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Federal Discovery and Admissiblity of Evidence of Prior Incidents in Product Liability Cases

Plaintiffs may achieve higher verdicts in product liability trials when there is evidence of prior claims establishing that the manufacturer had notice of the alleged defect in design, manufacture, or warning.  Therefore, in product liability litigation, most plaintiffs request discovery concerning prior claims, or incidents that did not give rise to formal claims, that are in any way related to the product.  For instance, a plaintiff’s lawyer might issue a broad discovery request for anything concerning prior incidents of any kind related to the model of product at issue or any version of that model.  Even more common and problematic are so-called “product line” requests that seek evidence of prior claims related to a broad range of allegedly similar products or similar models.

Requests for production concerning prior incidents might be routine for large companies that have large, sophisticated in-house legal teams and are likely to have storage, retrieval, and document retention policies, but such requests can be a terrible disruption for small businesses that may not have systems in place to handle aggressive discovery in litigation.

But no matter what size your client is, you should be prepared for a request for production seeking evidence of prior incidents and prior claims.  You should have discussions with your product liability clients early on in the case about the product’s incident and claim history, as well as potential discovery requests.

The first part of this article will discuss whether requests concerning prior incidents are actually discoverable.  We will discuss defense tactics for responding to requests for discovery concerning prior incidents, as well as representative cases from different U.S. federal court jurisdictions concerning discovery.

The second part of this article will discuss whether, even if discoverable, the evidence concerning prior incidents is ultimately admissible.  We will discuss strategies for preventing admission of evidence concerning prior incidents, as well as representative cases from different U.S. federal court jurisdictions concerning admissibility.    

Finally, the third part of this article will discuss strategies for assisting clients with the difficult process of discovery requests for evidence of prior incidents.

I. Whether requests concerning prior incidents are actually discoverable.

A. Defense tactics for responding to requests for discovery concerning prior incidents.

There is no single method for successfully defending against discovery requests for evidence concerning prior incidents.  Unfortunately, U.S. federal courts treat each case differently and, as explained below, various jurisdictions have different standards for the discovery of evidence of prior incidents.

That said, the facts and circumstances of each case are important, and any good defense will involve distinguishing the specific facts of your case from cases where the court allowed discovery.  Consider, for example, the distinguishing facts of the products, conditions, and intended uses at issue, particularly if you have a technical case.

Consider hiring an expert as early as possible and using your expert to assist you with defending against discovery requests.  Your can submit an affidavit from your expert explaining the differences between the incident involved in your case and the prior incidents.  The more technical your case, the more likely your expert will be useful and will be able to draw distinctions that the plaintiff is not prepared for.  An example of this might be important engineering differences in the product at issue versus the products involved in the discovery that plaintiff requests.

B. Representative cases from different U.S. federal court jurisdictions concerning discovery.

1) Discovery of evidence concerning prior incidents is generally allowed in                           federal court under Federal Rule of Civil Procedure 26(b)(1).

Federal Rule of Civil Procedure 26(b)(1) is broad and provides that discovery may be obtained as long as it is “relevant” and “reasonably calculated to lead to the discovery of admissible evidence.”  The advisory committee notes to Rule 26 provide that, “A variety of types of information not directly pertinent . . . could be relevant to the claims or defenses raised in a given action.  For example, other incidents of the same type, or involving the same product, could be properly discoverable . . . .”  Fed. R. Civ. P. 26 advisory committee’s note, 2000 amend., subdiv. (b)(1).

In Kozlowski v. Sears, Roebuck & Co., 73 F.R.D. 73, 75 (D. Mass. 1976), the court underscored how broad discovery can be in federal products cases when it noted that, “most courts have held that the existence and nature of other complaints in product liability cases is a proper subject for pretrial discovery.”

2) Some jurisdictions (the Eighth Circuit, the Northern District of California, Kansas,       the Southern District of Indiana, Maryland, and the Western District  of                 Pennsylvania) require a threshold showing of relevance before the discovery is                   permitted.  After a threshold showing of relevance, the burden shifts to the                           defendant to demonstrate that any relevance is outweighed by the harm that would             result from the evidence being admitted. 

The ambiguous nature of the term “relevance” illustrates the problematic nature of the discovery phase of a lot of product liability claims.  Plaintiffs will make requests for “other incidents of the same type” or “other incidents involving” the product (or products, i.e., “all washing machines manufactured by defendant”) at issue or prior incidents with “similar circumstances”.

Some jurisdictions will require a “threshold showing of relevance” before evidence of prior incidents will be discoverable.  See, e.g., Hofer v. Mack Trucks, Inc., 981 F.2d 377, 380 (8th Cir. 1992) (“Some threshold showing of relevance must be made before parties are required to open wide the doors of discovery and to produce a variety of information which does not reasonably bear upon the issues in the case.”); Barcenas v. Ford Motor Co., 2004 WL 2827249, *2 (N.D. Cal. Dec. 9, 2004) (quoting with approval Hofer’s requirement of the threshold showing of relevance); McCoy v. Whirlpool Corp., 214 F.R.D. 642, 643 (D. Kan. 2003) (requiring that the discovery appear “relevant on its face”); Chavez v. DaimlerChrysler Corp., 206 F.R.D. 615, 619 (S.D. Ind. 2002) (the discovery must first appear to be relevant, and then “the party resisting the discovery has the burden to establish the lack of relevance by demonstrating that the requested discovery is of such marginal relevance that the potential harm occasioned by discovery would outweigh the ordinary presumption in favor of broad disclosure.”); Tucker v. Ohtsu Tire & Rubber Co., 191 F.R.D. 495, 497 (D. Md. 2000) (“even though it relates to a light truck tire, not a passenger tire as is at issue here, the plaintiffs have established threshold relevance, as required by Fed. R. Civ. P. 26(b)(1) and Fed. R. Evid. 401.”); Swain v. General Motors Corp., 81 F.R.D. 698, 700 (W.D. Pa. 1979), (where the plaintiff met the “prima facie showing” of relevance to support his discovery request for evidence “concerning prior motor mounts” that allegedly failed in his vehicle).

3) Some jurisdictions (the Western District of Michigan, the Eastern District of                     Louisiana, and the Southern District of New York) require that prior incidents be “similar” to the incident that gave rise to the underlying case before allowing the discovery of evidence of prior incidents.  Whether the prior incidents are “similar” depends on the particular court and the facts and circumstances. 

Most jurisdictions generally do not apply the “substantially similar test”—requiring that the conditions of past incidents be substantially similar to those in the underlying case—until the admissibility phase.  However, some jurisdictions do require some amount similarity between the prior incidents and the incident that gave rise to the underlying case before allowing discovery.

For example, in Lohr v. Stanley–Bostitch, Inc., 135 F.R.D. 162, 164 (W.D. Mich. 1991), the court explained that, at the discovery phase, the circumstances surrounding prior incidents must be “similar enough”.  By contrast, at the admissibility phase, “Evidence of similar accidents is admissible so long as the conditions in effect during the past incidents are ‘substantially similar’ to those at the time of the incident in question and the two events arise from the same cause.”  Id. (internal citation omitted).

In State Farm Fire & Cas. Co. v. Black & Decker, Inc., 2003 WL 103016, *4 (E.D. La. Jan. 9, 2003), the court applied a “sufficiently similar” test and explained that, “In product liability actions it is frequently difficult to judge which of a manufacturer’s products are sufficiently similar to the allegedly defective product to be subject to discovery.”  As in Lohr, the Eastern District of Louisiana court in State Farm distinguished the less-stringent similarity standard for the discovery phase from the “substantially similar” standard applied to the admissibility phase.  State Farm, 2003 WL 103016 at *4 (quoting Lohr, 135 F.R.D. at 163).

In Fine v. Facet Aerospace Products Co., 133 F.R.D. 439, 441, 443 (S.D.N.Y. 1990), the Southern District of New York explained that the prior incidents must be “sufficiently similar” in order to meet the “threshold showing of relevance”.  The court explained that, if the models of product in the prior incidents are different from the one at issue in the underlying case, discovery may be allowed if the models involved in the prior incidents “share with the accident-causing model those characteristics pertinent to the legal issues raised in the litigation.  For example, where a plaintiff alleged that three-wheel all-terrain vehicles are inherently unstable, he was entitled to discovery with respect to each of the manufacturer’s models.”  Id. (citing Culligan v. Yamaha Motor Corp., 110 F.R.D. 122, 124, 126 (S.D.N.Y. 1986)).

A court may require expert testimony to support the showing that the prior incidents were “sufficiently similar”, particularly when there are technical issues that require more knowledge than a lay person.  In Fine, the court explained that the plaintiff may have been allowed discovery if it had proffered “the affidavit of an expert in aviation engineering.”  Id. at 443.  Because plaintiff did not proffer any such expert testimony, the court denied the plaintiff’s motion to compel discovery concerning alternative designs for planes.  Id. at 443.

4) In the discovery phase, a few of jurisdictions (the Northern District of                               California, the Northern District of Illinois, and the District of New Mexico)                             have applied the more stringent “substantially similar” test that most courts do                     not apply until the admissibility phase. 

In a few jurisdictions, the plaintiff bears the burden of showing that prior incidents involving different products are “substantially similar” before discovery will be allowedFor example, not only has the Northern District of California required a threshold showing of relevance before allowing discovery concerning prior incidents, but it has also required plaintiffs to show “that the different products are substantially similar . . . .”  Barcenas, 2004 WL 2827249 at *3

In Piacenti v. General Motors Corp., 173 F.R.D. 221, 225-26 (N.D. Ill. 1997),  the court held that the plaintiff failed to establish that a different model of vehicle was “substantially similar” and denied the plaintiff’s motion to compel.  The court explained that, “allowing discovery of models that are not substantially similar to the model at issue is truly the equivalent of comparing apples and oranges where there are differences between the other models and the model at issue in terms of wheelbase, width, and center of gravity.”  Id. at 225.  The court further stated that discovery concerning similar models should only be allowed if “the similar models have the same component parts or defects”.  Id.

In Gonzales v. Goodyear Tire and Rubber Co., the court noted that the “substantially similar” test applies if the plaintiff “seeks to discover or to introduce evidence of the design, testing or performance of other similar products . . . . .”  No. CIV 05–941 BB/LFG, 2006 WL 7290047, slip op., *7-9 (D.N.M., Aug. 10, 2001) (italics added).

Expert testimony may be helpful for both sides in these cases, but such testimony must be more than “conclusory.”  For example, in Piacenti, the court denied the plaintiff’s motion to compel answers to interrogatories and its supplemental request for production concerning evidence regarding other vehicle models manufactured by the defendant.  173 F.R.D. at 222.  The denial was without prejudice so that an expert opinion could be filed stating that the models “are sufficiently similar to the Suzuki Samurai [so] that tests performed on the Samurai would be relevant in determining liability with respect to the Geo Tracker [the plaintiff’s vehicle].”  Id.  Although the plaintiff submitted expert affidavits, the court found that they consisted of only “conclusory” statements as compared to the defendant’s expert affidavits, which were more detailed.  Id. at 225.  Therefore, the court ultimately disallowed discovery relating to models other than the one at issue in the lawsuit.  Id. at 225-26.

II. Whether, even if discoverable, the evidence concerning prior incidents is ultimately admissible.

A. Strategies for preventing admission of evidence concerning prior incidents.

As with requests for discovery, there is no silver bullet to fight against requests for the admissibility of evidence concerning prior incidents.  However, because the requirements for admissibility can generally be more stringent than the requirements for discovery, it is almost always worth fighting the admissibility of evidence of prior incidents.

You will be better prepared to fight against the admissibility of prior incidents if you hire your expert early in the case.  Prepare your expert to distinguish your case from evidence of any prior incidents that plaintiff might seek to admit at trial.  Expert testimony will almost always be helpful to distinguish your case from the prior incidents.  A good plaintiff’s lawyer will have an expert who will try to show that the prior incidents are similar to the case at issue.  Prepare for this early by ensuring that your expert is familiar with the product and with any evidence of prior incidents that plaintiff will seek to admit.  Make sure that your expert’s opinions are based on detail and technical knowledge and that they are not conclusory.

The value of the case may be significantly affected if the evidence of prior incidents is admitted.  It is always beneficial to know early on in the case whether the evidence will be admitted and the ways in which that can affect the case value.  Therefore, try to file your motions in limine early on in the case to prevent the admissibility of evidence of prior incidents.  Litigators generally wait too long to do motions in limine, e.g., we wait until the federal court deadline, just prior to the trial.  Consider filing motions in limine early on, especially in a technical case or if you feel that the evidence of prior incidents could really hurt you in front of the factfinder.

B. Representative cases from different U.S. federal court jurisdictions concerning admissibility.    

1) In most jurisdictions, evidence of prior incidents is generally admissible as long as the other incidents are “substantially similar” to the incident in the case at hand. 

Evidence of prior incidents is generally admissible as long as the plaintiff demonstrates that the other incidents are “substantially similar” to the incident in the case at hand.  Cooper v. Firestone Tire & Rubber Co., 945 F.2d 1103, 1105 (9th Cir. 1991).  See also Albee v. Contl. Tire N.A., Inc., 2010 WL 1729092, *6 (E.D. Cal. Apr. 27, 2010) (internal citations and some quotation marks omitted) (“The Ninth Circuit has repeatedly held      that . . . ‘substantial similarity is required when a plaintiff attempts to introduce evidence of other accidents as direct proof of negligence, a design defect, or notice of the defect.’  Minor or immaterial dissimilarity does not prevent admissibility.” ); Steede v. General Motors, LLC, 2013 WL 142484, *9 (W.D. Tenn. Jan. 11, 2013) (“the Sixth Circuit has recognized the substantial similarity doctrine and held, for example, that evidence of prior accidents is admissible to prove a defect so long as the prior accidents involved the same model, design, and defect, and occurred under similar circumstances”).

What is “substantially similar” will be determined on a case-by-case basis, depending on your jurisdiction.

For example, in Ramos v. Liberty Mut. Ins. Co., 615 F.2d 334, 338 (5th  Cir.), modified on other grounds, 620 F.2d 464 (5th Cir. 1980), the plaintiff sought to admit evidence of a prior incident involving the collapse of an oil rig mast.  The court ultimately found that the prior incident was substantially similar.  It explained that, “Evidence of similar accidents might be relevant to the defendant’s notice, magnitude of the danger involved, the defendant’s ability to correct a known defect, the lack of safety for intended uses, strength of a product, the standard of care, and causation.”  Id. at 338-39.  The court found that evidence of the prior collapse could be relevant to show “notice of the defect, its ability to correct the defect, the mast’s safety under foreseeable conditions, the strength of the mast, and, most especially, causation.”  Id. at 339.

The court also stated that the admissibility of evidence of prior incidents concerning a product “depends upon whether the conditions operating to produce the prior failures were substantially similar to the occurrence in question.  The requirement that the prior accident not have occurred at too remote a time is a special qualification of the rule requiring similarity of conditions.”  Id. (internal citations and quotation marks omitted).

A plaintiff may use expert testimony to assist with its burden to show that the prior incidents are “substantially similar” and a defendant may use expert testimony to show that the prior incidents are substantially dissimilar.  Id. at 339-340.  See also Haynes v. Am. Motors Corp., 691 F.2d 1268, 1271–72 (8th Cir. 1982) (the defendant’s expert testified concerning dissimilarities between two different models of Jeeps and the court ultimately excluded evidence from the operator’s manual of the non-subject model).

Evidence concerning prior incidents may also be admissible because it is relevant “to show a culpable state of mind on the part of the defendant, e.g., persevering in a refusal to provide available safety features on a product despite knowledge of other similar accidents.”  Gonzales, 2006 WL 7290047 at *6 (citing Smith v. Ingersoll–Rand Co., 214 F.3d 1235, 1250 (10th Cir. 2000)).

2) In the Fourth Circuit and the Tenth Circuit, the substantially similar rule may    be             relaxed if the evidence of prior incidents is used to prove notice or awareness                     of a dangerous condition (rather than causation). 

The Fourth Circuit and the Tenth Circuit may relax the “substantially similar” rule if the evidence of prior incidents is used to prove notice or awareness of a dangerous condition rather than causation.  For example, in Benedi v. McNeil–P.P.C., Inc., 66 F.3d 1378, 1386 (4th Cir. 1995), the court explained that, “When prior incidents are admitted to prove notice, the required similarity of the prior incidents to the case at hand is more relaxed than when prior incidents are admitted to provide negligence.  The incidents need only be sufficiently similar to make the defendant aware of the dangerous situation.”  (Internal citations omitted.)

In Ponder v. Warren Tool Corp., the court noted that, “When evidence of other accidents is used to prove notice or awareness of a dangerous condition, the rule requiring substantial similarity of those accidents to the one at issue should be relaxed.”  834 F.2d 1553, 1560 (10th Cir. 1987).

III. Strategies for assisting clients with the difficult process of discovery requests for evidence of prior incidents.

     Clients often feel strongly that the prior incidents are not relevant and should have no bearing upon their lawsuit.  As any experienced lawyer knows, extensive requests for production can lead many clients who are less experienced with such requests to anxiously perceive that their entire brand, company, or even their own personal judgment is being put on trial.

Client resistance to production of evidence concerning prior incidents may be mitigated with repeated early discussion of discovery practice and relative risks.  Engage in detailed discussions before the requests are actually made.  If you practice in a jurisdiction with very liberal discovery rules, and if you have a particularly unsophisticated or reluctant client, you may even want to discuss the potential for sanctions in the event that discovery is wrongly withheld.

As soon as possible, you should have a discussion with your client concerning issues such as the assigned judge, the jurisdictional tendencies, whether or not production or admissibility of the evidence would be damaging, and whether the prior incidents may show prior notice of an alleged defect.

Oregon Law Does Not Permit Experts to Testify in the Form of Legal Conclusions in Product Liability or Negligence Cases

Under Oregon law, witnesses are not allowed to testify as to legal conclusions.  See, e.g., Olson v. Coats, 78 Or App 368, 370 (1986) (excluding testimony by witness that certain road signs complied with statutory requirements).  “Each courtroom comes equipped with a ‘legal expert,’ called a judge, and it is his or her province alone to instruct the jury on the relevant legal standards.” Burkhart v. Washington Metro. Area Transit Auth., 112 F3d 1207 (D.C. Cir. 1997).  Examples of inappropriate testimony in the form of legal conclusions include, but are not limited, to:

  • Defendants were clearly reckless, acted in a reckless manner, or acted in a grossly reckless manner;
  • Plaintiff was negligent; and
  • The helicopter/engine had a known and recognized defect.

Neither plaintiff nor defendant should be permitted to elicit such legal conclusions at trial.  An increasing number of products liability cases have excluded similar expert testimony.  A district court was held to have correctly excluded expert testimony that “the lack of adequate warnings and instructions constituted defects which made the products unreasonably dangerous.”  Strong v. E.I. DuPont de Nemours Co., 667 F2d 682, 685-86 (8th Cir. 1981).  Similarly, in Harris v. Pacific Floor Machine Mfg. Co., 856 F2d 64, 67 (8th Cir. 1988), a district court was held to have properly refused to permit the plaintiff’s expert to opine as to the adequacy of the particular warning on the product.

Likewise, expert testimony that a party was “willful” was excluded in United States v. Baskes, 649 F2d 471, 478 (7th Cir. 1980).  On similar grounds, a federal district court excluded expert testimony that the plaintiff was “negligent.”  The court’s ruling also encompassed “any testimony . . . that contains a variation of the term ‘negligent,’” or any opinions that certain conduct was the “direct, proximate and efficient cause” of an accident.  Hermitage Industries v. Schwerman Trucking Co., 814 F Supp 484, 487-88 (D. S.C. 1993).

Defending the Pediatric Burn Case: How Knowing the Medical Literature and New Treatment Modalities Can Help Control Damages

Surgeons discussing computed tomography (CT) scans in operating theatre

Introduction

Most seasoned defense attorneys are well aware of the three subjects that often tend to cause far higher-than-expected verdicts: burns, kids, and cancer.  In this article we will address the danger of situations where there is not only a child, but the child is severely burned.

In prior posts we addressed burn classification, conventional treatment modalities, and aspects of expected outcomes.  We will not repeat that information here but instead address some general mortality statistics and where children, specifically those age six and younger, fit in.  We will also address experimental and new therapies for children, as described in the recent literature, including the use of virtual reality, albuterol inhalants, and aerosolized Heparin/Acetylcystine therapies.  All of these therapies have been shown to lower mortality rates in children.

Regardless of the burn mechanism, defending a pediatric burn case, especially if it was fatal, can be extremely difficult.  Juries tend to be very sensitive to burn injuries, especially in cases involving children.  Therefore, the product liability or aviation defense lawyer must have an in-depth understanding of the mechanics of burn injuries and available treatment options, particularly in those cases where inhalation injury is a component.  Both an aircraft cabin and a home are confined spaces that can be filled with fatal levels of smoke, sometimes within seconds.  Given these considerations, it is essential that the defense attorney be thoroughly prepared, armed with both knowledge and empathy.

Statistical Overview of Burn Injuries

According to the National Burn Repository,[1] which gathers and analyzes statistical data from burn centers throughout the United States and Canada, there were 126,000 hospital admissions for burns from 1995 – 2005.  The mean burn size was 13.4 percent total body surface area (TBSA) with sixty-two percent of the full thickness burns covering less than ten percent TBSA.  Sixty-one percent of patients were transferred to another hospital for a higher level of care.  Six and one-half percent of admissions had inhalation injuries.  The data also show that the patients were seventy percent male with a mean age of 33 years.  Flame and scald burns accounted for seventy-eight percent of all burn injuries.

The prognostic burn index, a sum of the patient’s age and percentage of TBSA burn, was used as a gauge for patient mortality for many years.  This index suggested that by taking into consideration the patient’s age and the size of their full thickness TBSA burn, and adding twenty percent for inhalation, the patient’s mortality probability could be predicted.[2]  Advances in early excision of burn eschar,[3] skin grafting, early enteral feeding,[4] and wound closure with advanced techniques (skin substitutes) have altered the simple mathematical calculation.[5]  Patients with a prognostic burn index of 90 – 100 now have a mortality rate in the 50 – 70% range with poorer outcomes at both extremes of age.[6]

The Importance of Pediatric Treatment in Cases Involving Inhalation Burns 

As noted above, mortality rates are higher in pediatric patients.  Smoke inhalation injury continues to be implicated as the leading cause of death in persons with burn injuries.  Smoke inhalation injury has a reported mortality of 20 – 80%.[7]  This is also supported by the addition of 20% traditionally added to the prognostic burn index.

In smoke inhalation injury, there is a destruction of the ciliated epithelium[8] that lines the tracheobronchial tree.  Casts[9] from these cells cause upper-airway destruction, and this leads to obstruction, causing pulmonary failure.  In one recent study, the reduction in mortality in pediatric patients with inhalation injuries placed on a regimen of aerosolized heparin[10] and acetylcystine[11] was tested.[12]  Forty-seven children, acting against forty-three controls, received 5000 units of heparin and 3 ml of a 20% solution of acetylcystine aerosolized every four hours for the first seven days of injury.  All patients were extubated when they were able to maintain spontaneous oxygen levels.  The number of patients requiring re-intubation for successive pulmonary failure was recorded, as was mortality.

The results indicate a significant decrease in re-intubation rates, incidence of atelectasis,[13] and mortality for patients treated with the regimen of heparin and acetylcystine when compared with the controls.  Heparin/acetylcystine nebulization in children with massive burn and smoke inhalation injuries results in a significant decrease in incidence of re-intubation for progressive pulmonary failure and a reduction in mortality.

The Use of Virtual Reality For Acute Pain Management in Pediatric Burn Patients

In one experimental case, virtual reality was tested for pain management.[14]  Managing high pain levels associated with pediatric burns can result in a decreased reliance on opioid medications and can potentially minimize future risk of developing psychiatric problems.  During the study, hospitalized patients over the age of six and without facial burns were selected.  A lightweight helmet with binocular display provided patients with a Virtual Reality (VR) experience during acute pain procedures such as wound care or therapy.  Pain levels were assessed using the Faces Pain Scale (FPS).[15] Constitutional signs and symptoms, opioid medication usage, as well as nursing and family member assessments of pain were also recorded.  VR provided a three-dimensional computer-simulated environment where patients could see, hear, and interact with objects displayed in the virtual world.

Preliminary results suggested at least a 20% decrease on FPS during VR intervention.  Pediatric patients report an increased tolerance to exposed dressing sites during VR.  It remains unknown which patient factors (age, sex, characteristics of the burn, background pain level, etc.) are predictive of effective pain management with VR.

Conclusion

Olson Brooksby has defended many product liability and aviation cases where the resulting injury was a serious, sometimes fatal, burn.  From a defense perspective, such cases pose difficulties if defense counsel is not prepared to skillfully handle the cross examination of the treating burn physician.  The best way to do so is to be familiar with the prevailing treatment methods and the relevant literature.  Conversance with the literature will provide a working understanding of the techniques that were available to the treatment team to minimize the pediatric burn patient’s pain and increase the likelihood of survival.

 


[1] Miller, S.F.M., et al., National Burn Repository, 2005, American Burn Association: Chicago, IL. P. 1-51.

[2] Grunwald, T.B. and Garner, W.L. Acute Burns. University of Southern California; Los Angeles County + USC Burn Center, Los Angeles, California.

[3] Dead matter cast off the surface of the skin after a burn.

[4] Tubal feeding through the intestine.

[5] Rose, D.D. and E.B. Jordan, Perioperative management of burn patients.  Aorn J, 1999. 69(6): p. 1211-22; quiz 1223-30.

[6] N., K. Aoki, and M. Yamazaki, Recent advances in the management of severely burned patients.  Nippon Geka Gakkai Zasshi, 1999. 100(7): p. 424-9.

[7] Thompson PB, Herndon DN, Taber DL, et al.  Effects of mortality of inhalation injury. J. Trauma 1986; 26:163-5.

[8] Threadlike projections from the free surface of epithelial cells such as those lining the trachea, or bronchi.  The propel or sweep materials, such as mucus or dust across a surface such as the respiratory tract.  Taber’s Cyclopedic Medical Dictionary, 19th Ed.. 2001. Venes. D., Ed., F.A. Davis Co., Philadelphia.

[9] Pliable or fibrous material shed in various  pathological conditions, the product of effusion.  It is molded to the shape of the part in which it has been accumulated, i.e., bronchial or tracheal casts.  Taber’s Cyclopedic Medical Dictionary, 19th Ed.. 2001. Venes. D., Ed., F.A. Davis Co., Philadelphia.

[10] Heparin is an aparenteral anticoagulant drug with a faster effect than warfarin or its derivatives.  It is composed of polysaccharides that inhibit coagulation by forming an antithrombin. An antithrombin is anything that prevents action on the thrombin.  The Thrombin is an enzyme formed in coagulating blood which reacts with soluble fibrinogen to form a blood clot.  Taber’s Cyclopedic Medical Dictionary, 19th Ed.. 2001. Venes. D., Ed., F.A. Davis Co., Philadelphia.

[11] Acetylcystine is a chemical substance that, when nebulized and inhaled, liquefies mucus and pus.  Taber’s Cyclopedic Medical Dictionary, 19th Ed.. 2001. Venes. D., Ed., F.A. Davis Co., Philadelphia.

[12] M.H. Desai, MD, R. Micak, RRT, RCP, J. Richardson, RCP, RRT, R. Nichols, MD, and D.N. Herndon, MD.  Reduction in Mortality in Pediatric Patients with Inhalation Injury with Aerosolized Heparin/Acetylcystiine Therapy.  University of Texas Medical Branch and Shriners Burns Institute, Galveston.  American Burn Association, 1998.

[13] Collapse of part (or, less commonly, all) of a lung.

[14] Minassian, A PhD; Kotay, A MS; Perry, W PhD; Tenenhaus, M MD, FACS; Potenza, B M. MD, FACS.  The Use of Virtual Reality for Acute Pain Management in Pediatric Burn Patients.  University of California San Diego, The American Burn Association, 2006.

[15] The Faces Pain Scale, also known as the Wong-Baker FACES Pain Rating Scale, is intended for children over three years of age.  It provides a series of six drawn facial expressions with an associated numerical value from zero through 5 representing the associated pain.  Hockenberry MJ, Wilson D:  Wong’s Essentials of Pediatric Nursing, 8th Edition. St. Louis:  2009: Mosby.

 

Effective Cross-Examination of Plaintiff’s Psychological Expert Can Reduce or Eliminate Damages for Misdiagnosed Claims of PTSD

Jurors in the jury box

Post-Traumatic Stress Disorder (“PTSD”) is a mental disorder within the trauma and stressor-related disorders included in The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM-5.  It was previously categorized in the anxiety classification of disorders in the “DSM-IV”.

Personal injury, product liability, and aviation defense lawyers should be well prepared to cross-examine forensic psychologists who testify on behalf of plaintiffs that they suffer from PTSD.  Reasons for thorough preparation include the frequent lack of critical information regarding a plaintiff’s background, inadequate psychological testing, improper reading of validity scales, or an absence of reliance on any other data or criteria by the forensic psychologist testifying on behalf of plaintiff.  If defense counsel is thoroughly familiar with the DSM-5 (and its criteria and commentary on PTSD) and is prepared for an effective cross-examination of plaintiff’s treating or forensic psychologist, damages for emotional distress in PTSD claims can be significantly reduced or eliminated.

Olson Brooksby primarily defends product liability, higher exposure personal injury, and aviation cases.  Over the past few years, we have seen a trend developing whereby almost every plaintiff filing a personal injury lawsuit in such cases claims they suffer from PTSD as a consequence of the alleged injury, without regard for any other potential causes or their own overall life experience.  As a result, most plaintiffs seek emotional distress damages for PTSD as an element of damages in their personal injury lawsuits.

This being the case, there is no substitute for thorough preparation, in-depth knowledge of the material, and the ability to translate “psycho-speak” into plain language in order to mount an effective cross examination.  This preparation should start with a rigorous study of the DSM-5.

Effectively Challenging Plaintiff’s Allegation of PTSD Can Significantly Reduce or Eliminate Plaintiff’s Claim For Emotional Distress Damages

Most plaintiff and defense attorneys would likely admit that handling PTSD claims on behalf of their respective clients, and in particular, dealing effectively with forensic psychological experts, is difficult.  In defending a personal injury action where PTSD is claimed, it is essential that defense counsel have a thorough understanding of the interaction between the DSM-5, standardized testing, how the testing was scored, whether the tests administered had validity scales, and what other personal historical factors and information the plaintiff’s examining physician had available to him or her.

It is also important to determine whether the plaintiff’s experts considered any other mental disease or defect, and, if so, how they reached their differential diagnosis of PTSD.  All of this is necessary for thoroughly cross-examining plaintiff’s experts and challenging misdiagnosed claims of PTSD.

There is no single test that will clinically establish the presence of PTSD.  Typically, tests such as the MMPI, the TSI, or other standardized tests are administered.  Defense counsel should know whether there are validity scales and what they show, and they should be prepared to cross-examine plaintiff’s expert on these issues.  Defense counsel should cross-examine plaintiff’s expert on his or her knowledge of recent longitudinal studies done on PTSD, many of which are authored or co-authored by members of the DSM-IV or DSM-IV-TR PTSD Work Group or other Task Force or advisors.

Other fertile strategies for cross-examination include probing the extent of the expert’s clinical experience, how they applied clinical judgment to reach the diagnosis, how they accounted for malingering, and extensive questioning regarding key diagnostic criteria such as “life-threatening” and “persistence.”

Essential Diagnostic Features of Post-Traumatic Stress Disorder (“PTSD”) 

“The essential feature of post-traumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events.  Emotional reactions to the traumatic event (e.g., fear, helplessness, horror) are no longer a part of Criterion A.  The clinical presentation of PTSD varies.  In some individuals, fear-based re-experiencing, emotional, and behavioral symptoms may predominate.  In others, anhedonic or dysphoric mood states and negative cognitions may be most distressing.  In other individuals, arousal and reactive-externalizing symptoms are prominent, while in others, dissociative symptoms predominate.  Finally, some individuals exhibit combinations of these symptom patterns.”  DSM-5 at p. 274.

The directly experienced traumatic events in Criterion A include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual physical assault (e.g., physical attack, robbery, mugging, childhood physical abuse), threatened or actual sexual violence (e.g., forced sexual penetration, alcohol/drug-facilitated sexual penetration, abusive sexual contact, noncontact sexual abuse, sexual trafficking), being kidnapped, taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human-made disasters, and severe motor vehicle accidents.

For children, sexually violent events may include developmentally inappropriate sexual experiences without violence or injury.  A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event.  Medical incidents that qualify as traumatic events involve sudden, catastrophic events (e.g., waking during surgery, anaphylactic shock).  Witnessed events include, but are not limited to, observing threatened or serious injury, unnatural death, physical or sexual abuse of another person due to violent assault, domestic violence, accident, war or disaster, or a medical catastrophe in one’s child (e.g., a life-threatening hemorrhage).  Indirect exposure through learning about an event is limited to experiences affecting close relatives or friends and experiences that are violent or accidental (e.g., death due to natural causes does not qualify).  Such events include violent personal assault, suicide, serious accident, and serious injury.  The disorder may be especially severe or long-lasting when the stressor is interpersonal and intentional (e.g., torture, sexual violence).

The response to the event must involve intense fear, helplessness, or horror.  In children, the response must involve disorganized or agitated behavior.  Characteristic symptoms include persistent re-experiencing of the traumatic event, persistence of stimuli associated with the trauma and numbing of general responsiveness and persistent symptoms of increased arousal.  The full symptom picture must be present for more than one month and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

An individual will have persistent symptoms of anxiety or increased arousal not present before the trauma.  These symptoms can include difficulty falling or staying asleep that may be due to recurrent nightmares during which the traumatic event is relived.  Other symptoms can include hyper-vigilance and exaggerated startle response.  Some individuals report irritability, outbursts of anger, or difficulty concentrating or completing tasks.

Associated Descriptive Features and Mental Disorders 

Developmental regression, such as loss of language in young children, may occur.  Auditory pseudo-hallucinations, such as having the sensory experience of hearing one’s thoughts spoken in one or more different voices, as well as paranoid ideation, can be present.  Following prolonged repeated and severe traumatic events (e.g., childhood abuse or torture), the individual may additionally experience dissociative symptoms, difficulties in regulating emotions, and/or difficulties maintaining stable relationships.

When the traumatic event produces violent death, symptoms of both problematic bereavement and PTSD may be present.  Part of the difficulty in accurately diagnosing PTSD is that it is associated with many other anxiety and mental disorders.  For example, PTSD is also associated with increased rates of Major Depressive Disorder, Substance-Related Disorders, Panic disorder, Agoraphobia, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Social Phobia, Specific Phobia, and Bipolar Disorder.  These disorders can precede, follow, or emerge concurrently with the onset of PTSD.

PTSD Prevalence Rates

In the United States, projected lifetime risk for PTSD using DSM-IV criteria at age 75 years is 8.7%.  Twelve-month prevalence among U.S. adults is about 3.5%.  Lower estimates of 0.5%-1.0% are seen in Europe, Africa, and Latin America.  The DSM-IV discusses community-based studies that reveal a lifetime prevalence for PTSD of approximately 8% of the adult population in the United States.  Information about general prevalence rates in other countries is not available.   Studies of at-risk individuals yield variable findings, with the highest rates (ranging between one-third and more than half of those exposed) found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

Differential Diagnosis

PTSD can occur at any age, beginning after the first year of life.  Symptoms usually begin within the first three months following the trauma, although there may be a delay of months, or even years, before criteria for the diagnosis are met.  There is abundant evidence for what DSM-IV called “delayed onset” but is now called “delayed expression,” with the recognition that some symptoms typically appear immediately and that the delay is in meeting the full criteria.

The DSM-5 emphasizes that with PTSD, the stressor must be of an extreme, (i.e., “life-threatening) nature.  In contrast, other mental disorders often mistakenly diagnosed as PTSD include Adjustment Disorder, where the stressor can be of any severity.  The test also points out that not all psychopathology that occurs in individuals exposed to an extreme stressor should necessarily be attributed to PTSD and may be the result of many other mental disorders.  Mentioned are Acute Stress Disorder, Obsessive Compulsive Disorder, Schizophrenia, and other psychotic disorders or mood disorders with psychotic features.  Although a discussion of all diagnostic criteria is beyond the scope of this article, virtually each of the diagnostic criteria for PTSD emphasize that persistence of the symptoms, the re-experiencing of the event, and the avoidance of associated stimuli is essential.

Conclusion

Scott Brooksby recently cross examined a plaintiff’s forensic psychologist in a high-exposure personal injury case he was defending.  Plaintiff’s expert typically diagnosed more than half of those he evaluated with PTSD.  On cross-examination, this expert was not familiar with the prevalence rates, the specific criteria, or the comorbidity issues associated with PTSD and published in the DSM.  Most significantly, he could not describe the single most important feature for a diagnosis of PTSD: a “characteristic set of symptoms following exposure to one or more traumatic events.”  Instead, the expert merely opined that, in so many words, plaintiff was unhappy, withdrawn, and appeared to be troubled by a series of events.  The expert could not describe the relative significance of the plaintiff’s life events or link them to the specific criteria needed to achieve an accurate PTSD diagnosis.

It is important that the cross-examination specifically pin down the basis for the expert’s diagnosis, especially now with the much more detailed DSM-5, and the breaking up of many of the negative cognition clusters and a much more specific list of negative experience categories.

Even a comprehensive summary of the methodology for most effectively questioning or challenging a plaintiff’s claim of PTSD is beyond the scope of this blog post.  However, when cross-examining plaintiff’s expert witness regarding a PTSD diagnosis, defense counsel should always keep in mind that the plain text of the DSM-5, and examples of the trauma and criteria typically associated with PTSD, can often be easily contrasted with the data to disprove or cast doubt on the PTSD diagnosis.

The Newly-Released DSM-5 and Its Use in Personal Injury Cases

Olson Brooksby primarily defends high-exposure product liability and personal injury cases.  Over the past few years, it seems as though many of these cases involve personal injury claims for mental disorders, particularly Post-Traumatic Stress Disorder (“PTSD”), as a result of the alleged accident at issue in the lawsuit.

PTSD is a mental disorder within the anxiety classification of disorders in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or “DSM”.  It is important to be familiar with the most recent version of the DSM when defending against a personal injury claim filed by a plaintiff who alleges a mental disorder.

In order to assist companies defending against personal injury claims requesting damages for various mental disorders, this article discusses the DSM and the recently-released DSM-5, and explains why it is important for personal injury defense lawyers to be familiar with the DSM-5 when defending against personal injury claims.

The DSM: The Single Most Authoritative Manual Regarding the Diagnosis of Mental Disorders

The DSM is universally recognized as the single most authoritative manual regarding the diagnosis of mental disorders.  The current version of the DSM, the DSM-5,was just released this week.  The previous version, the DSM-IV, was published in 1994 and the text was revised (DSM-IV-(TR)) in 2000.

The usefulness and credibility of the DSM for education, research, clinical, or forensic work depends upon the support of an extensive empirical foundation.  The DSM was created by the  American Psychiatric Association (APA) in order to provide a helpful guide to clinical practice with a uniform nomenclature that spans disciplines and purposes.  While a complete history of the development of the DSM-5 and earlier editions is far beyond the scope of this article, a short synopsis is crucial to the understanding of the universal acceptance of the text as authoritative.

The Principal Purpose of the DSM

The undisputed principal purpose of the DSM is to aid clinicians in the diagnosis of mental disorders, not for forensic purposes.  In fact, the DSM-IV and 5 both include disclaimers that spell out the significant risks that are present within the DSM categories, criteria, and textual descriptions when they are employed for forensic purposes.  The primary danger is that the diagnostic criteria will be misused or misunderstood.  This is because of the imperfect fit between the questions of ultimate concern to the law and the information used by clinicians to render a clinical diagnosis.

Additionally, in a forensic setting, nonclinicians should be cautioned that a diagnosis does not carry any necessary implications regarding the causes of the individual’s mental disorder or impairments.  The clinical diagnosis of a DSM mental disorder is not sufficient to establish the existence for legal purposes of a “mental disorder”.  In determining whether an individual meets a particular legal standard (e.g., a particular disability), additional information is usually required beyond the DSM diagnosis.

The DSM provides categorical classifications that divide mental disorders into types based on criteria sets with defining features.  It is a classification of mental disorders that was developed for use in clinical, educational and research settings.  The DSM is meant to serve as a guideline to be informed by clinical judgment and is not meant to be used in a cookbook fashion.  It is essential that the DSM not be applied by untrained individuals, since clinical training, judgment and experience are essential to proper diagnosis

The Development of the DSM-5

A Task Force and Work Groups made up of more than 160 world-renowned clinicians and researchers proposed the draft criteria for the DSM-5.  Those clinicians and researchers, all volunteers, consisted of experts in neuroscience, biology, genetics, statistics, epidemiology, social and behavioral sciences, nosology, and public health.

Applying Knowledge of the DSM-5 to Claims in Personal Injury Cases

Personal injury defense lawyers should be prepared to cross-examine forensic psychologists who testify on behalf of plaintiffs who allegedly suffer from any kind of mental disorder.  There are a number of reasons that extensive preparation is required when defending against personal injury claims for mental disorders, particularly claims for PTSD.  These include the nomenclature involved in the diagnosis, the relative complexity and universal acceptance of the DSM-5 as the authoritative source for the PTSD diagnostic criteria, and the dangers of malingering when financial remuneration is at issue.  Other reasons include what is typically a lack of the critical additional information regarding a plaintiff’s background, inadequate testing, improper reading of (or absence of) validity scales in a given standardized test, or an absence of reliance on any other data or criteria by the forensic psychologist testifying on behalf of the plaintiff.

If defense counsel is thoroughly familiar with the DSM-5, the DSM-5 criteria and commentary on the particular mental disorder at issue, and is prepared for an effective cross-examination of the plaintiff’s treating or forensic psychologist, the damages in cases involving personal injury claims for mental disorders can be significantly reduced or eliminated.

Strategies for companies defending against claims for PTSD

Most plaintiff and defense attorneys would likely admit that treatment of forensic psychological experts and posttraumatic stress disorder (PTSD) claims on behalf of their respective clients is difficult.  For the defense of a personal injury claim involving PTSD, it is essential that defense counsel have a thorough understanding of the interaction between the DSM-5, standardized testing, how the testing was scored, whether the tests administered had validity scales, and what other personal historical factors and information the plaintiff’s examining physician had available to him or her.  It is also important to determine whether the plaintiff’s expert considered other mental diseases or defects besides PTSD.  All of this is necessary for thorough cross-examination of a plaintiff’s expert and attacking misdiagnosed claims of PTSD.

There is no single test that will clinically establish the presence of PTSD.  Typically a number of tests such as the MMPI, the TSI or other standardized tests are administered.  Defense counsel should understand whether there are validity scales and what they show and be prepared to cross-examine the plaintiff’s expert in that regard.

Defense counsel should also cross-examine the plaintiff’s expert on his or her awareness of recent longitudinal studies done on PTSD  Defense counsel must determine whether the plaintiff’s expert is an experienced clinician.  What clinical judgment did the plaintiff’s expert apply to reach his or her diagnosis?  Did the plaintiff’s expert account for malingering?  If so, how?

Defense counsel should also cross-examine the plaintiff’s expert extensively on key diagnostic criteria such as “life-threatening” and “persistence”.

Posttraumatic Stress Disorder (“PTSD”) (DSM-IV-TR Code 309.81) is categorized by the DSM-IV(TR) as an Anxiety Disorder.

Posttraumatic Stress Disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. This move from DSM-IV, which addressed PTSD as an anxiety disorder, is among several changes approved for this condition that is increasingly at the center of public as well as professional discussion.
The

“The essential feature of PTSD is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person, or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.”  DSM-IV-TR at p. 463.

The response to the event must involve intense fear, helplessness, or horror.  In children, the response must involve disorganized or agitated behavior.  Characteristic symptoms include persistent re-experiencing of the traumatic event, persistence of stimuli associated with the trauma and numbing of general responsiveness and persistent symptoms of increased arousal.  DSM-IV-TR also states that the full symptom picture must be present for more than one month and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

A nonexclusive list of traumatic events that are experienced directly include military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, begin taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness.  For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence  or injury.

An individual will have persistent symptoms of anxiety or increased arousal that were not present before the trauma.  These symptoms may include difficulty falling or staying asleep that may be due to recurrent nightmares during which the traumatic event is relived, hyper-vigilance, and exaggerated startle response.  Some individuals report irritability or outbursts of anger or difficulty concentrating or completing tasks.

Associated Descriptive Features and Mental Disorders 

Part of the difficulty in an accurate diagnosis of PTSD, is that it is associated with many other anxiety and other mental disorders.  PTSD is also associated with increased rates of Major Depressive Disorder, Substance-Related Disorders, Panic disorder, Agoraphobia, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Social Phobia, Specific Phobia, and Bipolar Disorder.  These disorders can either precede, follow, or emerge concurrently with the onset of PTSD.

PTSD Prevalence Rates

The DSM-IV-TR discusses community-based studies which reveal a lifetime prevalence for PTSD of approximately 8% of the adult population in the United States.  Information about general prevalence rates in other countries is not available.   Studies of at-risk individuals yield variable findings, with the highest rates (ranging between one third and more than half of those exposed) found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

Differential Diagnosis

The DSM-IV-TR emphasizes that with PTSD, the stressor must be of an extreme, (i.e., “life-threatening) nature. DSM-IV-TR at p. 467.  In contrast, other mental disorders often mistakenly diagnosed as PTSD include Adjustment Disorder, where the stressor can be of any severity.  The test also points out that not all psychopathology that occurs in individuals exposed to an extreme stressor should necessarily be attributed to PTSD and may be the result of many other mental disorders.  Mentioned are Acute Stress Disorder, Obsessive Compulsive Disorder Schizophrenia  and other Psychotic Disorders or Mood Disorders with Psychotic Features.  Significantly, the test emphasizes that “[m]alingering should be ruled out in those situations in which financial remuneration, benefit eligibility, and forensic determinations play a role.”  DSM-IV-TR at p. 467.  Although a discussion of all diagnostic criteria is beyond the scope of this article, virtually each of the diagnostic criteria for PTSD emphasize that persistence of the symptoms, the re-experiencing of the event, and the avoidance of associated stimuli is essential.

Conclusion

Even a complete summary of the criteria and methodology for most effectively questioning or attacking a plaintiff’s claim of PTSD is far beyond the scope of this blog post.  Defense counsel must undertake a thorough investigation and consultation with a qualified expert, preferably one who also maintains a clinical practice.  When defense counsel is cross-examining plaintiff’s expert witness regarding a PTSD diagnosis, there is absolutely no substitute for thorough preparation and understanding of the DSM-IV criteria, clinical judgment, test results, current longitudinal or other studies and an awareness of all factors taken into account by plaintiff’s expert as the plain text of the DSM-IV-TR, and examples of the trauma and criteria typically associated with PTSD can often be easily contrasted with the data to disprove or minimize the emotional distress damages.  Olson Brooksby often defends high-exposure personal injury or product liability cases where plaintiffs seek damages for emotional distress and claim PTSD.  For more information, contact our office.