OPINION
Six dаys after being admitted to Sierra Providence Hospital in El Paso with atrial fibrillation, Rosario Carmona died of cardiac arrest. Her husband Andres sued the Hospital, attending physician Dr. Jose Ignacio Mendez-Martinez, and Dr. Mendez-Martinez’s practice group Cardiology Care Consultants for medical malpractice, alleging among other things that Dr. Mendez-Martinez’s failure to transfer Carmona from the' Hospital’s general wing to the intensive care unit for more frequent nursing care and monitoring resulted in the missing of certain medical warning signs that could have altered the course of her treatment and prevented her death.
As required by the Texas Medical Liability Act, Andres Carmona submitted an expert report from Dr. Louis Roddy certifying that this case was not frivolous. The parties agreed that Dr. Roddy’s initial report did not meet the Act’s formal requirements, and the trial court granted leave to supplement. Upon receipt of the second report, the trial judge decided that Dr. Roddy’s supplementation was detailed enough to sufficiently appraise him that the case against the healthcare providers was not wholly frivolous and should move into the discovery phase.
Only Dr. Mendez-Martinez appealed that decision. By two issues, he asks this Court to reject Dr. Roddy’s report and dismiss this case with prejudice, contending that the report was too vague and conclusory to allow the trial court to conclude that this case should move forward.
We will affirm.
BACKGROUND
On November 9, 2012, after filing suit, Andres Carmona filed Dr. Roddy’s expert report. Per his report, Dr. Roddy understood the facts to be as follows: Rosario Carmona arrived at Sierra Medical Center on May 1, 2010, complaining of shortness of breath, productive cоugh, lower back pain, and generalized weakness. She was diagnosed with atrial fibrillation, a left bundle branch block, bronchitis, asthma, chronic obstructive pulmonary disease, possible deep vein thrombosis, prerenal azotemia, hyperlipidemia, hypertension, anemia, and osteoporosis.
On May 7, 2010, at 8 p.m., a floor nurse in the Hospital’s general wing noticed that Carmona’s heart rate was over 100 beats per minute. The nurse informed Dr. Mendez-Martinez, who ordered treatment with Cardizem. At 10 p.m., the nurse administered 30 milligrams of Cardizem. At 10:30 p.m., Carmona’s heart rate was still оver
At 4 a.m., the nurse noted that Carmo-na’s pulse was in the 80’s and 90’s, and her blood pressure had dropped to 98/55. At 4:30 a.m., Carmona’s nurse found her with a heart rate in the 40’s. The nurse discontinued the Cardizem drip without notifying Dr. Mendez-Martinez, and Carmona’s hеart rate returned to the 80’s and 90’s range. At 5 a.m., Carmona’s heart rate returned to the 100’s range. At 7:14 a.m., following a gap in the medical records, Carmona was found without a pulse, and staff initiated CPR. At 7:40 a.m., resuscitation efforts ceased and Carmona was pronounced dead.
In his initial report, Dr. Roddy made the following findings:
20. The patient’s atrial fibrillation with rapid ventricular response and left sided bundle branch block placed the patient at risk for death due to cardiac arrest, which Dr. Mendez-Martinez and the hospital nurse knew or should have known.
21. When the patient’s heаrt rate increased to over 100 at 8:00 PM on May 7, the standard of care included the following:
a. that the physician, Dr. Mendez-Martinez, transfer the patient to an ICU for more frequent monitoring including vital signs, blood gases, and neurological status;
b. that the nurse assess the patient’s vital signs and saturations at least every 30 minutes and document the findings, and
c.that the physician be at the bedside to attend the needs of a patient with an acute change in clinical status.
22.The breach of the standard of care included the following:
a. the physician, Dr. Mendez-Martinez, failed to transfеr the patient to an ICU for more frequent monitoring including vital signs, blood gases, and neurological status;
b. the nurse failed to assess the patient’s vital signs and saturations at least every 30 minutes and document the findings, and
c. the physician, Dr. Mendez-Martinez, failed to be at the bedside to attend the needs of a patient with an acute change in clinical status.
The report also stated that when the patient developed bradycardia and her heart rate dropped down into the 40’s, the nursing standard of care required the floor nurse to notify the physician of acutе change of clinical status and assess the patient’s vital signs at least every thirty minutes and document the findings. Dr. Roddy concluded his report by stating:
25. Had the standard of care been followed, the patient would have received treatment for rhythm control (amiodar-one, sotalol, or dofetilide), or rate control (with beta blockers), which would have, more likely than not, prevented hemody-namic instability, and prevented the severe bradycardia, the cardiac arrest and death.
26. The failure to adhere to standards of care as applied to this patient did, to a reasonable medical probability, result in respiratory depression, cardiac arrest and death, which—in the absence of such failure of adherence to medicalstandards—would have not have occurred.
Dr. Mendez-Martinez objected to the report, arguing that it was conclusory as to causation. The trial court then entered an agreed order sustaining the objection as to causation and providing Carmona with thirty days to cure the deficiencies. Car-mona then timely filed a supplement from Dr. Roddy “explaining how Dr. Mendez-Martinez’s breach of the standard of cаre was a substantial cause of the patient’s cardiac arrest.” Dr. Roddy opined that “had Dr. Mendez-Martinez transferred Mrs. Carmona to ICU for more frequent monitoring including vital signs, blood gases, and neurological status, the ICU nursing staff, more likely than not, would have noted a significant change of these values and recognized that these may be signs of hemodynamic instability (oxygen deprivation). Such signs would have been immediately reported to the physician.” Dr. Roddy further stated:
2. ICU nurses are trained to understand that atrial fibrillation (AFib) may lead to heart failure. Heart failure means the hеart is not pumping enough blood to meet the body’s needs. AFib can lead to heart failure because the heart is beating so fast that it never properly fills up with blood to pump out to the body. As a result, when the heart does not efficiently pump the blood forward with strong contractions, symptoms develop because blood can ‘back up’ in the pulmonary veins (the vessels that return oxygen-rich blood from the lungs to the heart) which can cause fluid to back up into the lungs. This results in a significant change of vital signs, blood gases, and neurological status which the nurses are trained to recognize and report to the physician.
4. At 4:00 AM, the standard of care would have required that the ICU nursing staff immediately report the significant change of blood pressure to the physician.
5. Once reported to the physician, the standard of care would have required that the physician order immediate administration of medications for rhythm control (amiodarone, sotalol, or dofetil-ide), or rate control (with beta blockers).
6. In addition, once the significant change of vital signs (systolic pressure under 100 and heart rate down to the 40’s) were reported to the physician, the standard of care required that the physician, within 30 minutes, be at the bedside to attend the needs of a patient because of the acute change in clinical status.
7. The administration of the medications ... would have controlled the atrial fibrillation and prevented the he-modynamic instability. These medications would have prevented the severe bradycardia such as the 4:30 AM brady-cardia (heart rate in the 40’s).
8. By controlling the hemodynamic instability, more likely than not, this would have prevented Mrs. Carmona’s 7:14 AM cardiac arrest and death.
9. ICU nursing’s frequent monitoring (at least every 30 minutes) of vital signs, blood gases, and neurological status, would have noted a deterioration of the patient’s condition which would have been reported to the physician.
10. After 5:00 AM and prior to the arrest at 7:14 AM, her condition deteriorated (vital signs, blood gases, and neurological status), which would have been recognized by ICU nursing staff and reported to the physician. The physician would have ordered immediate treatment to prevent hemodynamic instability caused by AFib. Such medicaltreatment including cardioconvеrsion, more likely than not, would have prevented her cardiac arrest and death.
11. In summary, the standard of care included that Dr. Mendez-Martinez transfer Mrs. Carmona to the ICU by 10:30 PM on 5/7/2010, that Dr. Mendez-Martinez breached this standard of care, that the standard of care been followed [sic], Mrs. Carmona’s deterioration would have been recognized and treated, which would of [sic] prevented her cardiac arrest and death. Thus, the breach of the standard of care was a substantial cause of Mrs. Carmona’s cardiac arrest and death.
DISCUSSION
Dr. Mendez-Martinez arguеs that Dr. Roddy’s expert report accusing him of malpractice is deficient in two ways. First, in Issue One (a), Dr. Mendez-Martinez contends the report fails to articulate a sufficient causal link between his failure to order Carmona to the ICU and Carmo-na’s death. Second, in Issue One (b), Dr. Mendez-Martinez asserts that the report is defective because it did not adequately explain to what extent his alleged negligence, as opposed to the negligence of the nursing staff, caused Carmona’s death. We address these issues in reverse order.
Standard of Review and Applicable Law
In response to a perceived medical malpractice crisis in Texas, the Legislature passed the Texas Medical Liability Act in 2003, which created a new set of pretrial procedures aimed at allowing health care providers to test a broad class of “healthcare liability claims” for frivolousness at the pleading stage.
See generally
Tex.Civ. Prac.&Rem.Code Ann. §§ 74.001-.507 (West 2011 & West Supp.2015);
Tex.
W.
Oaks Hosp., L.P. v. Williams,
As is relevant here, the TMLA requires plaintiffs who sue doctors and hospitals for healthcare liability claims such as medical malpractice to provide the trial court with a sufficiently detailed expert report that essentially certifies the merit of the plaintiffs claim within 120 days of filing the original petition. Tex.Civ.Prac.&Rem.Code Ann. § 74.351(a)(West Supp.2015). “A valid expert report under the TMLA must provide: (1) a fair summary of the applicable standards of care; (2) the manner in which the physician or health care provider failed to meet those standards; and (3) the causal relationship between that failure and thе harm alleged.”
TTHR Ltd. P’ship v. Moreno,
The purpose of the TMLA’s expert report requirement is both to place healthcare providers on notice of what specific conduct is at issue in a particular case, and to provide judges who may have no medical training or knowledge of healthcare administration with the information needed to determine whether a healthcare liability claim is wholly frivolous.
Clapp v. Perez,
Improper Collectivization of Defendants
We deal first with Dr. Mendez-Martinez’s contention that Dr. Roddy’s report is defective because it improperly collectivizes the negligence allegations against the defendants. Specifically, Dr. Mendez-Martinez argues that Dr. Roddy essentially failed to assign comparative amounts of blame between Dr. Mendez-Martinez and the floor nursing staff, and Dr. Mendez-Martinez maintains that without specifying to what extent his own alleged negligence contributed to Carmona’s death in light of the Hospital nursing staffs negligence, the report is inadequatе. This argument is without merit.
Where a plaintiff sues multiple defendants in a health care liability case, the expert report must delineate the standards of care applicable to each defendant and then explain how the defendants’ respective breaches of those standards of care are causally linked to the plaintiffs injury.
Tenet Hosps., Ltd. v. Love,
Here, Dr. Roddy’s report clearly delineates how the responsibilities for patient care were divided between Dr. Mendez-Martinez and the nursing staff. Specifically, he states that the standard of care required Dr. Mendez-Martinez to transfer the patient to the ICU for more frequent monitoring, and to come to the patient’s bedside when there was an acute change in clinical status. Dr. Roddy also opines that the standard of care required nursing staff to assess the patient’s vital signs and satu-rations at least every thirty minutes and document the findings, and to notify Dr. Mendez-Martinez when Carmona developed bradycardia. Rather than improperly collectivizing different parties under a single standard of care, Dr. Roddy’s report explains the divided responsibilities of the cardiologist and the nursing staff and how each purportedly breached the standard of care.
Compare Clapp,
In the second place, we see no compelling reason to consider expanding the fair summary standard to embrace a relative negligence inquiry absent further legislative directive, particularly at this pleading stage of litigation, in which discovery against the defendants is largely рrohibited by statute.
See Gonzalez,
In short, Dr. Roddy’s report adequately identifies the relative standards of care, breaches, and causal links between Carmo-na and her individual caretakers. Reversal on this ground would be improper.
Issue One (b) is overruled.
Causation
In Issue One (a), Dr. Mendez-Martinez assets that Dr. Roddy’s causation assessment is conclusory because there is nothing in the report that would establish that transferring Carmona to the ICU would have actually resulted in a different level of nursing care that could have altered the outcome in this case. We disagree.
“An expert report must provide a fair summary of the causal relationship between the failure of a health care provider to meet the standards of care and the injury, harm, or damages claimed.”
De La Riva,
Dr. Mendez-Martinez advances multiple attacks on both
Clapp
factors. We begin
This argument holds some appeal at first glance. By comparing language in the first report dealing with flоor nurse monitoring with language in the second report dealing with ICU nurse monitoring, Dr. Mendez-Martinez suggests that the trial court should have concluded that ICU intervention would not have made a difference in this case because any nurse, regardless of assignment, should have been monitoring Carmona every thirty minutes based on her condition.
If the scope of our review only included the isolated provisions of Dr. Roddy’s report dealing with the two nursing staffs’ allegedly identical duty to monitor, reversal might be appropriate, since then Dr. Mendez-Martinez’s failure to transfer Car-mona from one nursing unit to another would not have made a difference with respect to that issue. But we read expert reports as a whole, not in isolated provisions. When reading the provisions Dr. Mendez-Martinez cites in the context of the report as a whole, we believe Dr. Rod-dy’s report can establish an adequate causal link under the fair summary standard because it also sets out other specialized duties and training ICU nurses have that could have made a difference in outcome.
Dr. Mendez-Martinez disagrees, complaining that while Dr. Roddy explained what special training ICU nurses receive to deal with patients, he failed to properly frame that training by detailing how it differed from the training floor nurses receive. He insists that because we cannot moor our analysis to that anchor point, and because we cannot draw inferences not explicitly stated in the report, the report is deficient for want of an adequate frame of reference and we must dismiss the case against him with prejudice. We concede that the report’s delineation of standards among floor and ICU nurses may be less than precise, and Dr. Mendez-Martinez is correct that the Court must not draw impermissible inferences from an expert report. Still, the TMLA was not an attempt to graft strict pleading standards onto Texas medical malpractice cases, nor was it an invitation to abandon the traditional commonsense rules of textual interpretation when looking at an expert’s report. The adequacy standard at the TMLA pleading stage is simple: courts are to look only at whether an expert report constitutes a “fair summary” of the issues at play, a summary that “include[s] an articulable, complete, and plausible explanation of how the alleged breaches led to the damages sustained[.]”
Garcia,
When we read these provisions outlining ICU nurse training and responsibilities contextually, we understand Dr. Roddy to say that the level of care Carmona would have recеived in ICU would have been different and more stringent by virtue of the ICU nurses’ specialized training and round-the-clock care. Under the fair summary standard, that is enough to push this case into the discovery phase, since it articulates a difference that would arguably create a fact issue on whether Dr. Mendez-Martinez’s actions would have made a difference that is ripe for later resolution. 1
We next turn to the logical linkage element of causation. A plaintiff must link the defendant’s alleged negligence to the injury suffered. A break in the logical chain between the negligent act and the injury renders the causation conclusions in a report insufficient.
See, e.g., Regent Health Care Ctr. of El Paso, L.P. v. Wallace,
In his final point, Dr. Mendez-Martinez asserts even if Dr. Roddy articulated a difference in monitoring duties as between floor nurses and ICU nurses, there is a logical break in the chain at the final link because Dr. Roddy’s report cannot establish that more frequent monitoring in the ICU would have made an actual difference in outcome. While acknowledging that we previously held failure to monitor can form the basis of a healthcare liability claim in
Bustillos,
Here, Dr. Roddy’s report meets the fair summary standard on causation by logically linking the alleged breach and the alleged harm step-by-step with enough medical detail to allow the trial court to decide that Carmona could state a claim under Texas law. Dr. Roddy explained that ICU nurses would be trained to know that atrial fibrillation can lead to heart failure if not treated correctly; they would know that heart failure leads to telltale changes in “vital signs, blood gases, and neurological status which the nurses are trained to recognize and report to the physieian[;]” they would monitor patients in the ICU ward at least every thirty minutes; and had thеy monitored Carmona at least every thirty minutes between 5 a.m. and when she was found pulseless at 7:14 a.m., ICU nurses more likely than not would have caught any signs of deterioration in her condition and reported them to Dr. Mendez-Martinez, who could have altered Carmona’s treatment to include rhythm-stabilizing drugs, beta blockers to control pulse, or cardioconversion that would have saved her life. Dr. Roddy also opined that the standard of care required Dr. Mendez-Martinez to transfer the patient to an ICU for more frequent monitoring once her heart rate increasеd to over 100 at 8 p.m. on May 7. By keeping her on the general care floor, Dr. Mendez-Martinez breached the standard of care, and as a result, his actions deprived her of the opportunity for potential intervention triggered by more frequent monitoring and were thus a substantial factor in Carmona’s cardiac arrest and death.
Facially, the contentions laid out in Dr. Roddy’s report provide an articulable, complete, and plausible path toward a cause of action against Dr. Mendez-Martinez. Whether the links in the logical chain are strong enough to support a liability finding against him is not a question to be resolved at the pleading stage. Dr. Roddy’s report provides a fair summary of the plaintiffs theory on causation.
Issue One (b) is overruled.
CONCLUSION
The judgment of the trial court is affirmed.
Notes
. Because we find that the alleged failure to transfer to ICU ground presents an adequately detailed theory to allow the case to move forward, and because one adequate theory is enough to justify upholding denial of an expert report challenge,
see Certified EMS, Inc.
v.
Potts,