Arthur F. Knight, Jr., individually and as executor of the estate of Barbara P. Knight (collectively “Knight”), brought the instant medical malpractice action against Dr. Fred T. Roberts, Dr. Terry A. Cone, and The Medical Center, Inc. d/b/a Columbus Regional Medical Center (“TMC”), alleging that the doctors and nursing staff had failed to timely diagnose Mrs. Knight’s aortic dissection heart condition, which led to her death. Dr. Roberts, Dr. Cone, and TMC each filed motions for summary judgment, contending that Knight had failed to present evidence that their acts or omissions caused or contributed to Mrs. Knight’s death. TMC also filed a motion to exclude the testimony of Knight’s expert nurse, Cathleen A. Provins Chubock, challenging her qualifications as an expert in emergency room nursing procedures.
We granted Dr. Cone’s and TMC’s applications for interlocutory appeal for review of the trial court’s denial of their motions for summary judgment. Knight cross-appeals the trial court’s order granting summary judgment for Dr. Roberts. Since these appeals involve the same set of facts and legal principles, we consolidated them for review. We conclude that the evidence presents a genuine issue of material fact as to whether the negligence of Dr. Roberts, Dr. Cone, and the nursing staff proximately caused Mrs. Knight’s death; therefore, we reverse the trial court’s grant of summary judgment in favor of Dr. Roberts in Case No. A12A0740. We affirm the trial court’s decisions denying summary judgment to Dr. Cone and TMC in Case Nos. A12A0741 andA12A0770. We also affirm the trial court’s denial of TMC’s motion to exclude the expert nurse’s testimony in Case No. A12A0770.
To prevail at summary judgment under OCGA § 9-11-56, the moving party must demonstrate that there is no genuine issue of material fact and that the undisputed facts, viewed in the light most favorable to the nonmoving party, warrant judgment as a matter of law. A defendant may do this by showing the court that the documents, affidavits, depositions and other evidence in the record reveal that there is no evidence sufficient to create a jury issue on at least one essential element of plaintiff’s case.
When ruling on a motion for summary judgment, the opposing party should be given the benefit of all reasonable doubt, and the court should construe the evidence and all inferences and conclusions therefrom most favorably toward the party opposing the motion. Further, any doubts on the existence of a genuine issue of material fact are resolved against the movant for summary judgment. When this Court reviews the grant or denial of a motion for summary judgment, it conducts a de novo review of the law and the evidence.
(Punctuation and footnotes omitted.) Beasley v. Northside Hosp.,
So viewed, the record shows that on the afternoon of February 17, 2001, Mrs. Knight was bathing her dog when she suddenly began experiencing a pain in her chest. Later that evening, Mrs. Knight went to TMC’s Emergency Department (“ER”), arriving at approximately 8:00 p.m. Mrs. Knight registered into the ER at approximately 8:14 p.m. and saw a nurse for an initial assessment at 8:20 p.m. Mrs. Knight reported that she was 61 years old, had a history of smoking and
Dr. Roberts was the attending physician in the ER that evening, and he saw Mrs. Knight at 8:35 p.m., approximately 15 minutes after her initial assessment. Dr. Roberts reviewed the nurse’s notes describing Mrs. Knight’s symptoms and history, and he performed a physical examination. Upon his examination at 8:35 p.m., he ordered a CCU panel, chest x-ray, placement on a monitor, sublingual nitroglycerine, and a GI cocktail. The nurses, however, did not begin to carry out the orders immediately; instead, Mrs. Knight was not placed on a monitor until 9:20 p.m., and her medications were not given until 9:30 p.m., almost an hour after the orders were given.
At 10:25 p.m., the results of the diagnostic testing were entered, and Dr. Roberts noted that Mrs. Knight’s vital signs appeared to be normal and that diagnostic testing indicated that her cardiac enzymes were normal, her chest x-ray was negative, and an EKG did not show any acute ischemic changes. The record shows that although Mrs. Knight’s blood pressure had decreased to 154/88, it remained elevated throughout her treatment in the ER. Based upon his examination, Dr. Roberts made a differential diagnosis of angina, myocardial infarction, pleurisy, costochondritis, esophageal reflux, and chest wall pain.
At approximately 11:45 p.m., Dr. Roberts contacted Dr. Cone, who was providing on-call coverage for Mrs. Knight’s family physician, and advised that Mrs. Knight was in the ER. Dr. Cone ordered that Mrs. Knight be admitted to the hospital for further observation and testing. Dr. Cone also ordered that Mrs. Knight be given Lovenox, a blood thinner. Dr. Roberts stated that after treatment, and by his reassessment at 11:45 p.m., Mrs. Knight’s symptoms were completely relieved. Notes in the medical record, however, indicate that Mrs. Knight had continued to complain of pain symptoms, and that Dr. Roberts gave a verbal order to give her morphine for pain in her back at 12:48 a.m.
On the following day, February 18 at 1:53 p.m., while Mrs. Knight remained hospitalized at TMC, Dr. Cone examined Mrs. Knight and reviewed her hospital chart. Dr. Cone indicated that Mrs. Knight’s blood pressure had decreased to 142/76, and that she did not appear to be in distress. Dr. Cone noted that the diagnosis was chest pain and that there was a need to rule out ischemic heart disease. Dr. Cone did not consider a differential diagnosis of aortic dissection. He ordered that Mrs. Knight undergo a stress test, which was scheduled for the next morning.
Mrs. Knight continued to receive morphine for pain and a nitroglycerine drip. She complained that she was feeling weak and had a headache. She was given aspirin and Darvocet to relieve the headache. At approximately 11:00 p.m. on February 18, the second day of Mrs. Knight’s hospital stay, another EKG was performed and a different attending physician diagnosed an acute inferior wall myocardial infarction. Mrs. Knight was immediately transferred to TMC’s intensive care unit, and a cardiologist at St. Francis Hospital was consulted. TMC did not have the capability of rendering non-medical treatment or performing heart surgery, and therefore, Mrs. Knight was transferred to St. Francis Hospital for a catheterization at approximately 1:00 a.m. on February 19, 2001.
The catheterization performed on February 19 revealed that Mrs. Knight had an aortic dissection, a tear in the ascending aorta above her heart, which required emergency surgery. She was immediately transferred to Emory Hospital for the emergency surgery at approximately 3:45 a.m. on February 19.
Thereafter, Mrs. Knight experienced a progressive deterioration of multiple organ systems since the heart was not able to pump enough blood to keep the rest of the body functioning. Mrs. Knight passed away less than a week later on February 27, 2001.
Case No. A12A0740
1. Knight contends that the trial court erred in granting summary judgment in favor of Dr. Roberts on the basis of causation. He argues that evidence shows that Dr. Roberts’s negligent misdiagnosis delayed Mrs. Knight’s treatment, which precluded immediate surgical intervention and repair and caused her death.
To recover in a medical malpractice case, a plaintiff must show not only a violation of the applicable medical standard of care but also that the purported violation or deviation from the proper standard of care is the proximate cause of the injury sustained. In other words, a plaintiff must prove that the defendants’ negligence was both the cause in fact and the proximate cause of his injury.
(Citations omitted.) Walker v. Giles,
Medical malpractice being a civil cause of action, a plaintiff must prove liability (i.e., duty, negligence, proximate cause) by a preponderance of the evidence. OCGA § 24-4-3. “Preponderance of the evidence” is statutorily defined as “that superior weight of evidence upon the issues involved, which, while not enough to free the mind wholly from a reasonable doubt, is yet sufficient to incline a reasonable and impartial mind to one side of the issue rather than to the other.” OCGA § 24-1-1 (5). The standard requires only that the finder of fact be inclined by the evidence toward one side or the other.
(Citation and punctuation omitted.) Zwiren, supra,
The parties’ arguments in this case focus upon the causation element of the medical malpractice claim.
(a) Cause-In-Fact. “Medical causation must be proved to a reasonable degree of medical certainty and cannot be based on mere speculation. Abare possibility of causing the injury complained of is not sufficient proof of causation as a matter of law.” (Citation and punctuation omitted.) Walker, supra,
because the question of whether the alleged professional negligence caused the plaintiff’s injury is generally one for specialized expert knowledge beyond the ken of the average layperson. Using the specialized knowledge and training of his field, the expert’s role is to present to the jury a realistic assessment of the likelihood that the defendant’s alleged negligence caused the plaintiff’s injury.
Applying the foregoing standards, the expert testimony in this case presented a genuine issue of material fact as to whether Mrs. Knight’s death could have been avoided if Dr. Roberts had properly diagnosed her condition in compliance with the applicable standard of care. The expert testimony bearing upon the causation issue in this case was given by Dr. Guyton, a cardiothoracic surgeon who had operated on between 100 and 150 ascending aortic dissections over the course of 30 years; Dr. Phillip L. Coule, who was an assistant professor of emergency medicine at the Medical College of Georgia and a physician with expertise in emergency medicine and prior experience in treating aortic dissections; and Dr. Lawrence L. Golusin-ski, Jr., who was a family practice physician with prior experience in diagnosing and treating aortic dissections. Each of the experts opined that Mrs. Knight’s aortic dissection began to occur in the early afternoon of February 17 when she started having chest pain while she was washing her dog at home. Based upon their testimony, Mrs. Knight’s aortic dissection condition existed at the time when she initially presented to the ER.
Dr. Coule and Dr. Golusinski both explained that the typical symptoms of aortic dissection include sudden, continuous chest pain, back pain, and hypertension.
Dr. Coule also testified that the diagnosis of an aortic dissection is a true emergency in which time is of the essence. Dr. Guyton similarly testified that since aortic dissections can either rupture or progress at any time, they must be treated on an emergent basis. The expert testimony indicated that the sooner the diagnosis could have been made and aggressive treatment instituted, the better Mrs. Knight’s chances of survival. Significantly,
Based on this combined expert testimony, we conclude that Knight presented evidence creating a genuine issue of material fact over whether the myocardial infarction, reflecting the rupture of Mrs. Knight’s aortic dissection, would have been prevented if Dr. Roberts had properly complied with the standard of care during Mrs. Knight’s examination in the ER. See Naik v. Booker,
Dr. Roberts nevertheless argues that there was no expert testimony suggesting that Mrs. Knight required immediate surgical intervention after he evaluated her. His argument, however, is without merit. As stated above, Dr. Guyton, the cardiothoracic surgeon, testified that since aortic dissections can either rupture or progress at any time, they must be treated on an emergent basis. Dr. Coule testified that Dr. Roberts had a duty to make the diagnosis and immediate transfer to a facility for emergency surgical intervention. Notably, Dr. Roberts himself acknowledged that “[t]he quicker that the thoracic surgeon [gets] . . . the patient with an aortic dissection, the better.” To the extent that the delay caused by Dr. Roberts’s misdiagnosis contributed to the delay in Mrs. Knight’s ability to receive timely treatment and surgical intervention, a jury question as to the element of causation existed. See MCG Health, supra,
To the extent that Dr. Roberts points to conflicting evidence that Mrs. Knight appeared to have been stabilized after he evaluated her such that emergency surgery may not have been performed,
(b) Proximate Cause. “The requirement of proximate cause constitutes a limit on legal liability; it is a policy decision that, for a variety of reasons, e.g., intervening act, the defendant’s conduct and the plaintiff’s injury are too remote for the law to countenance recovery.” (Citation and punctuation omitted.) Walker, supra,
It is well settled that there can be no proximate cause where there has intervened between the act of the defendant and the injury to the plaintiff, an independent act (or omission) of someone other than the defendant, which was not foreseeable by defendant, was not triggered by defendant’s act and which was sufficient of itself to cause the injury. However, it is equally well settled that [proximate cause is generally an issue for the jury, and] there may be more than one proximate cause of an injury in cases involving the concurrent negligence of several actors.
(Citations and punctuation omitted; emphasis supplied.) MCG Health, supra,
[P]revious Georgia cases permitting joint and several liability of two or more physicians who independently treat a patient at different times but together cause an indivisible injury to the plaintiff implicitly reject the notion that a first-treating physician is absolved of legal responsibility as a matter of law.
(Citations and punctuation omitted.) Walker, supra,
Here, Knight’s medical expert, Dr. Coule, testified that the longer that Mrs. Knight remained without appropriate diagnosis and treatment, the worse her condition progressed and her chances of survival diminished. Dr. Coule concluded that Dr. Roberts’s failure to timely diagnose Mrs. Knight’s aortic dissection in the ER was a contributing cause leading to Mrs. Knight’s ultimate death and amounted to a link in the continuum that culminated in her death. Dr. Roberts’s argument that he turned Mrs. Knight’s care over to Dr. Cone and was not involved in Dr. Cone’s evaluation and treatment is unavailing. Here, Dr. Cone’s alleged misdiagnosis and mistreatment of Mrs. Knight during her ongoing hospitalization at TMC was not unrelated to Dr. Roberts’s previous alleged failure to properly diagnose and treat Mrs. Knight. In light of evidence that Dr. Roberts’s negligence was “a link in the chain of incorrect decisions made with regard to [Mrs. Knight’s] treatment^” a jury question of proximate cause existed. See MCG Health, supra,
Case No. A12A0741
2. Dr. Cone contends that the trial court erred in denying his motion for summary judgment. Specifically, he argues that there was no evidence that his acts or omissions proximately caused or contributed to Mrs. Knight’s death.
Significantly, Knight’s medical malpractice claim against Dr. Cone is substantially the same as his claim against Dr. Roberts. Knight’s claim alleges that Dr. Cone likewise misdiagnosed and mistreated Mrs. Knight’s
As discussed in Division 1 above with respect to the claims and evidence against Dr. Roberts, the evidence likewise showed that Dr. Cone deviated from the standard of care when he failed to take the necessary steps to confirm the existence of Mrs. Knight’s aortic dissection. The evidence further showed that Dr. Cone’s misdiagnosis delayed the necessary surgical intervention and contributed to Mrs. Knight’s demise. See MCG Health, supra,
Case No. A12A0770
3. TMC challenges the trial court’s denial of its motion for summary judgment, contending that there was no evidence that the nurses’ alleged negligence caused or contributed to Mrs. Knight’s death. Again, we discern no error.
Knight alleged that the nurses negligently failed to triage Mrs. Knight in the emergent patient status, which contributed to the delay in her treatment and her death.
Nurse Churbock further testified that TMC deviated from the standard of care by allowing a student nurse to assist in Mrs. Knight’s care. TMC argues that the trial court erred in finding that a question of fact existed as to whether allowing the student nurse to participate in Mrs. Knight’s care was a deviation from the standard of care, and in failing to find that such act did not proximately cause Mrs. Knight’s death. To the extent that the student nurse was not sufficiently supervised, which contributed to the delayed treatment, as discussed above, we discern no error in the trial court’s decision denying summary judgment on this issue.
4. Lastly, TMC contends that the trial court erred in finding that Nurse Churbock was qualified to serve as an expert under OCGA § 24-9-67.1 when the statements of her affidavit regarding her qualifications conflicted with her deposition testimony. Again, no error has been shown.
OCGA § 24-9-67.1 (b) provides, in pertinent part that
[i]f scientific, technical, or other specialized knowledge will assist the trier of fact in any cause of action to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education may testify thereto in the form of an opinion or otherwise [.]
Subsection (c) of the statute further pertinently provides as follows:
[I]n professional malpractice actions, the opinions of an expert, who is otherwise qualified as to the acceptable standard of conduct of the professional whose conduct is at issue, shall be admissible only if, at the time the act or omission is alleged to have occurred, such expert:
(1) Was licensed by an appropriate regulatory agency to practice his or her profession in the state in which such expert was practicing or teaching in the profession at such time; and
(2) In the case of a medical malpractice action, had actual professional knowledge and experience in the area of practice or specialty in which the opinion is to be given as the result of having been regularly engaged in:
(A) The active practice of such area of specialty of his or her profession for at least three of the last five years, with sufficient frequency to establish an appropriate level of knowledge, as determined by the judge, in performing the procedure, diagnosing the condition, or rendering the treatment which is alleged to have been performed or rendered negligently by the defendant whose conduct is at issue; or
(B) The teaching of his or her profession for at least three of the last five years as an employed member of the faculty of an educational institution accredited in the teaching of such profession, with sufficient frequency to establish an appropriate level of knowledge, as determined by the judge, in teaching others how to perform the procedure, diagnose the condition, or render the treatment which is alleged to have been performed or rendered negligently by the defendant whose conduct is at issue; and
(C) ... (i) Is a member of the same profession [.]
(Punctuation omitted.)
Nurse Churbock submitted a curriculum vitae that set forth her nursing education, licensure in Georgia, and work experience. Nurse Churbock also gave deposition testimony reflecting she was currently employed as an acute care nurse practitioner with
Following her deposition, Nurse Churbock submitted an affidavit, which further attested that she had relevant work experience in a hospital emergency room within the five-year period prior to the incident on February 17, 2001. The affidavit reflected that from 1996 to 1997, she worked at two local hospitals in the ICU and ER departments. From 1997 through 2001, Nurse Churbock had worked full-time in various local hospital emergency rooms, triaged patients in emergency rooms to determine their status, taught emergency room nurses, and maintained her Georgia nursing license and national emergency room nursing certifications. Nurse Churbock concluded that based upon her experience and training, she was familiar with the standard of care required of ER nurses at the time of the incident.
While Nurse Churbock’s deposition testimony generally described her nursing experience, her affidavit supplemented the testimony with greater detail as to the dates of her experience. The full evidence reflected that Nurse Churbock had actual professional knowledge and experience in the relevant areas of nursing as a result of having been regularly engaged in the active practice of critical care and ER nursing for three of the five years preceding February 2001. The trial court was therefore authorized to conclude that she was qualified to serve as an expert in this case. See, e.g., Allen v. Family Medical Center,
The issue of the admissibility or exclusion of expert testimony rests in the broad discretion of the court, and consequently, the trial court’s ruling thereon cannot be reversed absent an abuse of discretion. Under Daubert [a. Merrell Dow Pharmaceuticals, Inc.,509 U. S. 579 (113 SC 2786, 125 LE2d 469) (1993)], disputes as to an expert’s credentials are properly explored through cross-examination at trial and go to the weight and credibility of the testimony, not its admissibility. Accordingly, we find no abuse of discretion.
(Citation omitted.) Gottschalk v. Gottschalk,
Judgment reversed in Case No. A12A0740. Judgments affirmed in Case Nos. A12A0741 and A12A0770.
Notes
TMC’s motion also sought to exclude the testimony of Knight’s expert nurse, Janice L. Singleton Rodgers. The motion noted that Ms. Rodgers died after providing her deposition testimony. The trial court granted TMC’s motion to exclude Ms. Rodgers’s testimony on the ground that her testimony was not going to he offered into evidence. The exclusion of Ms. Rodgers’s testimony is not the subject of these appeals.
Dr. Roberts testified that ER physicians generally make a diagnosis by exclusion. He further stated that TMC’s ER computer has a template system that generates the differential diagnosis required for insurance billing purposes.
Each of the experts testified that dissections are rare. Dr. Guyton and Dr. Golusinski testified that dissections are more common in men.
Dr. Roberts acknowledged that he could have gotten a CT scan on demand in the ER. He further acknowledged that symptoms of aortic dissection include chest pain that can radiate to the shoulders, back, and arms, along with hypertension. Dr. Roberts nevertheless conceded that he never considered the diagnosis of an aortic dissection or a thoracic aneurysm.
While Dr. Roberts asserts that Mrs. Knight was stable when he treated her and released her to Dr. Cone for further care, there was evidence contradicting his assertion. Notably, there was evidence that Mrs. Knight remained hypertensive, albeit at a lower level. The evidence also reflected that Mrs. Knight had continued to complain of pain symptoms and continued to receive morphine for pain.
We note that “[t]he practice of nursing is recognized as a profession subject to its own general standards of care and qualifications. OCGA §§ 9-11-9.1 (g) (12); 43-26-1 et seq. (registered nurses) [.]” (Citation and punctuation omitted.) Grady Gen. Hosp. v. King,
TMC challenges Dr. Coule’s opinion based upon its contention that Mrs. Knight was not hypertensive and had a reasonable blood pressure when she was in the ER. TMC’s contention is without merit. There was evidence establishing that Mrs. Knight was indeed hypertensive when she arrived at the ER, having a blood pressure of 228/104, and that she remained hypertensive throughout the time that she was in the ER.
We note that there appears to be an unexplained conflict in Dr. Coule’s deposition testimony regarding whether the delay in administering the nitroglycerine contributed to Mrs. Knight’s death. At one point, Dr. Coule testified that he could not say that Mrs. Knight would not have died if she had received the nitroglycerine earlier in her treatment. He further opined, however, that the delay in administering the medication worsened Mrs. Knight’s condition and allowed the dissection to progress. Significantly, Dr. Coule also testified that the delay in administering the nitroglycerine had contributed to Mrs. Knight’s ultimate death. Notwithstanding the apparent conflict, however, “the self-contradictory testimony rule of Prophecy Corp. v. Charles Rossignol, Inc., [