MEMORANDUM OPINION AND ORDER
SHERMAN G. FINESILVER, District Judge:
BACKGROUND AND OVERVIEW OF THE CASE
On November 16, 1976, plaintiff Ellen Bean, age sixty-two and a resident of Jefferson
In this suit, brought under the Federal Tort Claims Act
The questions presented are whether plaintiff's drop foot was caused by the vaccination, and if so, is defendant liable; also present is the issue of the adequacy of the warning given to plaintiff. On these pivotal issues, we find in favor of defendant, United States of America.
THE JUDICIAL PANEL ON MULTIDISTRICT LITIGATION
The action was filed on May 14, 1979. On June 20, 1979, it was transferred by the Judicial Panel on Multidistrict Litigation to the United States District Court for the District of Columbia for coordinated and consolidated pretrial proceedings pursuant to 28 U.S.C. § 1407.
A substantial portion of plaintiff's brief is addressed to the issue of whether in the Fall of 1976 the possibility of a swine flu epidemic posed a threat to the general population of the United States. The justification for the program, however, is not in issue. During consolidated pretrial proceedings, the transferee court, in ruling on a motion for summary judgment filed by the United States, held that:
See, Stipulation and Final Pretrial Order, In Re Swine Flu Immunization Products Liability Litigation, MDL No. 330, Misc. No. 78-0040, p. 2, 89 F.R.D. 695 (D.D.C. Nov. 15, 1979).
The Order also limits the litigants to local discovery only as distinguished from national discovery. Over seventy depositions were taken during the course of national discovery. Several of those were introduced in evidence in this case.
The case was remanded to this Court on December 21, 1979; a supplemental pretrial conference was held on May 1, 1980. Issues of liability and damages were bifurcated. A non-jury trial
The following are the facts established at trial and our conclusions of law. We highlight conflicts in the testimony.
THE NATIONAL SWINE FLU IMMUNIZATION PROGRAM
The Swine Flu Act of 1976 was an attempt by the Federal Government to inoculate the entire adult population of the United States against the threat of a swine flu epidemic. It was the largest immunization program in this country's history and over forty-five million Americans — or one-third of the adult population — were vaccinated. The initial vaccination was on October 1, 1976; and the program was suspended on December 16, 1976.
The Swine Flu Act became law on August 12, 1976 and was applicable to all swine flu inoculations administered after September 30, 1976. Important provisions of the Act include the following:
The program was prompted in part by the medical discovery in early February, 1976 at Fort Dix, New Jersey, of military servicemen having a new strain of influenza virus antigenically
In addition, the Swine Flu Act was prompted by the collapse of the commercial liability insurance market, both for vaccine manufacturers and other program participants. The cases of Davis v. Wyeth Laboratories, Inc., 399 F.2d 121 (9th Cir. 1968), and Reyes v. Wyeth Laboratories, 498 F.2d 1264 (5th Cir. 1974), which held a manufacturer of polio vaccine strictly liable in tort, greatly contributed to the insurance problem. For this reason, the Swine Flu Act provided that the exclusive remedy for injury caused by the vaccine would be against the United States.
History has demonstrated that no swine flu epidemic occurred during the winter of 1976-77. As can be expected, however, many people who were inoculated also incurred some type of illness, injury or adverse medical condition in a period relative to the vaccination. Lawsuits,
The critical question presented in these cases is the causal relationship between the immunization and claimed illness. However, mere temporal relation between the onset of a disease and the vaccination is insufficient to establish legal causation. Each plaintiff has the burden of proving that the swine flu inoculation was the proximate cause of a claimed injury or medical condition.
ADEQUACY OF THE WARNING: INFORMED CONSENT
On November 16, 1976, Mrs. Bean received a swine flu vaccination at a public health clinic in Jefferson County, Colorado. The testimony is in conflict as to whether she received adequate warning of the possible adverse effects of the vaccine prior to inoculation. Plaintiff testified that the only material distributed by the Jefferson County Health Department was a blue card (Plaintiff's Exhibit 3A) which advised her that she might suffer some minor discomfort such as redness and tenderness at the
Testimony indicated that the Jefferson County Health Department has been unable to locate any executed consent forms for November 16. Ms. Virginia Wolf, Assistant Director of Nursing for the County Health Department, testified that she was a coordinator for the vaccination program in Jefferson County; that it was the routine practice at the health center to give each person a registration (consent) form and a national fact sheet containing information about swine flu and the immunization program; and that the signed consent form was exchanged for a blue card which informed the person administering the vaccine whether the vaccinee was to receive a bivalent or monovalent vaccination.
Ms. Barbara Mertens, a communicable disease nurse worked at several of the Jefferson County Health Centers during the immunization program. She testified that a person could not be inoculated without first presenting the blue card and, that such a card was obtained only by exchanging an executed consent form. Both Mss. Wolf and Mertens testified that personnel were available to answer any questions a vaccinee might have, and that such questions were encouraged.
The question of whether evidence is admissible in a proceeding in federal courts is determined by reference to the Federal Rules of Evidence. Envirex, Inc. v. Ecological Recovery Associates, 454 F.Supp. 1329 (M.D.Pa.1978). With respect to evidence of habit and routine practice, Rule 406 of the Federal Rules of Evidence, is instructive:
Several cases are informative on the effect of evidence of habit or routine practice.
464 F.Supp. at 321.
In Meyer, the trial court considered evidence of a dentist's regular and routine practice of warning patients of the risks involved in oral surgery as persuasive on the issue of whether he provided such warning to the plaintiff. At trial, plaintiff had unequivocally testified that she received no advice or warning concerning the dangers attending oral surgery. In affirming the district court, the Tenth Circuit held that evidence of habit "does not stand in a special light nor is it to be referred to a second-class category which automatically carries little weight.... [T]he weight to be given to it is dependent on the particular circumstances." 638 F.2d at 158.
The Tenth Circuit has also held that the trial court had properly admitted evidence as to the defendant's customs and habits in operating a ski chairlift in a personal injury action. Ryan v. Aspen Highlands Skiing Corporation, No. 75-1533 (10th Cir. Aug. 17, 1976) (unpublished opinion). In Frase v. Henry, 444 F.2d 1228, 1232 (10th Cir. 1972), the court stated that "[e]vidence of habit or custom is relevant to an issue of behavior on a specific occasion because it tends to prove that the behavior on such occasion conformed to the habit or custom."
In United States v. Callahan, 551 F.2d 733 (6th Cir. 1977), the court ruled that evidence of a routine practice of a construction company would be relevant, under Rule 406, in proving the conduct of the company on a particular occasion. Defendant, who was charged with extortion, should have been able to cross-examine the company's job site supervisor as to other confrontations he had with other union representatives in similar circumstances. Such evidence might have established a routine practice of the company which employed non-union workers of paying off local unions for the sake of expediency and not out of fear.
We find that the Jefferson County Health Department's habit and routine practice of obtaining signed consent forms prior to administering the vaccine was present on November 16, 1976, and that the health center acted in conformity with the habit and custom in advising Mrs. Bean of the potential adverse effects of the swine flu vaccine.
Having determined that Mrs. Bean received information concerning the vaccine, we now address the issue of whether such information was sufficient to enable her to render an informed consent to be vaccinated. Defendant's Exhibit F-460 is the registration form entitled "Important Information About Swine and Victoria Influenza (Flu) Vaccine (Bivalent)." After describing the disease and the vaccine, this document discusses possible vaccine side effects and special precautions. Under possible side effects, it is stated: "Most people will have no side effects from the vaccine. However, tenderness at the site of the shot may occur and last for several days. Some people will also have fever, chills, headache or muscle ache within the first forty eight hours." Under the heading special precaution is the following:
At the bottom of the sheet patients are directed to ask any questions about the flu or flu vaccine which they might have.
The signed registration form states: "I have read the above statement about swine flu and Victoria flu, the vaccine and the special precautions. I have had an opportunity to ask questions, ... and understand the benefits and risks of flu vaccination. I request that it be given to me...".
Under the FTCA, the United States is only liable for the negligent or wrongful acts or omissions of its employees while acting within the scope of their office or employment. 28 U.S.C. § 1346(b). This has been interpreted to mean that the United States may not be held liable on theories of strict or absolute liability. Dalehite v. United States, 346 U.S. 15, 73 S.Ct. 956, 97 L.Ed. 1427 (1953) reh. den. 346 U.S. 841, 74 S.Ct. 13, 98 L.Ed. 363, 346 U.S. 880, 74 S.Ct. 117, 98 L.Ed. 386, 347 U.S. 924, 74 S.Ct. 511, 98 L.Ed. 1078.
State law determines the standard of conduct against which acts of government agent are to be measured under the FTCA. Laird v. Nelms, 406 U.S. 797, 92 S.Ct. 1899, 32 L.Ed.2d 499 (1972). Therefore, the law of the State of Colorado applies in the instant action. The Colorado rule on informed consent was enunciated in Mallet v. Pirkey, 171 Colo. 271, 466 P.2d 466, 473 (1970):
Stated differently it is not mandatory for a physician to make full and complete disclosure under all circumstances. This is especially true when disclosure of all risks may be impractical. A physician discharges his duty to disclose when he has informed the patient of the substantial risks involved in the treatment which the physician knows or reasonably should have known existed. See Colorado Jury Instructions, 2d, Civil, 15:16. The duty to disclose is a duty imposed by laws, and does not owe its existence to community medical standards. Hamilton v. Hardy, 37 Colo.App. 375, 549 P.2d 1099, 1104 (1976), cert. den. May 3 and May 24, 1976.
A persuasive case on the question of informed consent is Canterbury v. Spence, 464 F.2d 772 (D.C.Cir.1972), cert. den. 409 U.S. 1064, 93 S.Ct. 560, 34 L.Ed.2d 518 (1972), where the court held that the duty to disclose is not determined by medical custom, rather, it depends on the patient's right to know and to consent to treatment:
Canterbury, supra, 464 F.2d at 786-787.
In determining the breadth of disclosure, an objective standard with due regard to the patient's informational needs and the physician's situation must be considered. "A risk is thus material when a reasonable person ... would be likely to attach significance to the risk or cluster of risks in deciding whether or not to forego the proposed therapy." Id. at 787.
In duty to disclose cases, the focus of attention is on the physician's divulgence rather than the patient's understanding. While adequate disclosure and informed consent are two sides of the same coin, the former a sine qua non of the latter, the physician discharges his duty when he makes a reasonable effort to convey significant
Under both Canterbury and the Colorado standard, the patient's right to know and consent depends upon an objective determination of what information a prudent person would require in order to make an intelligent decision. To explain all the risks involved in a particular treatment might be inexpedient and confusing. Niblack v. United States, 438 F.Supp. 383, 389 (D.Colo. 1979). Here, the registration form executed by Mrs. Bean advised her of possible severe or potentially fatal reaction to the inoculation. Would the inclusion of potential neurologic disorders resulting from the vaccine be significant? We think not. A reasonable person, when informed that a treatment might lead to fatality, would not require advice concerning potential neurologic disorders in order to make an informed decision.
We find that the warning given to Mrs. Bean was sufficient to provide her with adequate information to make an informed decision as to whether she should be vaccinated. Resolving this issue adversely to plaintiff, we now consider the pivotal question of causation and the medical history of plaintiff prior to and after the swine flu immunization.
PLAINTIFF'S MEDICAL HISTORY
On the morning following her swine flu vaccination, Mrs. Bean began experiencing numbness in her left foot. Two weeks later, on November 30, plaintiff visited Gerald H. Hooper, D.O., her physician since 1971, complaining of back pain. Dr. Hooper was unable to relieve the pain with normal treatment. Plaintiff was then hospitalized by Dr. Hooper for treatment of acute sciatic neuritis and degenerative joint disease. She remained hospitalized for approximately two weeks. During that period, Mrs. Bean developed left foot drop. This condition, which all experts agree is permanent in the instant case, prevents Mrs. Bean from elevating her left foot, causing her toes to drag when she walks. She requires a leg brace to walk without stumbling.
Testimony indicates several hospitalizations of plaintiff over the past twenty years. She has an extensive history of back problems spanning more than thirty years. In the 1940's she fell while skating and injured her back; from that time on, plaintiff has had periodic bouts of back pain which have required treatment with physical therapy and traction. She has also been treated for degenerative arthritis for thirty years and has suffered from curvature of the spine and sciatica. In 1960, Mrs. Bean underwent back surgery. This was necessary to alleviate low back pain that radiated down her left foot. She also had paresthesia and burning in that foot. She apparently recovered from the operation and in 1963, began working as a beautician.
In 1967, plaintiff slipped on ice and reinjured her back. This caused her to miss several weeks of work. She continued as a beautician until 1971 when she sold her shop and retired. There is some conflict in the testimony as to the reasons for her retirement. Plaintiff asserts that she retired because she was exhausted, suffered from inner ear problems, and had recently remarried. Defendant, on the other hand, contends that Mrs. Bean retired because of leg and back pain which were aggravated by the constant standing required of a beautician. In support of this position, the government submitted Mrs. Bean's Social Security disability file (Defendant's Exhibit O). The application for benefits filed May 28, 1975, listed back problems as the reason she sold her shop in 1971. Donald Harder, M.D., examined plaintiff in connection with that application. He reported that Mrs. Bean complained of low back pain, numbness and pain in the lower left extremity, and occasional pain in the lower right leg. X-rays revealed a scoliosis (abnormal curvature) and advanced degenerative changes in the lumbar spine. It was Dr. Harder's impression that Mrs. Bean was considerably disabled as a result of back problems. Dr. Hooper also submitted a report that plaintiff
From 1971 to the present, Dr. Hooper has treated Mrs. Bean for sciatica, degenerative joint disease, arthritis and vertigo. In August, 1976, when plaintiff was hospitalized for rectal surgery, Dr. Hooper was one of her treating physicians. Admission records from that hospitalization indicate that plaintiff suffered from paresthesia and numbness in the second toe of her left foot. (Defendant's Exhibit N). While hospitalized, she also complained of deep pain in her left buttock, as well as back pain.
In 1974, plaintiff was hospitalized for two weeks with severe sciatic pains on her left side. Medical records for this hospitalization indicates that Mrs. Bean had been experiencing more pain during physical activities and while standing. (Defendant's Exhibit P). In March, 1977, plaintiff was hospitalized for left leg pain. Medical records for that incident indicate that the pain began in 1975 and became acute in December, 1976.
Plaintiff's medical history reveals that she has had various problems with her left leg prior to the swine flu immunization. These problems include tingling and numbness in her left foot. In addition, she has had numerous back problems and occasional difficulty in her lower right extremities.
The testimony is in conflict as to whether the swine flu vaccine caused plaintiff's drop foot. In support of plaintiff's position, several doctors rendered their expert opinions and analyses.
Martin Lewis, M.D., Chairman of the Pathology Department at Georgetown University, Washington, D.C., has conducted several studies concerning the effect of vaccination on the immune system. His testimony at trial pertained to one such test which seeks to determine a nexus between the swine flu vaccine and Guillain-Barre Syndrome (GBS). The methodology utilized involves reacting a person's blood serum with both peripheral nerve antigen and the swine flu vaccine. Dr. Lewis analyzed over 100 sera in this manner.
A summary of his findings indicates that sixty-six percent of the GBS patients who had been vaccinated demonstrated a positive reaction to both the nerve antigen and the vaccine, whereas only eight percent of the non-GBS patients evidenced two positive reactions. In Dr. Lewis' opinion, the significance of two positive reactions is that such an individual is one who had GBS or still has it and had been vaccinated.
It is urged by plaintiff that, since her blood serum yielded two positive reactions, the test results establish that she experienced GBS as a result of the vaccination. We are not persuaded that this contention is correct. Plaintiff has not established that she suffered any of the symptoms typically required for a diagnosis of GBS.
Additionally, Dr. Lewis testified that the test results were preliminary and inconclusive. On cross examination, the following colloquy occurred:
(See, Test. of Dr. Lewis).
At trial the government objected to the admissibility of Dr. Lewis' testimony on two grounds. First, it contends that plaintiff has not established an adequate chain of custody with respect to the blood samples of Mrs. Bean analyzed by Dr. Lewis; and second, the tests are not the type reasonably relied on by the medical profession in formulating opinions.
We have considered and overrule defendant's objection to the testimony of Dr. Lewis. The general purpose of requiring a chain of custody to be established is to insure that evidence being offered is what the proponent claims it to be. Rule 901(a), Federal Rules of Evidence; United States v. Zink, 612 F.2d 511, 514 (10th Cir. 1980). To establish a chain of custody, the proponent must trace the continuous wherea-abouts of the item in question. Id. Here, plaintiff has submitted affidavits of: (a) the nurse who drew the blood from Mrs. Bean and mailed it to plaintiff's attorney; (b) of plaintiff's attorney's secretary who received the blood and mailed it to Dr. Phillips at Georgetown University; and (c) of Dr. Phillips who received the blood and coded it in accordance with his laboratory's usual procedures. We are satisfied that these affidavits support a continuous chain of custody of Mrs. Bean's blood samples from the time it was drawn until it was analyzed.
Rule 703, Federal Rules of Evidence, upon which defendant's second objection is based, reads as follows:
The government bases its objection to Dr. Lewis' testimony on what we believe to be an incorrect interpretation of the second sentence of Rule 703. The thrust of the government's objection is that the medical community has not yet accepted Dr. Lewis' conclusions. It has, however, accepted the methodology in which his tests were conducted. The second sentence of Rule 703 allows experts to render opinions based upon information that otherwise might be hearsay, if this information or data is routinely relied upon by experts in the field. See, Smith v. Ford Motor Co., 626 F.2d 784, 793 (10th Cir. 1980); Bryan v. John Bean Division of FMC Corporation, 566 F.2d 541, 545 (5th Cir. 1978) (Rules 703 and 705, Federal Rules of Evidence, permits the disclosure of otherwise hearsay evidence for the purpose of illustrating the basis of the expert witness' opinion. United States v. Shields, # 77-1095 (10th Cir., March 22, 1978) (unpublished opinion) (a handwriting expert's testimony was admissible under Rule 703, even though the exemplars on which he relied were not admitted in evidence). See also, Notes of the Advisory Committee on Proposed Rules, Rule 703, Federal Rules of Evidence. Dr. Lewis, however, based his opinion upon tests conducted by laboratory personnel under his supervision. It is beyond question that physicians regularly base opinions on laboratory findings. Therefore, Dr. Lewis may base his opinion on the results of those tests.
The fact that Dr. Lewis could not state to a reasonable degree of medical certainty that the swine flu vaccine caused Mrs. Bean's illness goes to the weight we give his testimony, not to its admissibility. United States v. Cyphers, 553 F.2d 1064 (7th Cir. 1977), cert. den. 434 U.S. 843, 98 S.Ct. 142, 54 L.Ed.2d 107 (1977). Similarly, the fact that the results are preliminary, and may not generally be accepted by the medical community goes to the weight we
We believe the test for the admissibility of this testimony is its usefulness to the fact finder. Reference to Rule 702, Federal Rules of Evidence is helpful:
The testimony of Dr. Lewis is admissible in evidence in the case. It is useful for a better understanding of the medical issues inherent in this litigation.
Charles Poser, M.D., Professor of Neurology at the University of Vermont, opined at trial that Mrs. Bean suffers from a sciatic neuropathy on her left side which was caused by the swine flu vaccine. The sciatic nervous system consists of a number of nerve roots coming out of the spinal cord in the lumbrosacral area. In essence, it provides nerve and motor impulses to the legs and feet. Dr. Poser testified that the vaccine had a demyelinating effect on the sciatic nerve. This demyelination
Dr. Poser based his medical opinion on an examination of Mrs. Bean, a review of her medical records, and medical history related by plaintiff. The medical records indicate that Mrs. Bean complained of pain and numbness in her left leg and foot on three separate occasions. Significantly, Mrs. Bean told Dr. Poser that she had not had any left side problems prior to being vaccinated on November 16, 1976. In formulating his opinion, Dr. Poser relied on the facts as recited by Mrs. Bean rather than those contained in her medical records.
Plaintiff's final expert witness was Richard Baisel, M.D., a specialist in orthopedic surgery. He examined plaintiff on December 3, 1976, and testified that she suffered from nerve root irritation rather than nerve root compression at that time. In his opinion, nerve root irritation does not cause drop foot. Dr. Baisel did not render an opinion as to whether the swine flu vaccination caused plaintiff's drop foot.
One expert testified that there was no connection between the immunization and the injuries and ailments claimed by plaintiff. Steven Ringel, M.D., Professor of Neurology at the University of Colorado Health Center, conducted a physical examination of Mrs. Bean and reviewed her medical records. He explicitly testified that the disorder suffered by plaintiff was not Guillain-Barre Syndrome. In his opinion, the swine flu vaccine had no relation to plaintiff's foot drop and did not aggravate or contribute to her condition. He further stated that plaintiff's foot drop was caused by chronic back ailments and arthritis; that in particular, it is caused by chronic "L-5, S-1"
THE LAW OF CAUSATION
Under the Federal Tort Claims Act, the United States is liable "for injury ... under circumstances where the United States, if a private person, would be liable to the claimant in accordance with the law of the place where the act or omission occurred." 28 U.S.C. § 1346(b), 2674. In the instant action, the applicable law is that of the State of Colorado.
145 Colo. 151, 358 P.2d 36.
In the instant case, if plaintiff establishes that the swine flu vaccination aggravated her previous back problems thereby causing her drop foot or that the vaccine singly caused the drop foot, then the vaccination is the proximate cause of her condition.
All that is necessary to establish a causal connection between the inoculation and plaintiff's illness is to show facts and circumstances as would indicate with a reasonable probability that the drop foot resulted from, or was precipitated by the vaccine. Widefield Homes, Inc. v. Griego, 160 Colo. 225, 416 P.2d 365 (1966); Industrial Commission v. Royal Indemnity Co., 124 Colo. 210, 236 P.2d 293, 295 (1951); O'Connor v. Boulder Colorado Sanitarium Assn., 107 Colo. 290, 111 P.2d 633, 634-35 (1941); Ringsby Truck Lines v. Industrial Commission, 30 Colo.App. 224, 491 P.2d 106 (1971).
BURDEN OF PROOF
Plaintiff has the burden of proving by a preponderance of the evidence that the swine flu vaccine was the proximate cause of her drop foot. Exchange National Bank of Colorado Springs v. Sparkman, 191 Colo. 534, 554 P.2d 1090, 1092 (1976). While plaintiff presented the testimony of widely respected doctors, we are not persuaded that she has met her burden of proof. We have found nothing persuasive in the evidence establishing a causal connection between drop foot and the swine flu vaccine. Additionally, two of the experts who testified in support of plaintiff's position (Dr. Lewis and Dr. Baisel) were unable to state with a reasonable degree of medical certainty that the inoculation caused plaintiff's condition. Dr. Lewis' serum analysis is not persuasive in the instant case. It purports to establish a relationship between the vaccine and Guillain-Barre Syndrome. In his own words, the study is preliminary and inconclusive.
The only remaining opinions are those of Drs. Poser and Ringel. We believe that the process of reasoning by which Dr. Ringel supports his opinion convinces the Court that his opinion is entitled to greater weight. Based on the more persuasive evidence, we find that plaintiff has not established that the swine flu vaccination caused Mrs. Bean's condition or in any way contributed to her drop foot. Simply stated, the vaccination was not the proximate cause of plaintiff's injury.
We find and conclude that plaintiff has failed to establish by a preponderance of the evidence that the injuries she sustained were caused by the immunization. Several possible causes of drop foot have been advanced, however, in our role as trier of fact,
We find the issues joined in favor of defendant, United States of America, and against plaintiff, Ellen Bean. The Clerk of the Court is directed to enter judgment in favor of defendant and against plaintiff and the complaint and action are dismissed. Each party to pay its or her own costs.
This Order constitutes the findings of fact and conclusions of law as required by the Federal Rules of Civil Procedure, Rule 52(a).
Several courts have spoken on issues relating to the Swine Flu program. Sparks v. Wyeth Laboratories, 431 F.Supp. 411 (W.D.Okl.1977), aff'd per curiam (10th Cir. Dec. 22, 1978) (unpublished opinion), upheld the Swine Flu Act against an argument that it violated the Seventh Amendment. That Court stated at p. 418 "it is axiomatic that if a cause of action can be abolished [the court had ruled that the abolition of the cause of action against the program participants did not violate due process], the jury trial of that action is also abolished. The elemental fact is that suits against the sovereign were unknown as common law. Thus, perforce, there was no right of jury trial against the sovereign at common law."
The constitutionality of the Swine Flu Act was also upheld in Jones v. Wyeth Laboratories, Inc., 583 F.2d 1070 (8th Cir. 1978), and Ducharme v. Merrill National Laboratories, 574 F.2d 1307 (5th Cir. 1978). In Overten v. United States, 619 F.2d 1299 (8th Cir., 1980), another swine flu case, the court held that in order for funds to be considered collateral to an FTCA damage award, the plaintiff must demonstrate that he has contributed to the fund which he claims as a collateral source. The court upheld the damage award but deducted medicare payments received by plaintiff.