ÿWPCú ?{zU Z½º³wb¦Ö°nïn»³w/™*ôƒæsªLâÍ6äõ¤f€Ž/ Ê®XŸ0?Lâ¿Н {”\&kû¿ppvO}=)%ëK$þ¿‘9x/h`/M ,Ýå Q¢êÀ]ÝßÈ"PC‚r¸p°ãÝHÁ_W›ê,$ùr[oÂZ”H0¦ó@GòíÖ¦J ß8Wå¾C¯FL[ú<Çœ|1-`bwªzuÒ.ÿ´q6ò®Oå32dÅoÑÓô´)¾Â>ˆ©ÃqO‰;5/ûþüRh‰»¯¿§y=O\Ž­ŒÅ?ÅÃ#¥ßyâsönK‘uk4”;òó?êŠ>!É·(Ó%ÖÙQ)æEb1ó·:ãQm$fö5–ÓšŽ¢QKAa.·ì_ìÍ÷Fò_eš,A&¼"±Ìv~¥eêyÎN“ßïµã±©Iä-½ww:cP3Ýö>n•÷Ê&½l1…Ôƒç;¥]L¯µC( Å/)4Ê{è›;ç–0jÁÕÞªe0ά§ñ—ƒÀWÀ¦è4ªˆ?¤›zHh¢0¡[@Ë­<¿©à«*¨teVb¾ ~Ìa¥mƒÉ<\²ºÎ%aã6&D“UfïÌÁŸ(N]þ b#É\ %% ^ + 0ˆ7 UN¿ w 4 z% ÒŸ q € m‚ UN™ Æç Æ­ ÆsÆ9 0DÿNC¨EEEííííííííííííííííííííííííbïïïïïïïïïïïïïïïïïïïïïïïïïïïïïïïïïïïï 0ë÷÷÷÷ Bââ 0¤ÿ D3£ D-Ö 0K ASNÆ¡ 0¤g 0D  A«O˜\\IB01S08\KNOXCLERK4ÈÈ,,,,ÈÈ0»Ó}1Þ (`£ª$¡¡Ñ€.ÑÑ8€½­»»d»»d8ÑÑ ý ÑÓ  Ó(í€"  Z6Times New Roman RegularÖƒF1ê:i¢Ø+00 ˜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.wpt3|xÿU‹ÿÀÀÀ(ÖÃ9 Z‹6Times New Roman RegularLevel 1Level 2Level 3Level 4Level 5‚Level 1Level 2Level 3Level 4Level 5„Level 1Level 2Level 3Level 4Level 5…Level 1Level 2Level 3Level 4Level 5(#Ã$òòÚ  Ú0Ú  Úóó MECHELLEELOSIEBOLeadbetterviremiaSchaffnersubspecialty U.T.falciparumEvridgetortfeasorMcClenahantortfeasorsHemphillmisdiagnosingmisdiagnosedfactfinderRubright- ù-(|G2“£$¤¤Ý ƒ£ª!ÝÑ€.ÑÑ8€ »»dd8ÑÑ ý ÑÓ  ÓÝ  Ýà  àòòÚ  Ú0Ú  ÚóóÔ€XHYX»»Ô d(|3Gg$££Ý ƒ£ª!ÝÑ€.ÑÑ8€ »»dd8ÑÑ ý ÑÓ  ÓÝ  ÝVVVV'ÿÿdxd)!ÈÈÈÈdxdx( ±þ$’’ò òFigure€Ú  Ú1Ú  Úó ó^_X`YEþÿ<<CÿÿƒLevel 1Level 2Level 3Level 4Level 5(|3Gg$¢¢Ý ƒ£ª!ÝÑ€.ÑÑ8€ »»dd8ÑÑ ý ÑÓ  ÓÝ  Ý($$””ò òÚ  Ú1Ú  Úó óX[Z&OLE 2.0 Box <=8ÿÿÿÿÿÿÿÿÿÿCÿÿ HKKKKÝ ƒ£ª!ÝÑ€.ÑÑ8€ »»ddÈ8ÑÑ ý ÑÓ  ÓÝ  ÝÔ_ÔÔ€¼ »»»ÔÑ8€HYXXdì»»d8Ñà@¦ ¦ ìàIN€THE€COURT€OF€APPEALS€OF€TENNESSEEˆÐ ° Ðà@””$ìàAT€KNOXVILLEˆÐ  Ðà@ººìàSeptember€21,€2004€SessionˆÐ Ô$ ÐÔ‡XHYX»¼ ÔÌò òÔ#†¼ »XXHY¤#ÔÓ  ÓMECHELLE€E.€ELOSIEBO€v.€STATE€OF€TENNESSEEòòóóÔ‡XHYX»¼ Ôó óÐ Ò" ÐÓêÓÌà@¯¯ìàò òDirect€Appeal€from€the€Tennessee€Claims€Commission,€Eastern€Grand€DivisionˆÐ Ò " Ðà@ô ô ìàNo.€202000293€€€€€€Hon.€Vance€W.€Cheek,€Jr.,€CommissionerˆÐ ¾  ÐÌÌà@ìì*ìàßA€V) °°` d€÷E<` A߈Ð ‚Ò  ÐÌà@U U ìàNo.€E2003„02941„Ô_ÔCOAÔ_Ô„R3„CV€„€€FILED€NOVEMBER€29,€Ô_Ô2004Ô_ԈР}Í  ÐÌßA€V) °°` dE<T` AßÐ U¥  Ðó óÌThe€Commissioner€found€defendantððs€physician€breached€the€standard€of€care€in€the€treatment€ofÐ P   Ðplaintiff,€but€refused€to€award€damages.€€On€appeal,€we€affirm€Commissionerððs€finding€of€breach,Ð <Œ Ðbut€award€damages€and€remand€to€enter€Judgment.Ð (x ÐÌÔ#†¼ »XXHY&#ÔÔ‡XHYX»¼ ÔÌò òTenn.€R.€App.€P.3€Appeal€as€of€Right;€Judgment€of€the€Claims€Commission€Affirmed€in€Part,Ð ì< ÐReversed€in€Part,€Award€Damages€and€Remand.ó óÐ Ø( ÐÌÌòòHerschel€Pickens€Franks,€Ô_ÔP.Jóó.Ô_Ô,€delivered€the€opinion€of€the€court,€in€whichòò€D.€Michael€Ô_ÔSwineyÔ_Ô,Ð œì ÐJóó.,€and€òòGary€R.€Wadeóó,€Ô_ÔP.J.Ô_Ô,€Ô_ÔSp.J.Ô_Ô,€joined.Ð ˆØ ÐÌÔ#†¼ »XXHYý#ÔÔ‡XHYX»¼ ÔÌRichard€L.€Duncan€and€Cary€L.€Bauer,€Knoxville,€Tennessee,€for€Appellant.Ð Lœ ÐÌRonald€C.€Leadbetter,€Knoxville,€Tennessee,€for€Appellee.Ð $ t ÐÌÌÌà@66'ìàò òOPINIONó óÔ#†¼ »XXHY;#ÔÔ‡XHYX»¼ ԈРÔ#$# ÐòòóóÔ‡ X2³XXXHYÔÌà  àà ` àIn€this€action,€plaintiff,€a€student€at€the€University€of€Tennessee,€alleges€she€was€aÐ ¬%ü % Ðvictim€of€medical€malpractice€at€the€University€of€Tennessee€Student€Health€Clinic.€€She€alleges€sheÐ ˜&è!& Ðvisited€the€clinic€on€August€23,€2000,€after€returning€from€a€trip€to€Nigeria,€and€presented€symptomsÐ „'Ô"' Ðincluding€headache,€back€pain,€fever,€and€abdominal€cramps.€€Plaintiff€alleges€that€she€wasÐ p(À#( Ðdiagnosed€with€acute€viremia,€prescribed€fluids,€and€told€to€return€the€next€day€for€follow€up,€andÐ \)¬$) Ðthat€she€returned€to€the€clinic€the€next€morning,€and€was€given€an€IV€and€fluids,€but€was€never€testedÐ H*˜%* Ðfor€malaria.€€She€alleged€that€Dr.€Robert€L.€Rubright€and€the€clinic€violated€the€standard€of€care€byÐ 4+„&+ Ðfailing€to€test€for€and€rule€out€malaria.€€She€further€alleged€she€suffered€injuries€as€a€result€of€theÐ  ,p', ÐÔ_ÔmisdiagnosisÔ_Ô€including€coma,€brain€injury,€renal€failure,€liver€failure,€medical€expenses,€pain€andÐ  -\(-ý ÐÔ_Ôsuffering,€and€loss€of€earning€capacity.€€Ð ° ÐÌà  àà ` àDefendant€answered,€admitting€that€Dr.€Rubright€was€an€employee€of€the€State,€butÐ ˆØ Ðdenied€that€plaintiffððs€damages€were€caused€by€defendant.€Ð tÄ ÐÌà  àà ` à€€In€a€trial€before€the€Commissioner,€Dr.€Arthur€Williamson€testified€as€an€expertÐ L œ Ðwitness,€stating€that€he€was€familiar€with€the€standard€of€care€for€family€practitioners€in€KnoxvilleÐ 8 ˆ Ðand€similar€communities€for€the€relevant€time€frame,€and€opined€that€it€was€not€reasonable€toÐ $ t Ðdiagnose€plaintiff€with€a€virus,€and€fail€to€rule€out€malaria.€€He€testified€that€he€had€never€beforeÐ  ` Ðtestified€that€a€physician€had€breached€the€standard€of€care,€but€after€reviewing€the€records€he€feltÐ ü L  Ðcompelled€to€do€so€in€this€case.Ð è 8  ÐÌà  àà ` àNext,€Dr.€William€Schaffner€testified€to€his€credentials,€including€his€subspecialty€ofÐ À  Ðinfectious€diseases€within€the€specialty€of€internal€medicine.€€He€testified€that€he€was€familiar€withÐ ¬ü  Ðthe€standard€of€care€applicable€to€family€practitioners€in€East€Tennessee,€that€he€was€involved€at€theÐ ˜è  Ðstudent€health€clinic€at€Vanderbilt,€and€had€treated€cases€of€malaria.€€After€viewing€plaintiffððs€clinicÐ „Ô  Ðrecords€for€August€23,€he€€testified€that€plaintiffððs€symptoms€coupled€with€the€fact€noted€that€she€hadÐ pÀ Ðjust€returned€from€Nigeria€would€suggest€that€malaria€should€be€considered€and€ruled€out.€€Ð \¬ ÐÌà  àà ` àDr.€Rubright€testified€that€he€practiced€at€the€U.T.€Student€Health€Clinic€from€1970Ð 4„ Ðto€1988,€and€was€team€physician€for€the€menððs€athletics€program€from€1988€to€1993.€€He€testifiedÐ  p Ðthat€after€1993,€he€worked€at€the€clinic€when€they€were€short„handed,€and€averaged€working€30„40Ð  \ Ðdays€per€year.€€He€testified€that€he€knew€in€2000€that€malaria€was€the€#1€killer€in€the€world,Ð øH Ðespecially€falciparum,€and€that€it€could€kill€someone€in€a€short€time,€and€he€also€knew€that€WestÐ ä4 ÐAfrica€was€one€of€the€highest€risk€areas€for€malaria.€€He€further€testified€that€plaintiffððs€symptomsÐ Ð  Ðwere€consistent€with€malaria,€as€well€as€lots€of€other€illnesses.€€He€also€knew€in€2000€that€malariaÐ ¼  Ðhad€a€very€non„specific€presentation/symptoms.€Ð ¨ø ÐÌà  àà ` àHe€testified€when€plaintiff€left€the€clinic€on€Thursday,€she€still€had€a€fever,€and€whenÐ €Ð Ðshe€returned€on€Friday,€she€was€acutely€ill,€was€lethargic,€and€ð ðout€of€itðð.€€He€did€a€urinalysis€onÐ l¼ Ðplaintiff€which€indicated€that€she€was€having€kidney€problems,€so€he€decided€she€needed€to€go€to€theÐ X ¨ Ðhospital.€Ð D!” ÐÌà  àà ` àPlaintiff€was€admitted€to€the€University€of€Tennessee€Medical€Center,€where€aÐ #l! Ðpathologist€initially€diagnosed€the€wrong€type€of€malaria,€and€when€she€did€not€improve€from€theÐ $X" Ðprescribed€treatment,€her€chart€was€rechecked€and€she€was€diagnosed€with€falciparum€malaria.€€TheÐ ô$D # Ðevidence€shows€that€she€lapsed€into€a€coma€and€was€unresponsive€and€moaning,€with€no€attempt€atÐ à%0!$ Ðspeech.€€She€was€in€a€cerebral€malaria€coma€for€10€or€11€days,€received€an€infusion€of€two€units€ofÐ Ì&"% Ðpacked€blood€cells€secondary€to€malaria,€and€kidney€dialysis.€€She€remained€in€the€ICU€from€AugustÐ ¸'#& Ð31€to€September€7,€and€developed€pneumonia€while€in€the€hospital.€€She€suffered€acute€renal€failureÐ ¤(ô#' Ðwhich€required€an€invasive€catheter,€and€she€testified€that€when€she€awoke€from€the€coma,€she€hadÐ )à$( Ðtubes€in€her€legs,€tubes€up€her€nose,€tubes€in€her€chest,€and€was€tied€down€so€she€wouldnððt€removeÐ |*Ì%) Ðthe€tubes.€€As€a€result,€plaintiffððs€muscles€atrophied€and€she€needed€constant€care.€€After€beingÐ h+¸&* Ðdischarged€to€home,€she€spent€two€to€three€weeks€in€bed,€and€dropped€out€of€school€for€one€semesterÐ ° Ðand€graduated€later€than€her€entering€class.€€The€cost€of€her€hospitalization€was€$106,841.81.Ð œì ÐÌà  àà ` àFollowing€the€trial,€the€Commissioner€made€findings€of€fact€and€conclusions€of€law.€Ð tÄ ÐIn€his€findings€and€conclusions,€he€stated€that€he€believed€Dr.€Rubright€had€ð ðthree€huge€red€flags€thatÐ `° Ðscream€test€for€malariaðð€and€he€failed€to€do€so,€and€found€that€Dr.€Rubright€violated€the€standard€ofÐ L œ Ðcare,€because€he€felt€any€reasonable€practitioner€would€have€ordered€the€undisputedly€simple€bloodÐ 8 ˆ Ðsmear€test€just€to€rule€out€malaria.€The€Commissioner€also€found€that€he€had€ð ðno€evidence€.€.€.€as€toÐ $ t Ðwhat€the€damages€were€for€.€.€.€two€daysðð€because€Dr.€Rubrightððs€failure€to€test€caused€a€48€hourÐ  ` Ðdelay€in€the€diagnosis.€The€Commissioner€stated€that€the€hospitalððs€misdiagnosis€was€an€independentÐ ü L  Ðintervening€circumstance€which€was€the€proximate€cause€of€all€of€plaintiffððs€injuries.€He€found€thatÐ è 8  Ðhe€could€not€ð ðfind€a€quantified€set€of€damages€for€the€breach€of€standard€of€care€for€that€forty„eight„Ð Ô$  Ðhour€period.ðð€€Plaintiff€appealed,€and€charges€the€Commissioner€erred€in€awarding€no€damages€afterÐ À  Ðfinding€there€was€a€deviation€from€the€standard€of€care.Ð ¬ü  ÐÌà  àà ` àPlaintiff€first€argues€that€the€Commissioner€erred€in€finding€that€plaintiffððsÐ „Ô  Ðmisdiagnosis€at€U.T.€Hospital€was€an€independent€intervening€circumstance€which€proximatelyÐ pÀ Ðcaused€plaintiffððs€injuries.€€Ð \¬ Ðà  àÌà0  àà0` (#(#àRegarding€intervening€cause,€this€Court€has€previously€explained:Ð4„` (#` (# Ðà8  àÐ Ð Ð  Ðà0  àà0` (#(#à€The€intervening€cause€doctrine€is€a€common-law€liability€shifting€device.€€It€providesÐ  \ Ðthat€a€negligent€actor€will€be€relieved€from€liability€when€a€new,€independent€andÐ øH Ðunforseen€cause€intervenes€to€produce€a€result€that€could€not€have€been€foreseen.€Ð ä4 ÐThe€doctrine€only€applies€when€(1)€the€intervening€act€was€sufficient€by€itself€toÐ Ð  Ðcause€the€injury,€(2)€the€intervening€act€was€not€reasonably€foreseeable€by€theÐ ¼  Ðnegligent€actor,€and€(3)€the€intervening€act€was€not€a€normal€response€to€the€originalÐ ¨ø Ðnegligent€actor's€conduct.€€The€customary€explanation€of€the€doctrine€is€that€anÐ ”ä Ðindependent,€intervening€cause€breaks€the€chain€of€legal€causation€between€theÐ €Ð Ðoriginal€actor's€conduct€and€the€eventual€injury.€Ðl¼` (#` (# ÐÌà0  àà0` (#(#àThe€separation€of€causation€in€fact€from€legal€causation€and€the€adoption€of€theÐ D!” Ðcomparative€fault€doctrine€have€obscured€the€role€and€significance€of€the€interveningÐ 0"€  Ðcause€doctrine.€€Intervening€cause€appears€to€relate€more€to€legal€causation€than€toÐ #l! Ðcausation€in€fact€because€it€does€not€come€into€play€until€after€causation€in€fact€hasÐ $X" Ðbeen€established.€€The€doctrine€also€appears€to€have€survived€the€adoption€ofÐ ô$D # Ðcomparative€fault€even€though€other€similar€liability€shifting€doctrines€such€as€lastÐ à%0!$ Ðclear€chance,€implied€assumption€of€the€risk,€and€remote€contributory€negligenceÐ Ì&"% Ðhave€been€subsumed€into€comparative€fault.€€While€other€jurisdictions€haveÐ ¸'#& Ðconcluded€otherwise,€the€Supreme€Court€has€stated€that€proximate€cause€andÐ ¤(ô#' Ðintervening€cause€remain€jury€questions€in€the€comparative€fault€decision-makingÐ )à$( Ðprocess.€Ð|*Ì%)` (#` (# Ðà  àÐ h+¸&* ÐòòWaste€Management,€Inc.€of€Tennessee€v.€South€Central€Bell€Telephone€Co.óó,€15€S.W.3d€425,€432Ð ° Ð(Tenn.€Ct.€App.€1997)(citations€omitted).€€As€this€case€notes,€intervening€cause€relates€to€proximateÐ œì Ðor€legal€causation,€and€thus€is€a€question€of€fact€which€this€Court€must€review€òòde€novo€óówith€aÐ ˆØ Ðpresumption€of€correctness€unless€the€evidence€preponderates€otherwise.€€Intervening€cause€requiresÐ tÄ Ða€showing€of€the€above€listed€three€elements.€ò òà  àÐ `° Ðà  àà ` àÌà  àà ` àó óThe€first€element€is€that€the€intervening€act€must€have€been€sufficient€by€itself€toÐ 8 ˆ Ðcause€the€injury.€€The€expert€proof€in€this€case€was€that€if€plaintiff€had€been€properly€diagnosed€whenÐ $ t Ðentering€U.T.€Hospital€and€treated€appropriately,€her€condition€would€probably€not€have€worsened,Ð  ` Ðwhich€was€admitted€by€plaintiffððs€expert.€€Ð ü L  ÐÌà  àà ` àThus,€the€misdiagnosis€which€occurred€at€the€hospital€as€to€the€particular€type€ofÐ Ô$  Ðmalaria€could€have€been€sufficient€itself€to€cause€injury.€€The€other€elements€required,€however,Ð À  Ðcannot€be€established.€€The€hospitalððs€misdiagnosis€as€to€the€type€of€malaria€was€both€normal€andÐ ¬ü  Ðforeseeable,€as€those€items€are€defined€in€this€context.Ð ˜è  Ðò òó óà  àÌà0  àà0` (#(#àAs€regarding€foreseeability,€the€Supreme€Court€has€explained€as€follows:ÐpÀ` (#` (# Ðà8  àÐ Ð Ð  Ðà0  àà0` (#(#à"The€fact€that€an€intervening€act€of€a€third€person€is€negligent€in€itself€or€is€done€inÐ H˜ Ða€negligent€manner€does€not€make€it€a€superseding€cause€of€harm€to€another€whichÐ 4„ Ðthe€actor's€negligent€conduct€is€a€substantial€factor€in€bringing€about,€ifÐ p` (#` (# Ðà8  àà8` Ð Ð àÐ ` x` x Ðà0  àà0` (#(#àà0¸ ` (#` (#à(a)€the€actor€at€the€time€of€his€negligent€conduct€should€have€realized€that€aÐ øH Ðthird€person€might€so€act,€orÐä4¸ (#¸ (# Ðà8  àÐ Ð Ð  Ðà8  àà0` Ð Ð àà0¸ ` Ð ` Ð à(b)€a€reasonable€man€knowing€the€situation€existing€when€the€act€ofÐ ¼  Ðthe€third€person€was€done€would€not€regard€it€as€highly€extraordinaryÐ ¨ø Ðthat€the€third€person€had€so€acted,...."Ð”ä¸ Ð ¸ Ð  Ðà8  àÐ Ð Ð  ÐòòEvridge€v.€American€Honda€Motor€Co.óó,€685€S.W.2d€632,€635€(Tenn.€1985),€quoting€RestatementÐ l¼ Ð(Second)€of€Torts€ðð447.€€Ð X ¨ Ðà  àÌà  àà ` àIn€discussing€what€is€foreseeable€in€terms€of€proximate€causation,€our€Supreme€CourtÐ 0"€  Ðhas€said:Ð #l! Ðà8  àÐ Ð Ð  Ðà0  àà0` (#(#àThe€foreseeability€requirement€is€not€so€strict€as€to€require€the€tortfeasor€to€foreseeÐ ô$D # Ðthe€exact€manner€in€which€the€injury€takes€place,€provided€it€is€determined€that€theÐ à%0!$ Ðtortfeasor€could€foresee,€or€through€the€exercise€of€reasonable€diligence€should€haveÐ Ì&"% Ðforeseen,€the€general€manner€in€which€the€injury€or€loss€occurred.€€"The€fact€that€anÐ ¸'#& Ðaccident€may€be€freakish€does€not€per€se€make€it€unpredictable€or€unforeseen."€€It€isÐ ¤(ô#' Ðsufficient€that€harm€in€the€abstract€could€reasonably€be€foreseen.€Ð)à$(` (#` (# ÐÌòòMcClenahan€v.€Cooleyóó,€806€S.W.2d€767,€775€(Tenn.€1991)(citations€omitted).€€The€Court€went€onÐ h+¸&* Ðto€explain:Ð ° Ðà8  à€Ð Ð Ð  Ðà0  àà0` (#(#àWith€respect€to€superseding€intervening€causes€that€might€break€the€chain€ofÐ ˆØ Ðproximate€causation,€the€rule€is€established€that€it€is€not€necessary€that€tortfeasors€orÐ tÄ Ðconcurrent€forces€act€in€concert,€or€that€there€be€a€joint€operation€or€a€union€of€act€orÐ `° Ðintent,€in€order€for€the€negligence€of€each€to€be€regarded€as€the€proximate€cause€ofÐ L œ Ðthe€injuries,€thereby€rendering€all€tortfeasors€liable.€€There€is€no€requirement€that€aÐ 8 ˆ Ðcause,€to€be€regarded€as€the€proximate€cause€of€an€injury,€be€the€sole€cause,€the€lastÐ $ t Ðact,€or€the€one€nearest€to€the€injury,€provided€it€is€a€substantial€factor€in€producing€theÐ  ` Ðend€result.€€An€intervening€act,€which€is€a€normal€response€created€by€negligence,€isÐ ü L  Ðnot€a€superseding,€intervening€cause€so€as€to€relieve€the€original€wrongdoer€ofÐ è 8  Ðliability,€provided€the€intervening€act€could€have€reasonably€been€foreseen€and€theÐ Ô$  Ðconduct€was€a€substantial€factor€in€bringing€about€the€harm.€"An€intervening€act€willÐ À  Ðnot€exculpate€the€original€wrongdoer€unless€it€appears€that€the€negligent€interveningÐ ¬ü  Ðact€could€not€have€been€reasonably€anticipated."€€€Ð˜è ` (#` (# ÐÌòòÓÓId.€óó(citations€omitted).Ð pÀ ÐÓÓà  àà ` àWhat€is€considered€a€foreseeable€or€normal€consequence€has€been€further€explainedÐ H˜ Ðin€Restatement€(Secondòòóó)€of€Torts€ðð447,€wherein€it€is€stated€that€a€negligent€intervening€act€is€not€aÐ 4„ Ðsuperseding€cause€of€harm€to€another€where€the€actorððs€negligent€conduct€is€a€substantial€factor€inÐ  p Ðbringing€it€about,€if€ð ðthe€intervening€act€is€a€normal€consequence€of€a€situation€created€by€the€actorððsÐ  \ Ðconduct€and€the€manner€in€which€it€is€done€is€not€extraordinarily€negligent.ðð€€Comment€b€expoundsÐ øH Ðon€what€is€meant€by€ð ðnormal€consequenceðð,€and€states:Ð ä4 Ðà8  àÐ Ð Ð  Ðà0  àà0` (#(#àIt,€therefore,€denotes€that€the€court€or€jury€looking€at€the€matter€after€the€event€andÐ ¼  Ðknowing€the€situation€which€existed€when€the€act€was€done,€including€the€characterÐ ¨ø Ðof€the€person€subjected€to€the€stimulus€of€the€situation,€would€not€regard€it€asÐ ”ä Ðextraordinary€that€such€act,€though€negligent,€should€have€been€done.ЀÐ` (#` (# ÐÌComment€b€also€refers€to€the€definition€provided€for€ð ðnormalðð€in€ðð443,€Comment€b.Ð X ¨ ÐÌà  àà ` àòòóóThis€rule€has€been€followed€in€medical€negligence€cases€as€well.€€For€example,€the€Ð 0"€  ÐSupreme€Court€has€stated:Ð #l! Ðà0  àÐ (#(# Ðà0  àà0` (#(#àThis€Court,€like€most€others,€recognizes€that€if€one€is€injured€by€the€negligence€ofÐ ô$D # Ðanother,€and€these€injuries€are€aggravated€by€medical€treatment€(either€prudent€orÐ à%0!$ Ðnegligent),€the€negligence€of€the€wrongdoer€causing€the€original€injury€is€regardedÐ Ì&"% Ðas€the€proximate€cause€of€the€damage€subsequently€flowing€from€the€medicalÐ ¸'#& Ðtreatment.€€Ð¤(ô#'` (#` (# ÐÌòòTransports,€Inc.€v.€Perryóó,€414€S.W.2d€1,€4€(Tenn.€1967),€òòsee€alsoóó€òòTroy€v.€Herndonóó,€1998€WL€820698Ð |*Ì%) Ð(Tenn.€Ct.€App.€Nov.€24,€1998);€òòAtkinson€v.€Hemphillóó,€1994€WL€456349€(Tenn.€Ct.€App.€Aug.€24,Ð h+¸&* Ð1994).€€Ð ° ÐÌà  àà ` àThis€rule€has€survived€in€the€comparative€fault€scheme.€€òòTroyóó€and€òòAtkinsonóó.€€WhileÐ ˆØ Ðit€has€normally€been€applied€in€situations€where€the€plaintiff€was€injured€in€an€accident€and€then€hisÐ tÄ Ðinjuries€were€aggravated€by€medical€treatment,€it€equally€applies€where€there€are€two€separateÐ `° Ðinstances€of€medical€negligence.Ð L œ ÐÌà  àà ` àFor€these€reasons,€the€Commissionerððs€finding€that€the€hospitalððs€negligence€inÐ $ t Ðmisdiagnosing€the€type€of€malaria€was€an€intervening€cause€which€cut€off€defendantððs€liability€is€Ð  ` Ðin€error,€because€the€hospitalððs€misdiagnosis€was€a€normal€and€foreseeable€consequence.Ð ü L  Ðà  àÌà  àà ` àWhile€the€State€urges€us€to€hold€that€the€misdiagnosis€by€the€hospital€was€anÐ Ô$  Ðintervening€and€proximate€cause€of€plaintiffððs€injuries,€the€Stateððs€attorney€stated€in€his€closingÐ À  Ðargument€ð ðwe€donððt€suggest€that€any€physician€who€was€treating€her€at€the€Medical€Center€didÐ ¬ü  Ðanything€wrong.ðð€€He€went€on€to€state:Ð ˜è  Ðà8  àÐ Ð Ð  Ðà0  àà0` (#(#àTo€assess€comparative€fault€would€mean€that€the€State€would€have€to€point€a€fingerÐ pÀ Ðat€one€of€the€physicians€and€say€you€acted€negligently€or€you€acted€outside€theÐ \¬ Ðappropriate€standard€of€care.€€Our€whole€point€is€that€malaria€is€a€difficult€disease€toÐ H˜ Ðdiagnose,€thatððs€part€of€our€defense.€Ð4„` (#` (# ÐÌà  àà ` àEssentially,€the€State€conceded€that€the€hospitalððs€misdiagnosis€of€the€type€of€malariaÐ  \ Ðwas€not€extraordinary€or€unforeseeable.€€Dr.€Rubright€and€the€medical€experts€also€conceded€that€theÐ øH Ðtype€of€malaria€could€sometimes€be€misdiagnosed.€The€evidence€preponderates€against€theÐ ä4 ÐCommissionerððs€finding€of€an€intervening€cause.Ð Ð  Ðà  àÌà  àà ` àMoreover,€the€State€did€not€plead€comparative€fault€or€intervening€cause€in€itsÐ ¨ø ÐAnswer€with€regard€to€the€negligence€of€the€hospital.€€Accordingly,€the€Commissioner€should€notÐ ”ä Ðhave€raised€the€issue€òòsua€sponte€óóand€determined€it€to€be€dispositive,€when€the€hospital€actors€wereÐ €Ð Ðnot€before€him€as€defendants€and€the€plaintiff€had€no€notice€that€this€issue€would€be€raised.€€PursuantÐ l¼ Ðto€Tenn.€R.€Civ.€P.€8,€these€issues€are€required€to€be€pled€as€a€defense,€and€as€the€Comments€to€theÐ X ¨ Ðrule€point€out,€ð ðthe€defendant€must€identify€or€describe€other€alleged€tortfeasors€who€should€shareÐ D!” Ðfault,€or€else€the€defendant€would€normally€be€barred€from€shifting€blame€to€others€at€trial.ðð€€òòSeeÐ 0"€  Ðalso,€George€v.€Alexanderóó,€931€S.W.2d€517€(Tenn.€1996),€where€the€Supreme€Court€said:Ð #l! Ðà8  à€Ð Ð Ð  Ðà0  àà0` (#(#àWe€readily€acknowledge€that€the€factfinder€may€not€formally€attribute€fault€to€otherÐ ô$D # Ðpersons€at€trial€if€the€defendant€does€not€identify€them€under€Rule€8.03;€€thus,€theÐ à%0!$ Ðdefendant€does€have€some€incentive€to€plead€under€the€rule.€€This,€however,€does€notÐ Ì&"% Ðchange€the€fact€that€if€the€position€advocated€by€defendants€and€the€concurrence€wereÐ ¸'#& Ðto€prevail,€then€the€defendant,€by€carefully€limiting€its€evidence€of€another€person'sÐ ¤(ô#' Ðrole€in€causing€the€injuries€to€the€element€causation€in€fact,€could€completely€andÐ )à$( Ðeffectively€shift€the€blame€to€that€person€without€affording€the€plaintiff€any€noticeÐ |*Ì%) Ðwhatsoever€of€its€intent.€€A€defendant€would€still€be€justified€in€totally€surprising€theÐ h+¸&* Ðplaintiff€and€foisting€the€blame€on€other€persons,€a€result€that€violates€the€purpose€of€Ð ° ÐRule€8.03.Мì` (#` (# ÐÌòòId.€óóat€521.€€The€commissioner€was€in€error€to€attribute€fault€to€the€hospitalððs€negligence.€€Ð tÄ ÐÌà  àà ` àThe€Trial€Court€found€that€Dr.€Rubright€violated€the€standard€of€care,€which€heÐ L œ Ðbasically€conceded€in€his€testimony,€and€the€evidence€does€not€preponderate€against€this€finding,Ð 8 ˆ ÐTenn.€R.€App.€P.€13(d).€€The€issue€thus€becomes€in€our€òòde€novoóó€review€the€extent€of€damagesÐ $ t Ðsustained€as€a€result€of€Dr.€Rubrightððs€malpractice.€The€evidence€established€that€had€defendantÐ  ` Ðtimely€diagnosed€plaintiffððs€illness€and€administered€proper€treatment,€that€she€would€not€haveÐ ü L  Ðsuffered€the€severe€consequences€which€the€delay€in€treatment€caused.€€Ð è 8  ÐÌà  àà ` àThe€statutory€limits€on€damages€as€provided€in€Tenn.€Code€Ann.€ðð€9„8„307(a)(3)(e)Ð À  Ðis€$300,000.00,€and€the€evidence€of€damages€as€hereinbefore€detailed,€including€her€pain€andÐ ¬ü  Ðsuffering€establishes€damages€well€in€excess€of€the€statutory€limits.Ð ˜è  ÐÌà  àà ` àAccordingly,€we€remand€to€the€Commissioner€and€direct€that€a€Judgment€ofÐ pÀ Ð$300,000.00€be€entered€on€behalf€of€the€plaintiff€against€defendant.Ð \¬ ÐÌà  àà ` àThe€cost€of€the€appeal€is€assessed€to€the€State€of€Tennessee.Ð 4„ Ðà  àà ` àà ¸ àà  àÔ#†XHYXX X2³ˆ #ÔÔ#†¼ »XXHYM #ÔÔ‡XHYX»¼ ÔòòÌóóÔ#†¼ »XXHYÈb#ÔÔ‡XHYX»¼ ÔÌÌà  àà ` àà ¸ àà  àà h àà À àà  à______________________________Ð ä4 Ðà  àà ` àà ¸ àà  àà h àà À àà  àòòHerschel€Pickens€Franks,€P.J.Ð Ð  Ðóó