Present:   All the Justices

MARY H. NICHOLS
                              OPINION BY JUSTICE A. CHRISTIAN COMPTON
v.   Record No. 981388                      April 16, 1999

KAISER FOUNDATION HEALTH PLAN
OF THE MID-ATLANTIC STATES, INC.


             FROM THE CIRCUIT COURT OF FAIRFAX COUNTY
                      Jane Marum Roush, Judge

      Appellant Mary H. Nichols, the plaintiff below, had been a

patient and subscriber since at least 1990 of appellee Kaiser

Foundation Health Plan of the Mid-Atlantic States, Inc., a

defendant below.   Kaiser operated various medical facilities

available to its subscribers, including pharmacies at Falls

Church and Reston staffed by its employees.

      In this action for damages, the plaintiff alleged that

while being seen by a Kaiser physician in April 1995 for

respiratory disease she was given a prescription for medrol, a

steroid medication.   The plaintiff further alleged that the

prescription was filled at Kaiser's pharmacy at Falls Church and

refilled at Kaiser's pharmacy at Reston during that month.     She

also alleged that, without her knowledge, the pharmacies

negligently provided the wrong medication, namely dexamethasone,

a steroid five times more potent than medrol.

      The plaintiff further alleged that in May 1995 she

discontinued taking the wrong medication and resumed taking the
correct medication.   Thereafter, plaintiff alleged, she was

treated by Kaiser's physicians in an effort to relieve the

pronounced side effects she suffered from taking the wrong

medication.

     The plaintiff also alleged that Kaiser's pharmacy employees

failed to comply with the applicable standard of care in the

dispensing of her prescriptions.       As a result, plaintiff

alleged, she has suffered permanent injury, sustained expense,

and incurred other losses, for which she sought recovery in

damages.

     In a grounds of defense, Kaiser admitted responsibility for

the conduct of its pharmacy employees who, acting within the

scope of their employment, dispensed medication to the

plaintiff.    Kaiser also admitted that plaintiff had erroneously

been given dexamethasone, as alleged.      Kaiser denied, however,

that the negligence of its employees proximately caused the

injuries and damages alleged by plaintiff.

     In a March 1998 jury trial, the defendant moved to strike

the plaintiff's evidence both at the conclusion of the

plaintiff's case-in-chief and at the conclusion of all the

evidence.    The grounds of the motions were, first, that the

plaintiff had not presented any expert testimony that the

pharmacists had breached the applicable standard of care and,

second, that the plaintiff failed to present expert testimony of


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causation, viz., that her "complaints were as a result of taking

dexamethasone."

     The trial court denied the motions on the first ground,

ruling expert testimony was unnecessary because a jury could

understand, without the aid of such testimony, that dispensing

wrong medication is a breach of a pharmacist's standard of care.

The court took the second ground of the motions under

advisement, stating it was "concerned with the causation

testimony."

     The jury found for the plaintiff, fixing her damages at

$75,000.   The defendant renewed its motion to strike the

plaintiff's evidence and moved the court to set the verdict

aside.

     Following briefing and argument upon the motions, the court

granted them "on the basis there was insufficient expert

evidence of causation."   We awarded the plaintiff this appeal

from the April 1998 final judgment entered in favor of the

defendant.

     The sole question presented is whether the trial court

erred in ruling there was insufficient expert evidence of

causation to present an issue for the jury.

     Settled principles guide our consideration of the facts.

"When the verdict of a jury has been set aside by the trial

court, the verdict is not entitled to the same weight upon


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appellate review as one that has received the trial court's

approval.    But in considering the facts under these

circumstances, the appellate court will accord the plaintiff

benefit of all substantial conflicts in the evidence and all

reasonable inferences that may be drawn from the evidence."

Commercial Bus. Sys., Inc. v. Halifax Corp., 253 Va. 292, 296,

484 S.E.2d 892, 894 (1997).

        There are few conflicts in the evidence.   The plaintiff's

medical evidence was presented through the testimony of Kaiser

employees supplemented by her Kaiser medical records.     The focus

of the controversy is upon the two-month period of April-May

1995.

        The plaintiff's principal witness was Dr. Ronald J.

Klayton, a Kaiser physician specializing in internal medicine

with a subspecialty in pulmonary diseases.    He first treated her

on March 15, 1995 because her regular pulmonary physician was on

vacation.    The plaintiff, born in 1932, came for treatment of

lung disease and sinus drainage.

        The plaintiff's medical records, examined by Klayton,

revealed that her lung disease had been "severe in nature."     At

the time, the plaintiff was taking a number of medications

including the steroid medrol, 16 milligrams (mg) per day, and

two other steroids.    Following an examination of plaintiff,




                                   4
Klayton concluded she "had severe chronic obstructive pulmonary

disease."

     During the first visit, Klayton advised her to double the

dose of medrol to 32 mg per day.       He increased the dosage of

some of her other medications and prescribed an antibiotic.

Klayton understood that plaintiff had been taking various doses

of either medrol or prednisone, another steroid, for two or

three years.

     On March 22, plaintiff returned to see Klayton.       She was

"feeling better" and Klayton felt that her lung disease had

improved due to the increase of the medrol dose and institution

of the antibiotic.   During that visit, the medrol dose was

reduced to 28 mg per day and she was started on another

medication to help loosen thick secretions.

     On April 5, Klayton's "initial prescription" for medrol 4

mg tablets was filled for plaintiff at Kaiser's Falls Church

pharmacy.   It was filled correctly as medrol but it was entered

into the pharmacy computer system incorrectly as dexamethasone 4

mg tablets.    When plaintiff refilled the prescription on April

13 at Kaiser's Reston pharmacy, dexamethasone was dispensed, and

plaintiff began taking it.   That medication is "about five times

as potent" as medrol, according to Klayton.

     Plaintiff saw Klayton on April 5 and May 3.       On May 3, he

diagnosed her as "having diabetes secondary to steroids."


                                   5
Klayton was unaware that plaintiff was "on dexamethasone."

According to Klayton's review of plaintiff's medical record,

prior to April 5 no physician had noted in writing in the record

a diagnosis of diabetes nor had any physician indicated in

writing in the record that he had undertaken to actively treat

her for diabetes.

     On May 3, plaintiff "was upset over some bruises on her

skin" and Klayton observed "a hemorrhage underneath the skin.

It looks like a black and blue mark."    Plaintiff's glucose level

was 314 according to one test and 392 according to another.    The

"normal range" for a person like plaintiff was 118 and her

readings were "way too high," according to Klayton.   He

immediately began treating plaintiff's diabetes and asked that

she return to see him the next day.

     Upon plaintiff's return on May 4, Klayton learned that she

had been taking dexamethasone.   He said she was taking 16 mg of

dexamethasone and getting the equivalent of 80 mg of medrol.

     On that date, he noted in her record an "assessment" of

"dexamethasone induced hyperglycemia."   He testified:   "I

thought that the dexamethasone had induced her high blood

sugar."   Elaborating, the physician stated:   "I meant that she

had what's called secondary diabetes.    In this case, secondary

to the use of a steroid."




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        Klayton was asked:   "So you assessed her as having a high

sugar level because of the dexamethasone she was taking?"       He

answered:    "Because that was the steroid she was taking.     I mean

if she was on Medrol I would have blamed it on that.       They both

can do it.    But she was on dexamethasone."

        Klayton was asked to describe the side effects he noticed

"as a result of the amount of dexamethasone she was taking if

she was substituting one dexamethasone tablet for one Medrol

tablet" for the period of time in question.       He responded that

"the side effects are identical.        It's only because she was on

dexamethasone that we can say they were due to the

dexamethasone."

        Klayton then described the following side effects

experienced by plaintiff:     Bruising, elevated blood sugar, being

emotionally distraught and depressed, difficulty in sleeping,

leg weakness, hip pain upon movement, swelling of her body,

extreme thinning of skin, and appearing "cushingoid."       Klayton

described plaintiff's cushingoid appearance:       "It's a plethoric

face.    Weight primarily central, with thin arms and legs.     And

there tends to be a deposition of fat over the upper part of the

back."

        There was no reference in the plaintiff's medical record

from January 1, 1995 through April 4, 1995 "where a physician at

Kaiser assessed her as being cushingoid."       On April 14, 1995, a


                                    7
Kaiser physician had written in her record, "Appears

cushingoid."    There was no reference in her record prior to

April 5 "where a physician ha[d] made a physical exam and noted

the extreme thinning of her skin."

        On May 4, Klayton asked plaintiff to "restart the Medrol in

a dose of 16 milligrams a day and stop the dexamethasone."      He

examined her on May 8, May 10, and May 15.

        On May 8, her blood sugar reading was 303 and her diabetes

"wasn't doing well."    On May 10, her blood sugar reading was

"down to 144 . . . just getting close to the normal of 118."       On

May 15, her diabetes was "well controlled."    Plaintiff's last

visit to Klayton was on May 24, 1995; she "had a very prominent

cushingoid appearance."

        The plaintiff, a school teacher, testified that:   "Once I

got this wrong medication, this is when all these problems

started coming up one after another."    She stated that during

the period from January to the end of March 1995, she "was doing

very good, except I usually would get sinus infections or

bronchitis.    And then it would go to asthma."   She was "doing

great" emotionally, she said.

        She was asked to describe changes that took place in her

physical condition from April through the first few days of May

1995.    She testified that she "became very hyper," that she

could not "seem to sit down at all," that she could not sleep at


                                   8
night, that she "started noticing this huge round face and these

big lumps on my neck," that her "stomach just started to

protrude," that she gained weight, that her "skin would just

split," and that she began "getting all these marks if I would

just bump against anything."   She testified that "all this

started happening" at "the end of April."

     The plaintiff's son testified he saw his mother, who lived

alone, at least weekly from 1994 through March 1995.    According

to the son, during this period she was "fine" and worked daily

"at the schools," she "seemed healthy," and she was "very happy"

emotionally.

     The son testified he observed his mother weekly during the

period April-May 1995.   He corroborated the plaintiff's

testimony about the changes in her physical and emotional

condition during that period, adding that she began growing

facial hair.

     The defendant presented the testimony of Kaiser physicians

who had treated the plaintiff from 1990 through 1996.   In sum,

this testimony, as well as her medical record during that

period, revealed a continuing problem with emphysema (chronic

obstructive pulmonary disease) and chronic sinusitis.   She had

been smoking one pack of cigarettes daily for 40 years.

     In July 1991, a physician noted she had "[t]rouble with

steroids."   In October 1992, a physician noted she was taking


                                 9
prednisone ("an oral steroidal medication"), was having

difficulty sleeping, and was feeling "hyper."   In November 1992,

a physician noted the plaintiff "was still smoking."   In January

1993, a physician found that plaintiff "has a lot of side

effects from taking Prednisone" such as "restlessness, insomnia,

[and] becoming hyper."

     On August 16, 1993, plaintiff was prescribed medrol for the

first time, to replace prednisone.    Several days later, her

physician decreased the dose of medrol from 40 mg to 32 mg daily

because she was "tolerating" the medication and "feeling much

better;" she was experiencing no "unpleasant side effects."

     In April 1994, a physician noted plaintiff had gained

weight after having stopped smoking during the previous

September.   In May 1994, plaintiff had been taking medrol 48 mg

daily for four days and reported complaints of "bloating" and

"being moody."

     During the last six months of 1995 and during 1996,

plaintiff's physicians were of the opinion "that she developed

the diabetes or high glucose condition due to steroid."    She had

become "steroid dependent" due to her lung disease because "her

condition would aggravate if she would try to come off the

steroid."    She continued to exhibit many of the side effects

associated with steroid use to the time of trial.




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     On appeal, urging affirmance of the judgment below,

defendant bases its argument on what it says is the following

question presented:   "Is expert testimony required to

differentiate between the effects of taking dexamethasone in an

unknown quantity for an unknown number of days and the effects

related to continuing on medrol on a daily basis for at least

ten months, or is the difference sufficiently obvious to be

within common knowledge?"   That is not the question presented.

     Furthermore, the defendant builds its argument on a

contention never made in the trial court.   Defendant argues

"[t]here was no evidence and no one knows how many of the wrong

pills Nichols took between April 13 and May 4, 1995, when the

error was discovered."   Thus, defendant contends, "the jury was

forced to render a judgment based upon whatever they speculated

was the amount of dexamethasone consumed by Nichols."    This

argument was not made in the trial court and we will not

consider it for the first time on appeal.   Rule 5:25.   Indeed,

the record establishes the plaintiff ingested at least 183

dexamethasone tablets during the 21-day period in question, an

average of about nine pills per day.

     The proper question to be decided, as we have said, is

whether the trial court erred in ruling there was insufficient

expert evidence of causation to present an issue for the jury.

     On the subject of causation, this case is a hybrid as it


                                11
relates to the necessity of presenting expert testimony in

matters strictly involving medical science as opposed to

accepting testimony of lay or nonexpert witnesses who are

familiar with a person whose physical condition is in question.

See, e.g., Raines v. Lutz, 231 Va. 110, 113, 341 S.E.2d 194, 196

(1986) (expert testimony ordinarily necessary to establish that

health care provider's deviation from standard of care was

proximate cause of claimed damages); Todt v. Shaw, 223 Va. 123,

127, 286 S.E.2d 211, 213 (1982) (lay testimony of causal

connection between automobile accident and injury admissible

even when medical testimony fails to expressly establish such

connection); Roll 'R' Way Rinks v. Smith, 218 Va. 321, 330-32,

237 S.E.2d 157, 163-64 (1977) (causal connection between

accident and permanent disability factual matter for jury even

though medical testimony never "formally pronounced" such

connection); and Pepsi-Cola Bottling Co. v. McCullers, 189 Va.

89, 97-98, 52 S.E.2d 257, 260-61 (1949) (opinions of lay

witnesses on causation generally limited to opinions upon

physical condition and may not extend to matters determinable

only through peculiar experience, knowledge, and training of a

physician).

     Here, plaintiff did not present expert testimony in the

strict sense of that term, that is, a witness was not formally

qualified who responded to hypothetical questions.


                               12
Nevertheless, there was abundant opinion testimony from

plaintiff's treating physicians, particularly Dr. Klayton.    In

addition, lay testimony was offered from the plaintiff and her

son upon the plaintiff's physical and emotional condition as it

appeared before and after the critical April-May 1995 period.

     Consequently, the case reduces to whether there was

sufficient evidence, comprised of medical opinion and lay

testimony, to present a jury question on causation.    We answer

that query in the affirmative; testimony from a "pure" expert

witness was unnecessary.

     The evidence showed that, prior to April 1995, plaintiff

had suffered from a severe respiratory disease for at least five

years.   She had been taking various steroid medications during

the five-year period and had experienced side effects to a

moderate degree sporadically during that time.    She took medrol

for the first time on August 16, 1993.   Over the next 20 months

until April 1995, she used medrol in varying doses and tolerated

the medication with few unpleasant side effects even though she

had a history of "trouble" with steroids.   From January 1995 to

April 1995, she was "doing very good" physically, except for her

respiratory condition, and "doing great" emotionally.

     Then, her health worsened dramatically.     On April 13 she

began taking dexamethasone, a steroid five times as potent as

medrol, which Kaiser's Reston pharmacy negligently had furnished


                                13
her on that day.   The very next day, April 14, she appeared

cushingoid to a Kaiser physician.     Her side effects were

exacerbated and multiplied to a degree more severe than ever

before.   She testified that once she "got this wrong medication,

. . . all these problems started coming up one after another."

She said that "all this started happening" at "the end of

April."

     On May 3, after taking heavy doses of the wrong medication

for 20 days, Klayton found her glucose level was "way too high."

The next day, May 4, Klayton discovered plaintiff had been on

the wrong medication.   He was of the opinion that plaintiff

suffered from "dexamethasone induced hyperglycemia" and that

"the dexamethasone had induced her high blood sugar," as well as

the other severe side effects enumerated in his testimony.

     This evidence, and the other facts in the trial record,

were sufficient to present a question for the jury upon whether

the defendant's negligence caused the effects of which the

plaintiff complains.    One moment she was relatively well and the

next moment she was ill; intervening between those two

conditions was defendant's negligence.    Thus, medical facts and

medical opinion combined with lay testimony, without the

addition of "pure" expert testimony, entitled the plaintiff to

have a jury weigh the evidence of causation, and the trial court

erred in ruling to the contrary.


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     Hence, the judgment below will be reversed, the verdict of

the jury will be reinstated, and final judgment on the verdict

will be entered here.

                                     Reversed and final judgment.




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