MILLER, Judge.
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 Churbock, 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 and A12A0770. We also affirm the trial court's denial of TMC's motion to exclude the expert nurse's testimony in Case No. A12A0770.
(Punctuation and footnotes omitted.) Beasley v. Northside Hosp., Inc., 289 Ga.App. 685, 685-686, 658 S.E.2d 233 (2008).
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 later 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 18th 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 18th, 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 19th 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 19th.
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.
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.
(Citations omitted.) Walker v. Giles, 276 Ga.App. 632, 638, 624 S.E.2d 191 (2005). See also Zwiren v. Thompson, 276 Ga. 498, 499, 578 S.E.2d 862 (2003) (three essential elements to establish liability in a medical malpractice action under OCGA § 51-1-27 are "(1) the duty inherent in the doctor-patient relationship; (2) the breach of that duty by failing to exercise the requisite degree of skill and care; and (3) that this failure be the proximate cause of the injury sustained.") (citations omitted).
(Citation and punctuation omitted.) Zwiren, supra, 276 Ga. at 499, 578 S.E.2d 862.
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. A bare possibility of causing the injury complained of is not sufficient proof of causation as a matter of law." (Citation and punctuation omitted.) Walker, supra, 276 Ga.App. at 638(1), 624 S.E.2d 191. In a medical misdiagnosis case, the plaintiff must show "to any reasonable degree of medical certainty that the injury could have been avoided, had the physician complied with the applicable standard of care." (Citation and punctuation omitted.) Id. The element of causation must be established through expert testimony
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. Golusinski, 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 17th 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, 303 Ga.App. 282, 286-287, 692 S.E.2d 855 (2010) (affirming the denial of summary judgment to a physician who had failed to timely identify and stop the patient's hemorrhage, which contributed to the patient's ultimate death); MCG Health v. Barton, 285 Ga.App. 577, 583-584(2), (3), 647 S.E.2d 81 (2007) (affirming the denial of the Board of Regent's motion for summary judgment since a jury question regarding causation existed based upon expert testimony that the physician's delay in diagnosing the patient's torsion condition prevented emergency surgery to salvage the patient's testicle); Walker, supra, 276 Ga.App. at 641-642(1), 624 S.E.2d 191 (concluding that a jury issue as to causation was presented in the patient's medical malpractice action based upon combined expert testimony that the rupture of the patient's appendix could have been avoided if she had not been misdiagnosed upon her first admission into the hospital). Since there was expert testimony reflecting that Dr. Robert's misdiagnosis contributed to Mrs. Knight's death, the trial court erred in granting summary judgment in Dr. Roberts's favor.
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, 285 Ga.App. at 583-584(3), 647 S.E.2d 81 (jury question regarding causation existed where the delayed diagnosis led to the loss of the patient's testicle; the fact that the medical expert could not identify the exact point in time in which the condition became unsalvageable did not render the testimony speculative); see also Walker, supra, 276 Ga.App. at 641-642(1), 624 S.E.2d 191.
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 omitted.) Walker, supra, 276 Ga.App. at 643(2), 624 S.E.2d 191.
(Citations and punctuation omitted; emphasis supplied.) MCG Health, supra, 285 Ga. App. at 584-585(3), 647 S.E.2d 81; Walker, supra, 276 Ga.App. at 643(2), 624 S.E.2d 191. "[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, 276 Ga.App. at 644(2), 624 S.E.2d 191. Moreover, "the liability of a tortfeasor whose actions started the chain of events leading to the victim's injury is superseded and cut off only if there intervened between the act and the injury a distinct, successive, unrelated, efficient cause of the injury." (Citation, punctuation, and emphasis omitted.) Id.
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, 285 Ga.App. at 585(3), 647 S.E.2d 81; Walker, supra, 276 Ga.App. at 644-645(2), 624 S.E.2d 191; see also Schriever v. Maddox, 259 Ga.App. 558, 561(2)(b), 578 S.E.2d 210 (2003) (concluding that the subsequent treating physician's alleged negligence were not intervening, but were very similar to the initial physician's negligence, and therefore, merely compounded the initial physician's negligence). It thus follows that the trial court erred in granting summary judgment in Dr. Roberts's favor.
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, 285 Ga.App. at 583-584(3), 647 S.E.2d 81; Walker, supra, 276 Ga.App. at 641-642(1), 624 S.E.2d 191. Based upon the same standards and principles set forth in Division 1 above, summary judgment in favor of Dr. Cone was not authorized. The trial court therefore did not err in denying Dr. Cone's motion.
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:
(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 emergency room 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 emergency room 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, 287 Ga.App. 522, 525-526(2), 652 S.E.2d 173 (2007).
(Citation omitted.) Gottschalk v. Gottschalk, 311 Ga.App. 304, 310(2), 715 S.E.2d 715 (2011).
Judgment reversed in Case No. A12A0740; judgments affirmed in Case Nos. A12A0741 and A12A0770.
MIKELL, P.J., and BLACKWELL, J., concur.