€expert€testimony€is€a€matter€of€law€for€the€court,€not€the€jury.€€òòSee€McDaniel€v.Ð ”ä ÐCSX€Transp.,€Inc.óó,€955€S.W.2d€257,€263€(Tenn.€1997).€€The€trial€court€did€not€err€inÐ €Ð Ðrefusing€to€give€this€instruction.Ðl¼Ð Ð  ÐÌòòMilleróó,€òòóó73€S.W.3d€at€909.Ô#†¼W%»XX )æS#ÔÔ‡X )X»¼W%ÔÔ#†X )XXX )¤S#ÔÔ‡X )XXX )ÔÐ D!” ÐÌà  àThus,€Judge€Susano€correctly€points€out€the€only€justifiable€function€that€ð ðreasonable€degreeÐ #l! Ðof€medical€certaintyðð€ever€had.€€That€it€is,€(under€what€is€even€in€the€admissibility€of€evidenceÐ $X" Ðcontext€of€highly€questionable€utility),€a€gate€keeping€question€of€law€under€which€the€trial€courtÐ ô$D # Ðdecides€whether€or€not€a€doctorððs€opinion€is€admissible€in€evidence.€€It€is€not€jury€charge€materialÐ à%0!$ ÐÔ_ÔandÔ_Ô€can€only€lead€to€confusion.Ð Ì&"% ÐÌà  àIn€òòVolz€v.€Ledesóó,€895€S.W.2d€677€(Tenn.€1995),€the€supreme€court€said:Ð ¤(ô#' ÐÌà8  àà ` àT.C.A.€ðð€29„26„115(a)(3)€requires€that€a€plaintiff€in€a€medical€malpracticeÐ |*Ì%) Ðaction€prove€that€ðð[a]s€a€proximate€result€of€the€defendantððs€negligent€act€or€omissionÐ h+¸&* Ð[of€accepted€community€medical€standards],€the€plaintiff€suffered€injuries€whichÐ ° Ðwould€not€otherwise€have€occurred.ððÐœìÐ Ð  ÐÌà  àà8 ` àThis€statutory€language€is€simply€another€way€of€expressing€theÐ tÄ Ðrequirement€that€the€injury€would€not€have€occurred€but€for€theÐ `° Ðdefendantððs€negligence,€our€traditional€test€for€cause€in€fact.ÐL œ` x` x ÐÌà8  àòòKilpatrick€v.€Bryantóó,€868€S.W.2d€594,€602€(Tenn.€1993).€€Additionally,€causation€inÐ $ t Ðmedical€malpractice€cases€must€be€shown€as€a€matter€of€òòprobabilityóó,€i.e.€more€likelyÐ  ` Ðthan€not,€or€greater€than€a€50€percent€chance,€that€the€plaintiffððs€injuries€would€notÐ ü L  Ðhave€occurred€but€for€the€negligent€actions€of€the€defendant(s).€€òòIdóó.Ðè 8 Ð Ð  Ðà8  àà ` àThe€record€reveals€that€the€plaintiffs€proffered€sufficient€proof€at€trial€toÐ Ô$  Ðestablish€that€the€negligence€of€Dr.€Ledes€more€likely€than€not€was€the€proximateÐ À  Ðcause€of€the€death€of€Robert€Volz.€€Expert€medical€testimony€also€established€thatÐ ¬ü  Ðwhen€Volz€was€first€treated€by€the€defendant,€he€had€a€60€percent€chance€of€completeÐ ˜è  Ðrecovery.€€Further€the€plaintiffs€offered€uncontroverted€testimony€that€the€defendant,€Ð „Ô  ÐDr.€Ledes,€failed€to€act€in€accordance€with€accepted€community€standards€of€medicalÐ pÀ Ðpractice€for€treatment€of€the€disease€from€which€Volz€was€suffering.€€The€plaintiffsððÐ \¬ Ðproof€established,€that€as€a€result€of€the€defendantððs€deviation€from€such€medicalÐ H˜ Ðstandards,€Robert€Volz€suffered€a€death€which€otherwise€would€not€have€occurred.€Ð 4„ ÐStated€another€way,€the€record€reveals€that€it€was€more€likely€than€not€Robert€VolzÐ  p Ðwould€have€survived€the€cancer€but€for€the€defendantððs€negligent€actions.€€€Ð \Ð Ð  ÐÌòòVolz€v.€Ledesóó,€895€S.W.2d€677,€679„80€(Tenn.€1995).Ð ä4 ÐÌà  àIn€òòKilpatrick€v.€Bryantóó,€868€S.W.2d€594€(Tenn.€1993),€the€supreme€court€went€to€greatÐ ¼  Ðlengths€to€iterate€the€difference€between€causation€in€fact€and€proximate€cause€and€to€reassert€thatÐ ¨ø Ðeach€was€a€separate€element€of€negligence.€€Said€the€court:Ð ”ä ÐÌà8  àà ` àCausation€and€proximate€cause€are€distinct€elements€of€negligence,€and€bothÐ l¼ Ðmust€be€proven€by€the€plaintiff€by€a€preponderance€of€the€evidence.€€òòBradshawóó,€854Ð X ¨ ÐS.W.2d€at€869;€òòMcClenahan€v.€Cooleyóó,€806€S.W.2d€767,€774€(Tenn.€1991);€òòSmith€v.Ð D!” ÐGoreóó,€728€S.W.2d€738,€749€(Tenn.€1987).€€ð ðCausation€(or€cause€in€fact)€is€a€veryÐ 0"€  Ðdifferent€concept€from€that€of€proximate€cause.€€Causation€refers€to€the€cause€andÐ #l! Ðeffect€relationship€between€the€tortious€conduct€and€the€injury.€€The€doctrine€ofÐ $X" Ðproximate€cause€encompasses€the€whole€panoply€of€rules€that€may€deny€liability€forÐ ô$D # Ðotherwise€actionable€causes€of€harm.ðð€€King,€òòCausation,€Valuation,€and€Chance€inÐ à%0!$ ÐPersonal€Injury€Torts€Involving€Preexisting€Injuries€and€Future€Consequencesóó,€90Ð Ì&"% ÐYale€L.J.€1353,€1355€n.€7€(1981).€€Thus,€proximate€cause,€or€legal€cause,€concernsÐ ¸'#& Ða€determination€of€whether€legal€liability€should€be€imposed€where€cause€in€fact€hasÐ ¤(ô#' Ðbeen€established.€€òòMcKellips€v.€Saint€Francis€Hospóó.,€741€P.2d€467€(Okl.€1987).€Ð )à$( Ðð ðCause€in€fact,€on€the€other€hand,€deals€with€the€ððbut€forðð€consequences€of€an€act.€Ð |*Ì%) ÐððThe€defendantððs€conduct€is€a€cause€of€the€event€if€the€event€would€not€have€occurredÐ h+¸&* Ðbut€for€that€conduct.ðð€ðð€òòId.óó€at€470€(quoting€Prosser€and€Keeton,€òòThe€Law€of€Tortsóó,€266Ð ° Ð(5th€ed.€1984)).ÐœìÐ Ð  ÐòòKilpatrick€v.€Bryantóó,€868€S.W.2d€at€598.Ð ˆØ ÐÌà  àNeither€òòÔ_ÔKilpatrickÔ_Ô€v.€Bryantóó€nor€òòLindsey€v.€Miami€Development€Corp.óó,€689€S.W.2d€856Ð `° Ð(Tenn.€1985),€involve€jury€instructions€or€jury€questions€but€involve€rather€summary€judgment€and€òòÐ L œ Ðóógate€keeping€questions€of€law.€€As€said€in€òòÔ_ÔKilpatrickÔ_Ôóó:Ð 8 ˆ ÐÌà8  àThus,€proof€of€causation€equating€to€a€ððpossibility,ðð€a€ððmight€have,ðð€ððmay€have,ððÐ  ` Ðððcould€have,ðð€is€not€sufficient,€òòas€a€matter€of€lawóó€to€establish€the€required€nexusÐ ü L  Ðbetween€the€plaintiffððs€injury€and€the€defendantððs€tortious€conduct€by€aÐ è 8  Ðpreponderance€of€the€evidence€in€a€medical€malpractice€case.€€Causation€in€fact€is€aÐ Ô$  Ðmatter€of€probability,€not€possibility€and€in€a€medical€malpractice€case,€must€beÐ À  Ðshown€to€a€reasonable€degree€of€medical€certainty.Ьü Ð Ð  ÐÌòòKilpatrickóó,€868€S.W.2d€at€602.Ð „Ô  ÐÌà  àThis€Court€addressing€newly€adopted€Tenn.€Rule€of€Evidence€702€made€clear€thatÐ \¬ Ðadmissibility€was€the€question€involved€in€ð ðreasonable€degree€of€medical€certainty.ððÐ H˜ ÐÌà8  àÔ#†X )XXX )„o#ÔÔ‡X )XXX )Ôà ` àThe€expertððs€opinion€must€substantially€assist€the€jury€in€its€determination€andÐ  p Ðthe€question€of€what€will€ððsubstantiallyðð€assist€the€jury€is€one€for€the€trial€court€toÐ  \ Ðdetermine.€€The€expertððs€testimony€must€satisfy€Rule€702€and€the€threshold€questionÐ øH Ðfor€the€courtððs€determination€is€whether€the€witnessðð€testimony€ð ðwill€substantiallyÐ ä4 Ðassist€the€trier€of€fact€to€understand€the€evidence€or€to€determine€a€fact€in€issue.ðð€€TheÐ Ð  ÐTennessee€standard€is€much€more€stringent€than€its€federal€counterpart€which€merelyÐ ¼  Ðrequires€evidence€from€experts€which€ð ðassist€the€trier€of€factðð€rather€thanÐ ¨ø Ðð ðsubstantially€assist€the€trier€of€fact.ðð€€The€importance€of€the€courtððs€task€inÐ ”ä Ðdetermining€whether€the€evidence€will€substantially€assist€the€trier€of€fact€is€borne€outÐ €Ð Ðby€the€weight€given€to€an€expertððs€testimony.€€ð ðExpert€testimony€is€unique€becauseÐ l¼ Ðexperts€are€allowed€to€give€an€opinion€in€a€particular€situation€whereas€otherÐ X ¨ Ðwitnesses€are€prohibited€from€giving€opinion€testimony€in€areas€where€expertise€isÐ D!” Ðnot€required.ððÐ0"€ Ð Ð  ÐÌà  àà ` à.€.€.€.Ð $X" ÐÌà8  àà ` àNumerous€Tennessee€cases€establish€a€necessary€degree€of€medical€certaintyÐ à%0!$ Ðto€prove€causation.€€Testimony€which€amounts€to€mere€speculation€is€not€evidenceÐ Ì&"% Ðwhich€establishes€proximate€cause.€òòи'#&Ð Ð  ÐÌóóà8  àà ` àWe€find€nothing€in€the€record€or€in€the€deposition€which€shows€that€theÐ )à$( Ðâ âplaintiff€laid€the€necessary€foundation€to€prove€medical€expert€causation.€€There€isÐ |*Ì%) Ðno€evidence€to€establish€with€a€reasonable€degree€of€medical€certainty€that€plaintiffððsÐ ° Ðheart€attack€and€bypass€surgery€in€1990€resulted€from€the€accident€with€defendant.ÐœìÐ Ð  Ðâ âÌà8  àà ` àFor€the€testimony€of€a€physician€to€be€admissible,ÐtÄÐ Ð  ÐÌà8  àà0` Ð Ð àððIt€should€show€that€such€result€is€reasonably€certain€and€not€a€mereÐ L œ Ðlikelihood€or€possibility.ððÐ8 ˆ` Ð ` Ð  ÐÌà8  àà8` Ð Ð àððTo€warrant€a€recovery€for€a€permanent€injury,€the€future€effect€of€theÐ  ` Ðinjury€must€be€shown€with€reasonable€certainty.€€It€is€not€necessaryÐ ü L  Ðthat€the€evidence€show€conclusively€or€without€a€shadow€of€doubtÐ è 8  Ðthat€the€injuries€are€permanent.€€But€while€absolute€certainty€shouldÐ Ô$  Ðnot€be€required,€a€mere€conjecture,€or€even€a€probability,€does€notÐ À  Ðwarrant€the€giving€of€damages€for€future€disability€which€may€neverÐ ¬ü  Ðexist.ððИè ` x` x ÐÌà8  àà ` àTestimony€of€experts€as€to€the€probable€cause€of€injury€should€be€subject€toÐ pÀ Ðthe€same€rules€as€applied€supra€in€the€case€of€probable€effect€of€injury.€òòóóÐ\¬Ð Ð  ÐÌà  àà ` à.€.€.€.Ð 4„ ÐÌà8  àà ` àððA€doctorððs€testimony€that€a€certain€thing€is€possible€is€no€evidence€at€all.€€HisÐ  \ Ðopinion€as€to€what€is€possible€is€no€more€valid€than€the€juryððs€own€speculation€as€toÐ øH Ðwhat€is€or€is€not€possible.ðð€€ððThe€mere€possibility€of€a€causal€relationship,€withoutÐ ä4 Ðmore,€is€insufficient€to€qualify€as€an€admissible€expert€opinion.ðð€Ô#†X )XXX )5‰#ÔÔ‡X )XXX )ÔÔ#†¼W%»XX )Bo#ÔÔ‡X )X»¼W%ÔÐÐ Ð Ð  ÐÌòòÔ_ÔPrimmÔ_Ô€v.€Ô_ÔWickesÔ_Ô€Lumber€Co.óó,€845€S.W.2d€768,€770„71€(Tenn.€Ct.€App.€1992)€(citations€omitted).Ð ¨ø ÐÌà  àThus,€if€the€doctor€cannot€testify€as€to€cause€in€fact€to€a€reasonable€degree€of€medicalÐ €Ð Ðcertainty,€his€testimony€is€not€admissible€before€the€jury€and€if€there€is€no€other€expert€evidence€ofÐ l¼ Ðcausation€in€fact€in€a€medical€malpractice€case,€summary€judgment€would€be€proper.Ð X ¨ ÐÌà  àIn€the€case€at€bar,€in€their€special€request€number€nine,€Defendants€and€the€trial€court€haveÐ 0"€  Ðtaken€out€of€context€the€phrase€ð ðcausation€in€fact€is€a€matter€of€probability€and€not€possibility,€andÐ #l! Ðmust€be€shown€to€a€reasonable€degree€of€medical€certaintyðð€as€such€phrase€is€used€in€òòWhite€v.Ð $X" ÐMethodist€Hospital€Southóó,€844€S.W.2d€642,€648„49€(Tenn.€Ct.€App.€1992);€òòÔ_ÔKilpatrickÔ_Ô€v.€Bryantóó,€868Ð ô$D # ÐS.W.2d€594,€602€(Tenn.€1993);€and€òòWhite€v.€Vanderbilt€Universityóó,€21€S.W.3d€215,€232€(Tenn.€Ct.Ð à%0!$ ÐApp.€1999)€dealing€with€the€admissibility€of€expert€testimony€and€converted€it€into€a€jury€chargeÐ Ì&"% Ðwhich€is€exactly€what€òòMiller€v.€Choo€Choo€Partners,€L.P.óó,€73€S.W.3d€897€(Tenn.€Ct.€App.€2001)Ð ¸'#& Ðasserts€is€not€proper.Ð ¤(ô#' ÐÌà  àIt€is€noted€that€in€some€cases€as,€for€instance,€òòIn€re:€Twiningóó,€894€P.2d€1331,€1336„37€(Wash.Ð |*Ì%) ÐCt.€App.€1995),€the€term€ð ðreasonable€medical€certaintyðð€has€been€held€to€mean€ð ðmore€likely€thanÐ h+¸&* Ðnot.ðð€€One€is€compelled€to€ask€under€such€circumstances€why€ð ðreasonable€medical€certaintyððÐ ° Ðcontinues€to€exist.€€It€suffices€to€say€in€the€case€at€bar€that€nowhere€is€anyone€informed€that€the€twoÐ œì Ðterms€are€synonymous.Ð ˆØ ÐÌà  àThe€Supreme€Court€of€Nebraska€made€a€particularly€informative€observation€a€century€ago:€Ð `° Ðð ðIn€òòÔ_ÔAltschulerÔ_Ô€v.€Ô_ÔCoburnÔ_Ôóó,€38€Neb.€881,€891,€57€Ô_ÔN.W.Ô_Ô€836,€838,€(1894)€we€noted€that€an€attempt€toÐ L œ Ðgive€a€specific€meaning€to€the€word€reasonable€is€like€ððtrying€to€count€what€is€not€a€number,€andÐ 8 ˆ Ðmeasure€what€is€not€space.ðð€ðð€òòÔ_ÔGleasonÔ_Ô€v.€Ô_ÔGleasonÔ_Ôóó,€357€N.W.2d€463,€468€(Neb.€1984).Ð $ t ÐÌà  àAs€this€Court€has€held:€Ð ü L  ÐÌà8  àà ` àThe€real€question€on€this€issue,€then,€is€whether€the€error€should€beÐ Ô$  Ðconsidered€harmless.€.€.€.€Tenn.€R.€App.€P.€36(b)€states€that€a€judgment€should€not€beÐ À  Ðset€aside€unless,€considering€the€whole€record,€the€error€more€probably€than€notÐ ¬ü  Ðaffected€the€judgment€or€would€result€in€prejudice€to€the€judicial€process.€€Our€courtsÐ ˜è  Ðhave€held€that€in€order€to€amount€to€reversible€error€it€must€appear€that€the€jury€wasÐ „Ô  Ðmisled€by€the€erroneous€charge.€ÐpÀÐ Ð  ÐÌòòCarney€v.€Coco€Cola€Bottling€Works€of€Tullahomaóó,€856€S.W.2d€147,€150€(Tenn.€Ct.€App.€1993).Ð H˜ ÐÌà  àOn€this€subject,€the€supreme€court€has€said:Ð  p ÐÌà8  àà ` àLong€ago,€this€Court€established€the€rule€that€inconsistent€or€contradictoryÐ øH Ðinstructions€ð ðdo€not€neutralize€or€validate€each€other,€but€are€vitally€erroneous.€.€.€.€Ð ä4 ÐThe€parties€are€entitled€to€a€clear€and€consistent€charge,€as€well€as€a€correct€one,€thatÐ Ð  Ðjustice€may€be€reached.ðð€€òòCitizens€Street€Railroad€Co.€v.€Shepherdóó,€107€Tenn.€444,Ð ¼  Ð64€S.W.€710,€711€(1901).€€This€principle€was€more€recently€discussed€in€òòAbbottóó,€inÐ ¨ø Ðwhich€the€Court€of€Appeals€stated:ДäÐ Ð  Ðà  àà8 ` àInstructions€as€a€whole€must€be€consistent€and€harmonious,€notÐ €Ð Ðconflicting€and€contradictory.€.€.€.€€Where€instructions€given€to€theÐ l¼ Ðjury€for€their€guidance€present€contradictory€and€conflicting€rulesÐ X ¨ Ðwhich€are€unexplained,€and€where€following€one€would€or€might€leadÐ D!” Ðto€a€different€result€than€would€obtain€by€following€the€other,€theÐ 0"€  Ðinstructions€are€inherently€defective.€€This€is€true€although€one€of€theÐ #l! Ðinstructions€correctly€states€the€law€applicable€to€the€facts€of€the€case,Ð $X" Ðsince€the€correct€instruction€cannot€cure€the€error€in€the€contradictoryÐ ô$D # Ðerroneous€instruction.€.€.€.Ðà%0!$` x` x Ðà8  à682€S.W.2d€at€209,€quoting€75€Am.Jur.2d€òòTrialóó€ðð€628,€920€(1974),€and€citing€88Ð Ì&"% ÐC.J.S.€òòTrialóó€ðð€338„39€(1955).и'#&Ð Ð  ÐÌòòState€v.€Stephensonóó,€878€S.W.2d€530,€555€(Tenn.€1994).Ð )à$( Ðâ âÐ |*Ì%) Ðà  àUnless€one€can,€as€a€matter€of€every€day€common€sense,€say€that€ð ðreasonable€degree€ofÐ ° Ðâ âmedical€certaintyðð€and€ð ðmore€probably€than€notðð€are€synonymous€terms,€the€instructions€in€this€caseÐ œì Ðare€inconsistent€and€contradictory€and€misleading€to€the€jury.€€The€erroneous€charge€is€not€harmlessÐ ˆØ Ðbut€reversible€error.€Ð tÄ ÐÌÔ#†X )XXX )5˜#ÔÔ#†¼W%»XX )w˜#ÔòòÔ€X )X»¼W%ÔÓ  ÓFORESEEABILITYóóÐ L œ ÐÓE¯ÓÌà  àPlaintiffs€also€allege€error€in€another€jury€instruction,€which€reads€as€follows:€€ð ðIn€order€forÐ $ t Ðyou€to€find€either€defendant€to€have€been€liable,€you€must€find€by€a€preponderance€of€the€evidenceÐ  ` Ðthat€the€death€of€Sophia€Lynn€Bara€was€reasonably€foreseeable€to€the€Defendant.ðð€€Plaintiffs€assertÐ ü L  Ðthat€they€are€not€required€to€show€that€the€specific€injury,€death,€sustained€by€Sofia€was€foreseeable,Ð è 8  Ðonly€that€some€harm€was€foreseeable;€thus,€the€court€erred€in€stating€that€Plaintiff€had€to€prove€thatÐ Ô$  Ðòòdeathóó€was€foreseeable.€€However,€Defendants€argued€that,€toò òó ó€prove€foreseeability,€a€plaintiff€mustÐ À  Ðshow€that€harm€of€the€same€general€character€was€reasonably€foreseeable,€so€the€jury€instruction€wasÐ ¬ü  Ðproper.€€We€find€this€instruction€to€be€a€misleading€and€improper€statement€of€the€law.Ð ˜è  ÐÌà  àThe€Tennessee€Supreme€Court€has€clearly€set€out€the€foreseeability€requirement€for€findingÐ pÀ Ðproximate€cause.Ð \¬ ÐÌà8  àà ` àTaken€as€a€whole,€our€cases€suggest€a€three„pronged€test€for€proximateÐ 4„ Ðcausation:€(1)€the€tortfeasorððs€conduct€must€have€been€a€ð ðsubstantial€factorðð€inÐ  p Ðbringing€about€the€harm€being€complained€of;€and€(2)€there€is€no€rule€or€policy€thatÐ  \ Ðshould€relieve€the€wrongdoer€from€liability€because€of€the€manner€in€which€theÐ øH Ðnegligence€has€resulted€in€the€harm;€and€(3)€the€harm€giving€rise€to€the€action€couldÐ ä4 Ðhave€reasonably€been€foreseen€or€anticipated€by€a€person€of€ordinary€intelligence€andÐ Ð  Ðprudence.€òò€See€Smith€v.€Goreóó,€728€S.W.2d€738,€749„50€(Tenn.€1987);€òòFord€MotorÐ ¼  ÐCo.€v.€Eadsóó,€224€Tenn.€473,€457€S.W.2d€28,€32€(Tenn.€1970);€òòRay€Carter,€Inc.€v.Ð ¨ø ÐEdwardsóó,€222€Tenn.€465,€436€S.W.2d€864,€867€(Tenn.€1969);€òòLancaster€v.€Montesióó,Ð ”ä Ð216€Tenn.€50,€390€S.W.2d€217,€221€(Tenn.€1965);€òòRoberts€v.€Robertson€County€Bd.Ð €Ð Ðof€Ed.óó,€692€S.W.2d€863,€871€(Tenn.€App.€1985);€òòCaldwell€v.€Ford€Motor€Co.óó,€619Ð l¼ ÐS.W.2d€534,€541„43€(Tenn.€App.€1981);€òòWyatt€v.€Winnebago€Industries,€Inc.óó,€566Ð X ¨ ÐS.W.2d€276,€280„81€(Tenn.€App.€1977).€€The€foreseeability€requirement€is€not€soÐ D!” Ðstrict€as€to€require€the€tortfeasor€to€foresee€the€exact€manner€in€which€the€injury€takesÐ 0"€  Ðplace,€provided€it€is€determined€that€the€tortfeasor€could€foresee,€or€through€theÐ #l! Ðexercise€of€reasonable€diligence€should€have€foreseen,€the€general€manner€in€whichÐ $X" Ðthe€injury€or€loss€occurred.€€òòRobertsóó€at€871;€òòWyattóó€at€280„81.€€ððThe€fact€that€anÐ ô$D # Ðaccident€may€be€freakish€does€not€per€se€make€it€unpredictable€or€unforeseen.ðð€€òòCityÐ à%0!$ Ðof€Elizabethton€v.€Sluderóó,€534€S.W.2d€115,€117€(Tenn.€1976).€€It€is€sufficient€thatÐ Ì&"% Ðharm€in€the€abstract€could€reasonably€be€foreseen.€€òòShell€Oil€Co.€v.€Blanksóó,€46€Tenn.Ð ¸'#& ÐApp.€539,€330€S.W.2d€569,€572€(Tenn.€1959).€Ð¤(ô#'Ð Ð  ÐÌòòMcClenahan€v.€Cooleyóó,€806€S.W.2d€767,€775€(Tenn.€1991).Ð |*Ì%) ÐÐ h+¸&* Ðà8  àà ` àThe€defendant€argues€that€the€deceasedððs€act€was€so€unusual€andÐ ° Ðextraordinary€that€the€act€was€unforeseeable;€therefore,€the€defendant€was€under€noÐ œì Ðduty€to€guard€against€such€an€act.€€Accidents,€however,€ððalmost€invariably€areÐ ˆØ Ðsurprises,€in€the€sense€that€the€precise€manner€of€their€occurrence€cannot€beÐ tÄ Ðforeseen.ðð€€òòSpivey€v.€St.€Thomas€Hospitalóó,€31€Tenn.€App.€12,€211€S.W.2d€450,€455Ð `° Ð(Tenn.€Ct.€App.€1947).€€Accordingly€the€particular€harm€need€not€have€beenÐ L œ Ðforeseeable€if€another€ððharm€of€a€like€general€character€was€reasonably€foreseeable.ðð€Ð 8 ˆ ÐòòId.óó€at€457.Ð$ tÐ Ð  Ðà8  àà ` àThe€defendant€stresses€that€the€accident€was€not€foreseeable,€since€there€is€noÐ  ` Ðindication€that€another€patient€had€ever€severed€an€endotracheal€tube.€€The€record,Ð ü L  Ðhowever,€is€clear€that€a€risk€of€some€harm€is€foreseeable€if€an€endotracheal€tube€isÐ è 8  Ðoccluded€or€impaired.€.€.€.€€If€a€jury€were€to€find€that€some€harm€resulting€fromÐ Ô$  Ðocclusion€was€foreseeable€in€light€of€the€circumstances,€then€the€defendant€wouldÐ À  Ðalso€owe€a€duty€to€protect€Mr.€Garrett€from€completely€severing€the€endotrachealÐ ¬ü  Ðtube,€even€though€this€specific€harm€was€never€foreseen.€€òòSpiveyóó,€211€S.W.2d€at€457.Иè Ð Ð  ÐÌòòMoon€v.€St.€Thomas€Hospitalóó,€983€S.W.2d€225,€229€(Tenn.€1998).Ð pÀ Ðà  àÌà  àThese€cases€make€clear€that€Plaintiffs€were€not€required€to€prove€that€death€was€foreseeable,Ð H˜ Ðbut€merely€that€some€harm€could€have€foreseeably€resulted€from€Defendantsðð€action€or€inaction€and,Ð 4„ Ðthrough€the€exercise€of€reasonable€diligence,€could€have€been€foreseen.€€This€foreseeabilityÐ  p Ðinstruction€standing€alone€might€not€constitute€reversible€error€under€Ô_ÔT.R.A.P.Ô_Ô€36(b)€but€nonethelessÐ  \ Ðis€error€and€should€be€corrected€on€re„trial.Ð øH ÐÌòòÓ  ÓCONCLUSIONÐ Ð  ÐÓÄÅÓÌà  àóóThe€issue€asserted€by€Appellant€that€the€verdict€is€against€the€overwhelming€weight€of€theÐ ¨ø Ðevidence€presents€no€issue€for€appellate€review€since€Ô_ÔT.R.A.P.Ô_Ô€13(d)€provides€in€part:€€ð ðFindings€ofÐ ”ä Ðfact€by€a€jury€in€civil€actions€shall€be€set€aside€only€if€there€is€no€material€evidence€to€support€theÐ €Ð Ðverdict.ððÐ l¼ Ðà  à€Ð X ¨ Ðà  àWe€find€no€error€in€the€verdict€and€judgment€in€favor€of€Clarksville€Memorial€Hospital€andÐ D!” Ðindeed€Appellant€all€but€concedes€as€to€the€hospital€at€the€bar€of€this€court.€€We€find,€however,€thatÐ 0"€  Ðthe€charge€to€the€jury€concerning€the€burden€of€proof€on€causation€is€erroneous,€confusing,€andÐ #l! Ðmisleading€and€reversible€error.€€We€further€find€the€charge€as€to€foreseeability€to€be€in€error.Ð $X" ÐÌà  àThe€judgment€in€favor€of€Clarksville€Memorial€Hospital€is€in€all€respects€affirmed€with€costsÐ à%0!$ Ðin€that€case€assessed€against€Appellant.€€The€judgment€in€favor€of€Dr.€Miller€is€reversed€andÐ Ì&"% Ðremanded€for€a€new€trial€with€costs€assessed€to€the€appellee€Miller.Ð ¸'#& ÐÌÌÌÐ h+¸&* Ðà  àThis€case€is€remanded€to€the€trial€court€for€proceedings€in€conformity€with€this€opinion.Ð ° ÐÌà  àÌÌà  àà ` àà ¸ àà  àà h àà À à__________________________________________Ð `° Ðà  àà ` àà ¸ àà  àà h àà À àWILLIAM€B.€CAIN,€JUDGE