1. In a malpractice case where negligence is alleged against a physician in improperly applying a plaster cast to a patient who had sustained a compound fracture of the forearm and in thereafter improperly failing to diagnose an impending circulatory impairment resulting from the placement of the cast in time to correct it without damage to the arm, medical testimony is necessary to establish whether the defendant exercised care and skill under the circumstances.
2. In Georgia, the reasonable degree of care and skill prescribed in the Code for the practice of medicine is not that ordinarily employed by the profession in the immediate locality, but is that employed by the profession generally. In determining what is reasonable care and skill under the circumstances, it is the prerogative of the jury to consider what is the degree of care and skill employed by the profession in the locality or community where the action arose.
The plaintiff in this malpractice action, an 11 year old boy, suffered a fracture of the ulna and radius midway of the right forearm on February 5, 1957. The notes and affidavit of the defendant physician, introduced in evidence on his motion for summary judgment, show that after reduction of the fracture he placed the patient's arm in a skin-type circular plaster cast which was then suspended from an overhead frame. The doctor noted that the hand was moderately swollen the following day and that on February 7, it was more swollen and slightly dusky. On the 8th a small slit was made between the thumb and forefinger at the wrist end of the cast. Swelling continued but motion and sensation were found by the doctor to be normal through 9 a.m. on the 9th. At 3:30 that afternoon, however, the hand had become blue and insensitive; the cast was bi-valved and spread and color then returned to the fingers, but the hand remained numb. It then appeared that the plaintiff had suffered from Volkmann's ischemic contracture, a failure of circulation in the arm resulting in tissue necrosis, loss of use, and deformity. The arm withered, is noticeably shorter than the corresponding limb, and several skin and bone grafts were later performed at Mayo Clinic in an unsuccessful effort to ameliorate the situation.
The notes of the attending nurse show further that the patient suffered considerable pain for which he was given codeine on prescription; that he complained of numbness in his hand on February 6 at 4:30 a.m. and that at 10:45 p.m. the hand and nails were slightly cyanotic and the defendant was notified; that there was pain and more swelling on the 7th, the hand appeared blue and cold, and the doctor was again notified; that the base of the cast was slit around noon of the 8th but the patient was complaining of his hand and arm hurting during the afternoon, and that the cast was finally split at 3:30 p.m. on the 9th.
The defendant's motion for summary judgment included his own affidavit and that of another physician. Affidavits offered by physicians on behalf of the plaintiff were rejected and thereafter the defendant's motion was granted. The exceptions are to these rulings.
1. There is no serious contention that the evidence in the record would not be sufficient to authorize a finding that the ischemic contracture or withering of the plaintiff's arm resulted from a circulatory embarrassment caused by excessive swelling of the arm within the rigid cast, and that if the cast had not been unyielding the circulation would not have been shut off when the swelling increased and the injury would not have occurred. From this it is argued that even in the absence of expert medical testimony for the plaintiff a jury question is presented as to whether the defendant's treatment constituted negligence. The question, however, is not whether the treatment resulted in disaster as it all too often may although every precaution known to medical science has been employed, but whether the services were performed in an ordinarily skillful manner. This is a medical question and the proper standard of measurement must be established by the testimony of medical experts. Pilgrim v. Landham, 63 Ga. App. 451 (4) (11 SE2d 420)
; Shea v. Phillips, 213 Ga. 269
, 271 (98 SE2d 552
); Hayes v. Brown, 108 Ga. App. 360
, 363 (133 SE2d 102
Q. You have never practiced in Georgia? A. No, sir. Q. You are not personally familiar with the standards that exist in the practice in Georgia? A. No, sir." Again asked about teaching standards, he replied: "We teach what is the highest standard but we also explain to the students that all of them are not going to be able to follow the highest standards but if they are going to practice medicine or surgery that there are standards that they have to follow. And so they are acquainted with the fact that they cannot go below reasonable standards." After testifying that Dr. Bohler and others who developed the so-called skin type plaster cast used on the plaintiff have repeatedly stated that the cast must be split immediately all the way up (which was not done in this case), and after further questioning as to whether this is not up to the attending physician in the exercise of professional judgment, he replied: "I disagree there, sir. One of the fundamentals in the handling of fractures in which you have a right to expect difficulty is that you must lean over backward to avoid his terrible complication. You just simply can't play this type of situation by ear . . . Q. That of course is the high standard which you expect? A. No, sir, it is the way all patients should be handled with this type of fracture. Now, if a surgeon is unaware of the need for this type of thing then he had no business handling this fracture."
Sufficient testimony has been set out to show (a) that Dr. Frankel was well qualified to state his opinion on the procedures employed by Dr. Little unless his lack of personal familiarity with medical practice in Georgia generally and Valdosta in particular was sufficient to disqualify him, and (b) that his testimony, if admissible, would be sufficient to take the case to a jury on the issue of negligence. Code 84-924, which provides the "reasonable degree of care and skill" standard in the practice of medicine does not further circumscribe the requirement by limiting it to locality. In Kuttner v. Swanson, 59 Ga. App. 818 (1) (2 SE2d 230)
an instruction to the jury that "this standard of care . . . is defined in law to be such . . . as . . . is ordinarily employed by the profession generally in this locality" was held to be error. "The true rule is that the reasonable degree of care and skill prescribed in the Code is not such as is ordinarily employed by the profession in the locality or community. It is a question of fact for the jury to determine what is reasonable care and skill under the circumstances, and in so determining the jury may consider the degree of care and skill practiced by the profession generally in the locality, or the community." This language from Kuttner was quoted and applied in Mason v. Hall, 72 Ga. App. 867
, 874 (35 SE2d 478
). Noting these cases and thereby placing Georgia in the minority group, the following is stated in 70 CJS 950, 952, Physicians and Surgeons, 43: "Under a statute which expressly requires a physician or surgeon to exercise a 'reasonable degree of care and skill,' the standard is the degree of care and skill which is ordinarily employed by the profession generally and not such as is ordinarily employed by the profession in the locality or community." Where there is testimony on the issue by a medical expert, the question of whether the defendant physician has used that degree of care and skill required by law in attending his patient is generally a question for the jury's determination. Norton v. Hamilton, 92 Ga. App. 727
, 731 (89 SE2d 809
, 57 ALR2d 426); Pace v. Cochran, 144 Ga. 261 (3) (86 SE 934)
. A contrary holding is not required by Akridge v. Noble, 114 Ga. 949 (41 SE 78)
especially in view of the discussion of that case in Pace, supra. Thus, Georgia does not follow the rule required in California and some other States that the expert witness must show personal knowledge of medical standards in the particular locality or community where the alleged tort was committed, nor has it ever done so. Reasons for the more narrow rule which knight have obtained in times past, where transportation was difficult, medical schools and hospitals often inaccessible, and doctors licensed to practice with little or no formal training, no longer have any validity. Medical practitioners frequently receive a part or all of their education in States other than the one in which they settle to practice, and, as an example, the defendant here graduated from Johns Hopkins Medical School where the witness took his residency, interned in Baltimore City Hospital, and took his residency at the Mayo Foundation.
There are doubtless areas of medicine where knowledge of proper treatment is limited geographically by prevalence of the disease or by reason of special facilities for study, but the human race has suffered from broken bones for as long as it has been in existence. Hippocrates wrote a treatise, "On Fractures" in the fourth century B.C. in which he observed that a "blackening of the swelling" of the injured limb might result, among other causes, from the tightness of the bandage. Where medical testimony is required in cases of this kind, an otherwise qualified medical expert familiar with the standards of care considered by the profession generally to represent a reasonable degree of care and skill may testify, and the jury, in determining what weight to ascribe to the evidence, may consider any evidence before them as to the standards of practice in the particular locality or community where the injury is treated. Where the medical testimony offered creates an issue of fact on the question of whether reasonable care and skill was used, the question is for the jury rather than the court. Word v. Henderson, 220 Ga. 846 (142 SE2d 244)
The trial court erred in sustaining the objections to the deposition of Dr. Frankel and to the deposition and affidavit of Dr. Kite, and thereafter erred in granting the defendant's motion for summary judgment.
ON MOTION FOR REHEARING.
Objections to hypothetical questions on the ground that they assume facts not in evidence must be timely made in order for the question to be excluded. Ellis v. Southern R. Co., 89 Ga. App. 407 (79 SE2d 541)
. Certain of the hypothetical questions appearing in Dr. Frankel's deposition assumed codeine had been administered every four hours, which error was called to his attention later in the deposition and he reaffirmed the opinion after consulting the hospital records that the administration of five doses in one day, as shown by the hospital records, "should have alerted somebody." Other hypothetical questions not including facts regarding drug administration, in the opinion of the witness, revealed negligence in the application of the cast prior to any question of follow-up observation. It therefore appears that the fact erroneously assumed, which was corrected later in the deposition, which originally infected some but not all of the questions asked, is not of itself a sufficient reason for disallowing the entire deposition, particularly when no specific objection was urged before the trial court.