Affirmed and Opinion filed August 29, 2019.




                                          In The

                       Fourteenth Court of Appeals

                                  NO. 14-18-00476-CV

   MEMORIAL HERMANN HEALTH SYSTEM, INDIVIDUALLY AND
  D/B/A MEMORIAL HERMANN-KATY HOSPITAL; MIKAEL LUCAS,
  M.D.; MIKAEL LUCAS, M.D., PLLC; RANDOLPH WHITFORD, M.D.;
         AND EYES OVER TEXAS EYE CARE P.A., Appellants

                                            V.
                            DONNIE HEINZEN, Appellee

                      On Appeal from the 129th District Court
                              Harris County, Texas
                        Trial Court Cause No. 2017-33241

                                    OPINION

      Under the Texas Medical Liability Act (“the Act”),1 a medical-negligence
claim is subject to dismissal on the motion of the defendant physician or health-care
provider if the claimant fails to timely serve reports by qualified experts opining that


      1
          TEX. CIV. PRAC. & REM. CODE ANN. § 74.001–.507.
the defendant’s breach of the applicable standard of care caused the harm alleged.
Appellee Donnie Heinzen brought medical-negligence claims after she suffered
permanent vision loss from acute angle-closure glaucoma, and she alleges that the
damage would have been minimal and reversible but for the breaches of the
respective standards of care by a hospital’s emergency-room nurses, an emergency-
room doctor, and the ophthalmologist who examined her in the hospital. The various
defendants challenged some or all of Heinzen’s four expert reports, and the trial
court denied their respective motions to dismiss.

      On appeal, the defendants argue that the trial court improperly gave Heinzen
three 30-day extensions to serve the required expert reports rather than the single 30-
day extension authorized by the Act, and that the trial court improperly considered
expert reports served after the initial extension expired. Some defendants also
challenge the qualifications of a given report’s author and the adequacy of the reports
themselves.

      We conclude that the trial court did not give Heinzen a 30-day extension from
the date of the oral hearing on the defendants’ objections as they contend, and that
each of the trial court’s three signed orders granted Heinzen a 30-day extension,
beginning from the date the order was signed, to cure the original expert report’s
deficiencies concerning the defendant or defendants named in the order. We further
conclude that Dr. David Tasker was qualified to render the expert opinions he
expressed, and that his opinion or opinions applicable to each defendant before us
satisfied the Act’s requirements. We accordingly affirm the trial court’s orders
denying the motions to dismiss.

                                  I. BACKGROUND

      Heinzen contends that she sought treatment for angle-closure glaucoma from
physicians and health-care providers Dr. Mikael Lucas and Mikael Lucas M.D.,
                                          2
PLLC (collectively, “Dr. Lucas”);2 Memorial Hermann Health System d/b/a
Memorial Hermann–Katy Hospital (“Memorial Hermann”), and Dr. Randolph
Whitford.3 According to the allegations in Heinzen’s petition, these individuals and
entities, whom we refer to collectively as “the Providers,” failed to timely recognize
and treat Heinzen’s angle-closure glaucoma, and the delay in treatment caused
permanent damage to Heinzen’s retina and loss of her visual field.

       After Heinzen served the Providers with the original expert report and
curriculum vitae of board-certified ophthalmologist Dr. David I. Tasker, the
Providers timely objected to the report’s sufficiency. Memorial Hermann and Dr.
Lucas additionally objected that Dr. Tasker was not qualified to render an expert
opinion. All of the Providers contend that at the December 11, 2017, hearing on their
objections, the trial court orally granted Heinzen a 30-day extension—that is, until
January 10, 2018—to supplement her expert report. Heinzen served no supplemental
expert reports by that date.

       On January 24, 2018, the trial court signed two orders, each of which granted
Heinzen a 30-day extension to cure any defects in the expert report. The two orders
differ only in that one order recites that the trial court considered Memorial
Hermann’s “Objections to Plaintiff’s Expert Report, the response, and the arguments
of counsel,” and the other substitutes Dr. Whitford’s name for Memorial Hermann’s.
Thirty days after the trial court signed the orders, Heinzen supplemented Dr.


       2
           Both at trial and on appeal, the parties have included Dr. Lucas’s professional limited-
liability company in their references to Dr. Lucas as an individual, and we do likewise.
       3
           Heinzen also alleged that other individuals and entities were medically negligent, but the
case before us concerns only the objections and motions to dismiss of Dr. Lucas, Memorial
Hermann, and Dr. Whitford. Although Eyes Over Texas Eye Care P.A. purports to join in Dr.
Whitford’s brief, that entity did not object to any expert report, move to dismiss the claims against
it, or file a notice of appeal. Thus, unlike Dr. Lucas’s company, Eyes Over Texas Eye Care P.A.
is not a party to this proceeding.

                                                 3
Tasker’s original expert report with a second report by Dr. Tasker and with the report
and curriculum vitae of Dr. Lige B. Rushing Jr., who is board-certified in internal
medicine, rheumatology, and geriatrics. Both of Dr. Tasker’s reports address the
conduct of all of the Providers, but Dr. Rushing offered no opinion regarding Dr.
Whitford.

      The Providers objected that these supplemental reports served on February
23, 2018, were untimely and could not be considered. Drs. Whitford and Lucas also
objected that Dr. Tasker’s second report did not adequately address the standard of
care, breach, and causation, and Dr. Lucas repeated those objections as to Dr.
Rushing’s report. Memorial Hermann reurged its objection to Dr. Tasker’s
qualifications and objected that both of the February 2018 reports contained
conclusory opinions of causation. All of the Providers moved for dismissal of the
respective claims against them.

      On February 28, 2018, the trial court signed a third order granting Heinzen a
30-day extension. It is identical to the trial court’s two previous orders except that
the Provider named is Dr. Lucas. On March 30, 2018, Heinzen served the parties
with a second report by Dr. Rushing. This report was directed only to the alleged
negligence of Dr. Lucas and to Dr. Rushing’s qualifications to opine on that issue.
Dr. Lucas again objected and moved for dismissal.

      The trial court overruled all objections to the supplemental expert reports and
denied the Providers’ respective motions to dismiss. The Providers bring this
interlocutory appeal challenging those rulings.

                               II. ISSUES PRESENTED

      All of the Providers argue in their first issue that the trial court abused its
discretion by giving Heinzen three 30-day extensions to supplement her expert


                                          4
report and by considering untimely reports. Memorial Hermann also asserts in its
second issue that Dr. Tasker is not qualified to render an expert opinion regarding
the conduct of the nursing staff, and that the reports of Drs. Tasker and Rushing are
conclusory as to causation. In his second issue, Dr. Lucas challenges both experts’
qualifications and argues that their reports do not adequately address the applicable
standard of care, breach, or causation.

            III. TIMELINESS OF THE SUPPLEMENTAL EXPERT REPORTS

      A claimant under the Act must serve an expert’s report and curriculum vitae
upon each defendant within 120 days after the defendant answers the suit. TEX. CIV.
PRAC. & REM. CODE ANN. § 74.351(a). The defendant must file and serve any
objections to the report’s sufficiency within twenty-one days after the later of (a) the
date the defendant answered the suit, or (b) the date the report was served. See id. If
the report is deficient, the trial court may grant the claimant one 30-day extension to
cure deficiencies. Id. § 74.351(c). “If the claimant does not receive notice of the
court’s ruling granting the extension until after the 120-day deadline has passed, then
the 30-day extension shall run from the date the plaintiff first received the notice.”
Id.

      All of the Providers answered the suit on June 9, 2017, and Heinzen timely
served Dr. Tasker’s curriculum vitae and first expert report on all of the Providers
on August 2, 2017. The Providers timely objected, and the trial court held an oral
hearing on their objections on December 11, 2017, which was more than 120 days
after the Providers answered the suit. Thus, the 30-day extension began to run from
the date Heinzen first received notice of the trial court’s ruling granting the extension
to cure the report’s deficiencies as to a given Provider.

      The Providers contend that Heinzen received such notice when the trial court
orally granted Heinzen’s request for an extension at the hearing, and that the trial
                                           5
court improperly granted second and third extensions in January and February 2018.
Based on this view of events, the Providers argue that the trial court could not
properly consider any of Heinzen’s three supplemental reports or Dr. Rushing’s
curriculum vitae. Heinzen responds that the trial court did not orally grant an
extension at the hearing, and that in each of the trial court’s three signed orders, it
granted a single 30-day extension to supplement her expert report as to a different
Provider.

A.     The Alleged Oral Order of December 11, 2017

       In asserting that the trial court granted Heinzen an extension during the oral
hearing on their objections, the Providers rely on these two excerpts from the
transcript:

       MR. HELLER [Heinzen’s counsel]: Your Honor, of course what we’re
       asking for is if—if you feel that any of the reports as to any specific
       defendants [is] deficient, we ask—we’re requesting a 30-day—
       THE COURT: I will give you the 30 days.
                                             ...
       THE COURT: So—so I’m going to go ahead and grant the objection
       and give you 30 days, and I’ll—I’ll sign the order.

       By this language, the trial court did not grant an extension. The trial court
instead stated it “will give you the 30 days”; that it was “going to go ahead and grant
the objection” and that it shall or will “sign the order.”4 When used in the first person,
“going to,” “shall,” and “will” are all verbs in the future tense.5 Thus, the words the
trial court used at the hearing expressed its intention to grant an extension in the
future. Cf. State v. Naylor, 466 S.W.3d 783, 788 (Tex. 2015) (“A trial court renders

       4
        “I’ll” is a contraction for “I shall” or “I will.” NEW OXFORD AMERICAN DICTIONARY 866
(Angus Stevenson & Christine Lindberg eds., 3d ed. 2010).
       5
           See id. at 742, 1604, and 1977.

                                             6
judgment orally when it announces rendition as a present act and not as an ‘intention
to render judgment in the future.’” (quoting S & A. Rest. Corp. v. Leal, 892 S.W.2d
855, 857 (Tex. 1995) (per curiam)). The oral statements were ineffective to grant the
extension. See Reese v. Piperi, 534 S.W.2d 329, 330 (Tex. 1976) (trial court’s
statements “I have to grant a new trial” and “I will grant it” did not constitute oral
rendition but expressed the trial court’s intention to render judgment in the future);
Inwood Forest Cmty. Improvement Ass’n. v. Arce, 485 S.W.3d 65, 71–72 (Tex.
App.—Houston [14th Dist.] 2015, pet. denied) (trial judge’s statement “that she was
‘going to grant the motions to dismiss’” was “ineffective to constitute a ruling”); see
also Lopez v. Brown, 356 S.W.3d 599, 602–03 (Tex. App.—Houston [14th Dist.]
2011, no pet.) (“[T]he notice [of the court’s ruling] provided for in section 74.351(c)
must be in the form of a written order, rather than a trial court’s mere oral
pronouncement from the bench.”). We therefore reject the Providers’ argument that
Heinzen had to serve any supplemental expert reports within thirty days after the
hearing, and we overrule this part of the Providers’ first issue.

B.    The Signed Orders

      The trial court signed two orders on January 24, 2018 (“the January Orders”),
each granting a 30-day extension to cure any deficiencies in Dr. Tasker’s original
August 2018 report. Pursuant to those orders, Heinzen served the Providers on
February 23, 2018, with Dr. Tasker’s second report and with Dr. Rushing’s
curriculum vitae and first report. On February 28, 2018, the trial court signed a third
order (“the February Order”) granting Heinzen another 30-day extension to cure any
deficiencies in the original expert report, and in accordance with that order, Heinzen
served the Providers on March 30, 2018, with Dr. Rushing’s second report. The
question is, which materials are included within the scope of our review in


                                           7
determining whether the trial court erred in denying a given Provider’s motion to
dismiss?

      Under the Act, the deadline to serve an expert report is specific to a given
Provider. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a) (“[A] claimant shall,
not later than the 120th day after the date each defendant’s original answer is filed,
serve on that party or the party’s attorney one or more expert reports, with
curriculum vitae . . . for each physician or health care provider against whom a
liability claim is asserted.”) (emphasis added). If the report—that is, the report as to
“that party”—is deficient, the trial court may grant a single 30-day extension to cure
the deficiency as to “that party.” Id. § 74.351(c). Thus, in determining whether the
trial court erred in denying each Provider’s motion to dismiss, we consider (1) the
materials served within 120 days of that Provider’s answer, and (2) the materials
served within thirty days after the trial court signed an order granting Heinzen an
extension to cure the initial report’s deficiencies as to that Provider.

      The first set of materials is the same for all Providers: all of the Providers
answered the suit on the same day, and within 120 days, Heinzen served all of the
Providers with Dr. Tasker’s curriculum vitae and his first report, in which he opined
on the conduct of each Provider. In contrast, the supplemental materials included
within the scope of our review are different for different providers.

      Heinzen contends that the trial court’s January Orders granted her a 30-day
extension to cure any deficiencies in Dr. Tasker’s first report as it pertains to
Memorial Hermann and Dr. Whitford, and the February Order granted her a 30-day
extension to cure deficiencies in Dr. Tasker’s first report with respect to Dr. Lucas.
We agree, and that conclusion dictates the scope of our review as to the Providers’
appeals of the denials of their respective motions to dismiss.

                                           8
       1.      The supplemental material included in our review of Memorial
               Hermann’s and Dr. Whitford’s motions to dismiss consists only of Dr.
               Tasker’s second report, Dr. Rushing’s curriculum vitae, and Dr.
               Rushing’s first report.
       Of the two January Orders, one states that the trial court considered Memorial
Hermann’s objections, the response, and the arguments of counsel, and the other
states that the trial court considered Dr. Whitford’s objections, the response, and the
arguments of counsel. By their terms, these orders granted Heinzen thirty days to
cure the original report’s deficiencies pertaining to Memorial Hermann and Dr.
Whitford. If the trial court intended in its January Orders to grant Heinzen an
extension to cure the deficiencies in Dr. Tasker’s first report with respect to all of
the Providers, there would have been no need to sign two orders on the same day, or
to sign a total of three orders, each referring to a different Provider.6

       Because Heinzen served Dr. Tasker’s second report and Dr. Rushing’s first
report and curriculum vitae thirty days after the trial court signed the January Orders,
the trial court could properly consider these materials when ruling on Memorial
Hermann’s and Dr. Whitford’s respective objections and motions to dismiss. We
therefore overrule Memorial Hermann’s and Dr. Whitford’s challenge to the
timeliness of these reports, and we include them within the scope of our review as
to these Providers. Because Dr. Rushing’s second report was served after the January
Orders’ extension expired, we sustain Memorial Hermann’s and Dr. Whitford’s


       6
         Although the January Orders are not ambiguous, this result accords with the longstanding
rule that when construing an ambiguous judgment, the reviewing court must “adopt the
construction that correctly applies the law.” MacGregor v. Rich, 941 S.W.2d 74, 75 (Tex. 1997)
(per curiam) (citing Gough v. Jones, 212 S.W. 943, 944 (Tex. Comm’n App. 1919, judgm’t
adopted)). If one of the January Orders granted Heinzen a 30-day extension to cure the original
expert report’s deficiencies as to all of the Providers, then the trial court would have incorrectly
applied the law in signing the February Order impermissibly granting Heinzen a second thirty-day
extension.

                                                 9
challenge to the timeliness of that report, and we do not include it within the scope
of our review of the trial court’s denials of their motions to dismiss.

      2.     The only supplemental material included in our review of Dr. Lucas’s
             motion to dismiss is Dr. Rushing’s second report.
      The February Order contains the same language as the January Orders, except
that it refers only to Dr. Lucas. Because Heinzen served Dr. Rushing’s second report
within thirty days after the trial court signed this order, we overrule Dr. Lucas’s
challenge to the timeliness of that report, and we include it in the scope of our review
in determining whether the trial court erred in denying Dr. Lucas’s motion to
dismiss.

      On the other hand, we do not consider Dr. Tasker’s second report, Dr.
Rushing’s curriculum vitae, or Dr. Rushing’s first report, because these materials
were neither served within 120 days of Dr. Lucas’s answer nor served within thirty
days after the trial court granted Heinzen an extension to cure deficiencies in the
original expert report regarding Dr. Lucas. We sustain Dr. Lucas’s challenge to the
timeliness of this material, and we do not include it within the scope of our review
of the denial of his motion to dismiss.

                           IV. DR. WHITFORD’S APPEAL

      Dr. Whitford challenges the denial of his motion to dismiss only on the ground
that the trial court improperly considered the supplemental material served on
February 23, 2018. Because we have concluded that this material was timely served,
and Dr. Whitford does not contend the reports are otherwise deficient, we affirm the
order denying Dr. Whitford’s motion to dismiss.




                                          10
                        V. MEMORIAL HERMANN’S APPEAL

      Memorial Hermann contends that Dr. Tasker is unqualified to offer an expert
opinion regarding the conduct of the hospital nurses, and that Drs. Tasker and
Rushing offer only conclusory statements of causation. When reviewing the trial
court’s rulings on an expert’s qualifications and the adequacy of the expert’s report,
we apply the abuse-of-discretion standard. San Jacinto Methodist Hosp. v. Bennett,
256 S.W.3d 806, 811 (Tex. App.—Houston [14th Dist.] 2008, no pet.). A trial court
abuses its discretion if it acts without reference to guiding rules or principles such
that its ruling is arbitrary or unreasonable. Downer v. Aquamarine Operators, Inc.,
701 S.W.2d 238, 241–42 (Tex. 1985). A trial court does not abuse its discretion
merely because an appellate justice in similar circumstances would have decided the
matter differently. Id. at 242.

A.    Dr. Tasker’s Qualifications

      To be qualified to opine that an institutional health-care provider breached the
applicable standard of care, a person must have “knowledge of accepted standards
of care for health care providers for the diagnosis, care, or treatment of the illness,
injury, or condition involved in the claim” and be “qualified on the basis of training
or experience to offer an expert opinion regarding those accepted standards of health
care.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.402(b)(2), (b)(3).

      Dr. Tasker’s curriculum vitae states that he graduated from Temple University
School of Medicine in 1969; that he has had a private ophthalmology practice since
1975; and that he has been board-certified in ophthalmology since 1976. He states
in his supplemental report that in his last year of medical school, he “was a
contracted floor nurse at Temple University School of Medicine for ten weeks full-
time.” He also states that during his three-year residency from 1970 to 1972, he
worked in the emergency rooms of Painesville Memorial Hospital, Kaiser
                                          11
Permanente Hospital of Cleveland, Altman General Hospital of Akron/Canton, and
Mt. Sinai Hospital of Cleveland, and that he “became intimately familiar with the
minimum standards for emergency room nurses, floor nurses, and staff in hospitals
like Memorial Hermann Hospital.”

      Memorial Hermann challenges Dr. Tasker’s qualifications only on the ground
that these experiences predate Heinzen’s claim by several decades. Memorial
Hermann emphasizes that “Dr. Tasker has not practiced as a nurse in 46 years, and
he has no current training or experience as a nurse, nor does his report or CV indicate
he is familiar with the current requirements of conducting and documenting a
nursing triage assessment in 2015.”

      While it is true that for certain medical-negligence claims against non-
physicians, a person is qualified to render an expert report only if the person is or
was engaged in a field of health-care practice “that involves the same type of care or
treatment as that delivered by the defendant health care provider . . . at the time the
testimony is given or . . . at the time the claim arose,” that requirement applies only
“if the defendant health care provider is an individual.” Id. § 74.402(b)(1). Because
Memorial Hermann is not an individual, this provision does not apply to Dr. Tasker’s
expert report regarding the care Memorial Hermann provided through its nursing
staff. See, e.g., Harvey v. Kindred Healthcare Operating, Inc., __S.W.3d__, No. 14-
17-00479-CV, 2019 WL 2063110, *3–4 (Tex. App.—Houston [14th Dist.] May 9,
2019, no pet.) (holding this subsection inapplicable to an expert report addressing a
claim against a hospital for its nursing staff’s conduct).

      Although Memorial Hermann does not dispute that Dr. Tasker’s experiences
working in emergency rooms and as a floor nurse were sufficient to familiarize Dr.
Tasker with the standard of care applicable to emergency-department nurses in the
early 1970s, Memorial Hermann offers no argument or authority for its implicit

                                          12
assumption that the knowledge gained from these experiences has somehow expired.
A person can be qualified to render an expert opinion about the standard of care
applicable to a hospital’s nursing staff based on experience acquired years earlier.
For example, in Columbia Valley Healthcare System L.P. v. Zamarripa (“Zamarripa
I”), the claimant relied on an expert report by a registered nurse to establish the
standard of care applicable to registered nurses staffing a hospital’s labor-and-
delivery unit. 520 S.W.3d 62, 69–70 (Tex. App.—Corpus Christi-Edinburg 2015)
(mem. op.), rev’d on other grounds (“Zamarripa II”), 526 S.W.3d 453 (Tex. 2017).
The defendant hospital objected to the nurse’s qualifications, pointing out that she
currently practiced in a hematology-and-oncology unit and had last practiced in a
labor-and-delivery unit nine years earlier as a licensed vocational nurse. See id. at
69. Although the Texas Supreme Court reversed on other grounds, it expressly held
that “[t]he trial court was within its discretion to determine that [the nurse’s] training
as a registered nurse and her prior experience in the labor and delivery unit qualified
her to opine on the standard of care.” Zamarripa II, 526 S.W.3d at 461 n.37.

      Applying this reasoning to the present case, we conclude that the trial court
did not abuse its discretion in overruling Memorial Hermann’s objections to Dr.
Tasker’s qualifications.

B.    The Adequacy of Dr. Tasker’s Reports

      An expert report satisfies the Act’s requirements if it “provides a fair summary
of the expert’s opinions . . . regarding applicable standards of care, the manner in
which the care rendered by the physician or health care provider failed to meet the
standards, and the causal relationship between that failure and the injury, harm, or
damages claimed.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6). Regarding
causation, “[a]n expert must explain, based on facts set out in the report, how and
why [a health care provider’s] breach [of the standard of care] caused the injury. A

                                           13
bare expert opinion that the breach caused the injury will not suffice.” Zamarripa II,
526 S.W.3d at 459–60 (quoting Van Ness v. ETMC First Physicians, 461 S.W.3d
140, 142 (Tex. 2015) (per curiam) (alterations in original)).

      In his first report, Dr. Tasker stated that Heinzen’s primary complaint in the
emergency room was eye pain, and that days passed before a non-party
ophthalmologist diagnosed her acute angle-closure glaucoma. Dr. Tasker explained
that in acute angle-closure glaucoma, intraocular eye pressure “rises rapidly as a
result of relatively sudden blockage of the trabecular meshwork by the iris via
papillary block mechanisms.” He stated that prolonged elevation of intraocular eye
pressure leads to glaucomatous changes in the optic nerve head and loss of optic
nerve axons, which in turn leads to a progressive loss of the visual field.

      Dr. Tasker related that when Heinzen was in the emergency room, her eye
pain was so severe that she rated it as a 10, and the emergency-room nurse gave
Heinzen three doses of morphine. Under “primary pain location,” the nurse wrote
“eye,” but the nurse described “the reason for the visit was headache, with the chief
complaints of nausea and vomiting for two days, light sensitivity on arrival, and no
apparent distress.” Dr. Tasker also explained in his first report that if Heinzen had
been treated in the emergency room, the damage to her vision likely would have
been minimal and reversible, but the damage to her vision increased each hour that
her acute angle-closure glaucoma remained untreated.

      In his second report, Dr. Tasker stated,

      [It] is critically important for nurses and hospital staff to properly
      document complaints and patient history accurately and in order of
      importance. That is true because each successful [sic] healthcare
      provider who reviews the history and complaints taken down by the
      emergency room nurses and staff will rely upon that history to make
      critical decisions. If a nurse makes an error in the order of the history
      and the importance of the history, successive healthcare providers are
                                          14
       likely to rely on that data and make further errors in treatment and
       diagnosis. . . . [T]he emergency-room nurse breached the standard of
       care by failing to take a proper history and to indicate the most
       important item in [Heinzen’s] history was eye pain. Instead the nurse
       focused on headaches. This caused each successive practitioner to focus
       on headaches rather than eye injuries. Needless wasted time was caused
       by the emergency room nurses because they failed to take a proper
       history. The physicians started looking for a head injury and obscure
       diseases rather than the eye injuries that were presented. The nurses
       caused a delay in proper diagnosis by the physicians and further caused
       Donnie Heinzen to suffer acute angle closure for hours and days after
       it should have been diagnosed, and further caused her permanent eye
       injuries as a result of the untreated glaucoma.
       Memorial Hermann contends that Dr. Tasker’s reports insufficiently address
causation because he does not explain how a nursing assessment caused the
physician defendants to delay making the correct diagnosis, given that “[p]hysicians
perform their own assessment and create a differential medical diagnosis after
performing their own examination of the patient.” Memorial Hermann argues that
under the reasoning of Zamarripa II regarding causation, Dr. Tasker had to explain
how the nurses had the right or the means to persuade the physicians to make a
different medical diagnosis.7

       In Zamarripa II, Yolanda Flores was in the third trimester of a pregnancy
when she experienced fever, vomiting, abdominal pain, and contractions. 526
S.W.3d at 456. She was taken by ambulance to Valley Regional Medical Center’s
emergency room, where Dr. Patrick Ellis ordered her transferred to another hospital
159 miles away. Id. at 456–57. While en route, Flores began to bleed and went into

       7
          Memorial Hermann seeks to further support this argument with seven pages of medical
records, which it includes in the appendix to its brief. When evaluating the sufficiency of expert
reports, however, courts consider only the reports themselves. Am. Transitional Care Ctrs. of Tex.,
Inc. v. Palacios, 46 S.W.3d 873, 878 (Tex. 2001). Because the medical records are not part of the
expert reports—indeed, they are not even part of the appellate record—we do not consider them
or Memorial Hermann’s characterization of their contents. See also TEX. R. APP. P. 34.1.

                                                15
cardiac arrest. See id. at 457. She died shortly after doctors at the receiving hospital
delivered her stillborn child by cesarean section. See id.

      The guardian of Flores’s surviving minor children sued the transferring
hospital, among others, and served the expert reports of an obstetrician/gynecologist
and of a nurse with labor-and-delivery and emergency-room experience. See id. The
hospital argued that the expert reports did not adequately show causation. See id.
The nurse stated in her report that the transferring hospital’s nursing staff breached
the standard of care by allowing Flores’s transfer to a distant hospital while in
preterm labor and “by not advocating for” additional treatment, for further
investigation of Flores’s condition, and for Flores’s retention at Valley Regional.
See id. at 457–58. The obstetrician’s expert report stated that the nursing staff’s
breaches of care “in permitting and facilitating” the transfer caused Flores to be in
an ambulance, where an emergency cesarean section and hysterectomy were
unavailable, when she began to bleed, and that the bleeding caused her cardiac arrest
and death. See id. at 458.

      Valley Regional argued that the reports failed to show how it caused Flores’s
death, given that it was the doctor, and not the hospital, who ordered the transfer. Id.
The Texas Supreme Court agreed, stating that the plaintiff’s physician expert “does
not explain how Valley Regional permitted or facilitated Flores’s transfer, or even
whether Valley Regional had any say in the matter.” Id. at 461. The court pointed
out that the nurse’s expert report does not explain how further investigation of
Flores’s condition would have averted the transfer, and that neither expert
“explain[ed] how Valley Regional had either the right or the means to persuade Dr.
Ellis not to order the transfer or to stop it when he did.” Id.

      The facts in this case are distinguishable from those of Zamarripa, which dealt
with an expert’s unexplained assumption that a hospital’s nursing staff had the right

                                           16
and ability to persuade a doctor either to refrain from ordering the patient transferred
or to revoke the order once issued. In contrast, Dr. Tasker opined that Memorial
Hermann’s nursing staff omitted relevant information and mischaracterized a
patient’s primary complaint in medical records on which other health care providers
could and did rely, and that this reliance on faulty records contributed to the delay
in correctly diagnosing and treating the patient. These circumstances differ from
those presented in Zamarripa, and more closely resemble the facts in Abshire v.
Christus Health Southeast Texas, 563 S.W.3d 219 (Tex. 2018) (per curiam).

      In that case, the plaintiff Abshire had osteogenesis imperfecta (OI), which
causes brittle bones that easily fracture. See id. at 221. She presented to the defendant
hospital’s emergency room with complaints of chest and back pain, and the hospital
discharged her with instructions to follow up with a cardiologist. See id. at 221 &
n.2. Two days later, Abshire was back, and although her OI was noted, the physician
ordered only a chest x-ray before releasing her. Id. at 221. She returned the next day
complaining of pain in her shoulder, neck, back, and chest. Hospital staff again
documented Abshire’s history of OI and discharged her with diagnoses of
constipation, musculoskeletal pain, and pleurisy, which is an inflammation of the
lungs. See id. at 221 & n.4.

      Six days later, Abshire was taken by ambulance to the same emergency room,
again complaining of chest and back pain. She remained hospitalized for three days
and a second chest x-ray was taken, but throughout this time, her OI was not
documented in her chart. Id. at 221. The day after the hospital discharged her, she
returned to the emergency room with complaints of weakness in her legs. Id. at 222.
She was transferred to a rehabilitation facility, with continuing complaints of pain
and severe weakness, which now were accompanied by bowel and bladder
incontinence. See id. Abshire was sent back to the same hospital for further

                                           17
evaluation and once more was medically cleared. Id. at 222. When the hospital again
tried to send Abshire to the rehabilitation facility, a doctor there intervened and had
her transferred to another hospital. See id. There, doctors ordered an MRI and
discovered a compression fracture in a thoracic vertebrae, and the injury to Abshire’s
spinal cord from the untreated fracture rendered her paraplegic and incontinent. See
id.

      In Abshire’s suit against the original hospital, her expert opined that the
nursing staff failed to consider the patient’s prior relevant medical history and
ignored signs of spinal injury so that they instead focused on a possible cardiac
problem as the source of Abshire’s symptoms. See id. at 224. The expert explained
that these breaches of the standard of care caused delay in diagnosing and treating
the compression fracture, which in turn led to Abshire’s paralysis and incontinence.
See id.

      The Texas Supreme Court held that the expert report sufficiently addressed
causation by “draw[ing] a line directly from the nurses’ failure to properly document
Abshire’s OI and back pain, to a delay in diagnosis and proper treatment (imaging
of her back and spinal fusion), to the ultimate injury (paraplegia).” Id. at 225. The
intermediate court of appeals had held that the opinion suffered from an analytic gap
in that doctors did not order tests or provide spinal treatment even on those occasions
when Abshire’s OI was noted in the record. See id. The Texas Supreme Court
rejected that view, stating, “it appears the court of appeals simply did not agree with
[the expert’s] conclusions in light of Abshire’s overall course of treatment,” but “the
court’s disagreement with the expert’s opinion does not render the expert report
conclusory.” Id. at 226.

      Just as the expert report in Abshire drew a line of causation from the nursing
staff’s failure to properly document the patient’s relevant medical history to the

                                          18
delay in diagnosis and treatment and thence to the resulting injury, so too do Dr.
Tasker’s reports causally link the failure of Memorial Hermann’s nursing staff to
properly document Heinzen’s primary complaint, to the delay in her diagnosis and
treatment, and then to her resulting vision loss.

       We conclude that the trial court did not abuse its discretion in overruling
Memorial Hermann’s objection that Dr. Tasker’s reports were conclusory on the
causation issue. Thus, without deciding whether Dr. Rushing’s report similarly
supports Heinzen’s claims against the hospital, we affirm the order denying
Memorial Hermann’s motion to dismiss.

                                VI. DR. LUCAS’S APPEAL

       Dr. Lucas challenges the qualifications of Drs. Tasker and Rushing and argues
that the reports of both experts fail to adequately address the standard of care, breach,
and causation. Because we conclude that Dr. Tasker was qualified to opine that Dr.
Lucas’s breach of the applicable standard of care caused Heinzen’s vision loss, and
that his opinion satisfied the statutory requirements, we need not consider Dr.
Lucas’s issues concerning Dr. Rushing.8

A.     Qualifications

       The qualifications necessary to author an expert report in a medical-
negligence claim against a physician are described in the Act as follows:

       (a)    In a suit involving a health care liability claim against a physician
              for injury to or death of a patient, a person may qualify as an
              expert witness on the issue of whether the physician departed
              from accepted standards of medical care only if the person is a
              physician who:

       8
         As previously discussed, the scope of our review of Dr. Lucas’s appeal includes Dr.
Tasker’s first report and curriculum vitae and Dr. Rushing’s second report, but does not include
Dr. Tasker’s second report, Dr. Rushing’s first report, or Dr. Rushing’s curriculum vitae.

                                              19
             (1)    is practicing medicine at the time such testimony is given
                    or was practicing medicine at the time the claim arose;
             (2)    has knowledge of accepted standards of medical care for
                    the diagnosis, care, or treatment of the illness, injury, or
                    condition involved in the claim; and
             (3)    is qualified on the basis of training or experience to offer
                    an expert opinion regarding those accepted standards of
                    medical care.
                                         ...
      (c)    In determining whether a witness is qualified on the basis of
             training or experience, the court shall consider whether, at the
             time the claim arose or at the time the testimony is given, the
             witness:
             (1)    is board certified or has other substantial training or
                    experience in an area of medical practice relevant to the
                    claim; and
             (2)    is actively practicing medicine in rendering medical care
                    services relevant to the claim.
TEX. CIV. PRAC. & REM. CODE ANN. § 74.401.

      When determining whether the person meets these qualifications, we look
only to the four corners of the expert report and the curriculum vitae. Methodist
Hosp. v. Addison, 574 S.W.3d 490, 503–04 (Tex. App.—Houston [14th Dist.] 2018,
no pet.) (citing Mem’l Hermann Healthcare Sys. v. Burrell, 230 S.W.3d 755, 758
(Tex. App.—Houston [14th Dist.] 2007, no pet.)). These materials must establish
the expert’s knowledge, skill, experience, training, or education regarding the
specific issue before the court. Id. at 504 (citing Baylor Coll. of Med. v. Pokluda,
283 S.W.3d 110, 118–19 (Tex. App.—Houston [14th Dist.] 2009, no pet.)).

      Dr. Lucas contends that Dr. Tasker is not qualified to render an expert opinion
regarding the claims against Dr. Lucas because Dr. Tasker was not actively
practicing emergency medicine at the time the claim arose or at the time of his report.


                                          20
To clarify the required qualifications, an expert must know the “accepted standards
of medical care for the diagnosis, care, or treatment of the illness, injury, or condition
involved in the claim.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.401(a)(2)
(emphasis added). By its plain language, the statute does not focus on the defendant
doctor’s area of expertise, but on the condition involved in the claim. See Blan v.
Ali, 7 S.W.3d 741, 746 (Tex. App.—Houston [14th Dist.] 1999, no pet.). As
previously mentioned, a witness providing an expert report concerning a non-
physician individual must be “practicing health care in a field of practice that
involves the same type of care or treatment as that delivered by the defendant health
care provider . . . at the time the testimony is given or was practicing that type of
health care at the time the claim arose,” TEX. CIV. PRAC. & REM. CODE ANN.
§ 74.402(b)(1), but the provision governing qualifications to issue an expert report
concerning a physician does not contain this language. See id. § 74.401.

      The “illness, injury, or condition” involved in Heinzen’s claim is acute angle-
closure glaucoma. Thus, to offer an expert opinion, Dr. Tasker must be “qualified
on the basis of training or experience to offer an expert opinion regarding those
accepted standards of medical care,” that is, “the accepted standards of medical care
for the diagnosis, care, or treatment” of acute angle-closure glaucoma. See id.
§ 74.401(a)(3) (emphasis added). And to determine whether Dr. Tasker is qualified
on the basis of training or experience to offer an expert opinion on the standards of
care for the diagnosis, care, or treatment of acute angle-closure glaucoma, the trial
court was required to consider whether, at the time the claim arose or at the time he
authored the reports, Dr. Tasker had substantial training and experience in “an area
of medical practice relevant to the claim” and was actively practicing medicine in
rendering medical care services “relevant to the claim.”



                                           21
      Dr. Tasker is board-certified in ophthalmology, and Dr. Lucas does not
dispute that Dr. Tasker knows the accepted standards of medical care for the
diagnosis, care, or treatment of acute angle-closure glaucoma; Dr. Lucas instead
asserts that Dr. Tasker failed to demonstrate any experience, training, or education
in emergency medicine. But Dr. Tasker stated in his report, “I currently care for
patients with similar conditions as Ms. Donnie Heinzen and in hospital facilities
similar to Memorial Hermann emergency room”9 and “[t]he standard of care that
applies to the care I provide, applies in an identical manner to that of Memorial
Hermann Hospital emergency room.” He further stated,

      I am qualified to have an opinion on the standard of care of any and all
      physicians who treat patients who have ophthalmologic emergencies,
      ophthalmologic diseases, and conditions, as every medical doctor who
      specializes in the field of ophthalmology and who treats such patients
      as Ms. Heinzen. Also, I have a fundamental knowledge of the effects
      of misdiagnosis and the inability to recognize the ophthalmologic
      emergency condition of angle closure glaucoma. I know and understand
      how to do an ophthalmologic examination on a patient like Ms. Heinzen
      and how to emergency [sic] conditions such as angle closure glaucoma
      and how to follow patients like Ms. Heinzen during and after angle
      closure glaucoma. I am qualified to have an opinion on the standard of
      care of emergency room physicians presented with an ophthalmologic
      emergency such as angle closure . . . , as they should have been trained
      on what actions to take and how to diagnose and treat a patient with
      angle closure glaucoma who presents to the hospital with severe eye
      pain, severe visual loss in both eyes, headache, red eyes, conjunctiva
      swelling, nausea, and vomiting such as Ms. Heinzen.
      Given these statements, we cannot say that the trial court abused its discretion
in concluding that Dr. Tasker is qualified to render an expert opinion concerning
Heinzen’s claims against Dr. Lucas.




      9
          Emphasis added.

                                         22
B.    Adequacy of the Report

      Dr. Lucas also contends that Dr. Tasker’s expert reports fail to adequately
address the applicable standard of care, breach, and causation. Because the same
excerpts from Dr. Tasker’s first report address both the standard of care and breach,
we address those alleged deficiencies together.

      1.     The Standard of Care and Breach

      According to Dr. Lucas, Dr. Tasker opines that the standard of care requires
that an emergency-room physician (1) must recognize angle-closure glaucoma,
(2) must not misdiagnose angle-closure glaucoma as some other condition, (3) must
call or refer the patient to an ophthalmologist for emergency treatment, and (4) must
treat angle-closure glaucoma to lower intraocular pressure to avoid vision loss. Dr.
Lucas argues that Dr. Tasker’s reports are deficient in that he does not state how an
emergency-room physician is to avoid misdiagnosis; how or why the physician is to
recognize angle-closure glaucoma; why the physician must call or refer the patient
to an ophthalmologist for emergency treatment; or how the physician must lower
intraocular pressure.

             (a)   Failure to Correctly Diagnose, or to Transfer for Diagnosis
      Dr. Lucas’s arguments are based solely on Dr. Tasker’s second report, which
we do not consider, but the standard of care applicable to an emergency-room
physician and the breach of that standard were addressed in Dr. Tasker’s first report.
There he wrote,

      The standard of care is clear for the history, examination, testing,
      diagnosis, and treatment of the ophthalmologic emergency of angle
      closure glaucoma. It should be recognized by any emergency room
      staff, emergency room physician, and of course an ophthalmologist.
      Acute angle closure, as with Ms. Heinzen[,] is clear when one presents
      with blurring of vision, painful red eye, headache, nausea, and

                                         23
vomiting. Diagnosis is made by testing for high intraocular pressure
(IOP), corneal edema, shallow anterior chamber, and a closed angle on
gonioscopy. Medical or surgical therapy is directed at widening the
angle and preventing further angle closure. The pressure must be
lowered or the patient [sic] peripheral vision loss will occur due to the
destruction of the nerve fiber layer and optic nerve. . . . A typical
history of angle closure includes reduced vision, eye redness, corneal
edema, engorged conjunctival vessels, halos around lights, aching eye
or brow pain, and headache. Here, Ms. Heinzen presented with severe
eye pain in both eyes, severe visual loss, headache, redness, conjunctiva
swelling, tearing, light sensitivity, a hazy cornea and nausea and
vomiting. These signs and symptoms are classic for angle closure
glaucoma and high intraocular pressure. These alone should have made
the emergency room doctor and ophthalmologist think to rule out angle
closure glaucoma. If properly examined[,] reduced acuity, a closed
angle upon gonioscopy, high intraocular pressure, corneal edema, a
fixed dilated pupil, and engorged conjunctival vessels are typically
found. Dr. Lucas should have been able to diagnose Ms. Heinzen as
presenting with angle closure glaucoma. Proper examination was not
done by Dr. Lucas. . . .
       It is imperative that a thorough ophthalmologic examination is
done by an emergency room physician or ophthalmologist. If these tests
cannot be done at the presenting hospital, the patient should be
immediately transferred to a hospital or facility with the ability to
assess, test, diagnose, and treat the patient. A thorough ophthalmologic
examination is not documented in the medical record by Dr. Lucas on
the date of Ms. Heinzen’s presentation to the emergency room. A slit
lamp exam, gonioscopy examination, and perimetry were never done.
There is no documentation that an intraocular pressure was ever
done. . . . Without an intraocular pressure being taken one would never
even know if the intraocular pressure was high or suspect angle closure
glaucoma. Not doing an accurate ophthalmologic examination in a
timely fashion is below the standard of care. Not recognizing the typical
signs and symptoms of angle closure and ophthalmologic emergency is
below the standard of care.
       If properly diagnosed upon presentation dynamic gonioscopy,
oral carbonic anhydrase inhibitors and or topical beta blocker and or
topical alpha 2 agonist, topical cholinergic agonists, hyperosmotic


                                   24
      agents and of course laser peripheral iridotomy after the acute attack is
      resolved and corneal edema resolves should be done.
                                             ...

      First tests to order after the history and exam reveals symptoms of angle
      closure glaucoma:
            Gonioscopy:
              Definitive test for diagnosing angle closure; gonioscopy of both
              eyes should be performed on all patients in whom angle closure
              is suspected.10 It should also be performed prior to instilling
              dilating medications to rule out eyes susceptible to angle closure.
                                               ....
              Gonioscopy may be therapeutic in breaking the attack of acute
              angle closure.
              Result: TM is not visible in angle closure because the peripheral
              iris is in contact with it.
              Dr. Lucas . . . did not do this test.
            Slit lamp examination:
              The best method of examining the optic disc is with the slit lamp
              combined with a high magnification posterior pole lens. The
              anterior chamber depth should be noted and the size of the phakic
              lens.
              Result: shallow anterior chamber; and signs of glaucoma: large
              optic cup, narrowing of the neuroretinal rim, splinter
              hemorrhage, nerve fiber loss.
              This was not documented as done by Dr. Lucas . . . .
            Automatic static perimetry:
              Identifies the presence, and quantifies the amount, of
              glaucomatous visual field loss during initial diagnosis and
              subsequently during follow-up care.
              Result: visual field defects

      10
          Dr. Tasker explained elsewhere in his report, “Gonioscopy enables the health care
provider to view the anterior chamber angle so as to evaluate the angle structures.”

                                             25
             This was not done by Dr. Lucas. . . .
      As Dr. Tasker stated, the standard of care requires an emergency room
physician to recognize that “severe eye pain in both eyes, severe visual loss,
headache, redness, conjunctiva swelling, tearing, light sensitivity, a hazy cornea and
nausea and vomiting” are “classic” symptoms of acute angle-closure glaucoma. He
further explained that when a patient presents with such symptoms, acute angle-
closure glaucoma must be diagnosed or ruled out by performing gonioscopy, a slit
lamp examination, and automatic static perimetry. Gonioscopy is the “[d]efinitive
test for diagnosing angle closure,” and “may be therapeutic in breaking the attack.”
He also stated that the emergency-room physician must view the optic disc and note
the depth of the anterior chamber and the size of the phakic lens by performing a slit
lamp examination and must additionally identify and quantify any glaucomatous
visual field loss by ordering or performing automatic static perimetry. Having
identified the symptoms suggesting acute angle-closure glaucoma and the diagnostic
tests required by the standard of care, Dr. Tasker added that if the hospital could not
perform the tests, then the standard of care required the emergency-room physician
have the patient transferred to a facility that could do so. He opined that Dr. Lucas
did none of these things.

      We accordingly conclude that Dr. Tasker sufficiently (i) identified the reasons
that Dr. Lucas would have recognized acute angle-closure glaucoma if he had
adhered to the standard of care, and (ii) described how Dr. Lucas’s breach of the
standard of care delayed Heinzen’s correct diagnosis and treatment.

             (b)    Failure to Treat, or to Transfer for Treatment
      Dr. Lucas also contends that Dr. Tasker’s reports are deficient in that he
opines that the standard of care required an emergency-room physician in the
circumstances presented here to call or refer the patient to an ophthalmologist and

                                          26
to treat angle-closure glaucoma to lower intraocular pressure, but he does not say
why an ophthalmologist must be called or how the condition must be treated.

      In support of these arguments, Dr. Lucas again cites only Dr. Tasker’s
inapplicable second report, but the treatment required by the standard of care and the
role of an ophthalmologist are detailed in Dr. Tasker’s first report:

             Once diagnosed, the initial intervention includes acetazolamide,
      a topical beta-blocker, and a topical steroid. Acetazolamide should be
      given as a stat dose of 500 mg IV followed by 500 mg PO. A dose of a
      topical beta-blocker (i.e., carteolol, timolol) will also aid in lowering
      IOP [intraocular pressure]. Beta-blockers and acetazolamide decrease
      aqueous humor production and help to open the angle. An alpha-agonist
      can be added for a further decrease in IOP. Inflammation causes the
      pathophysiology and presenting symptoms. Topical steroids are used to
      decrease the inflammatory reaction and reduce optic nerve damage. The
      current recommendation is for 1-2 doses of topical steroids. . . .
      Analgesics for pain and antiemetics for nausea and vomiting can
      increase IOP beyond its already elevated level. Ms. Heinzen was given
      antiemetics and pain medication which would have typically increased
      the intraocular pressure. Placing the patient in the supine position may
      aid in comfort and reduce IOP. This was not done. It is also believed
      that, while supine, the lens may fall away from the iris decreasing
      pupillary block. After the initial intervention, the patient should be
      reassessed. Reassessment includes evaluating IOP, evaluating drops,
      and considering the need for further intervention, such as osmotic
      agents and immediate iridotomy. . . .
             Approximately 1 hour after beginning treatment, pilocarpine, a
      miotic that leads to opening of the angle, should be administered every
      15 minutes for 2 doses. In the initial attack, the elevated pressure in the
      anterior chamber causes a pressure-induced ischemic paralysis of the
      iris. At this time, pilocarpine would be ineffective. During the second
      evaluation, the initial agents have decreased the elevated IOP and
      hopefully have reduced the ischemic paralysis so pilocarpine becomes
      beneficial in relieving pupillary block. This standard of care treatment
      [sic] was not provided due to the fact that no one in the emergency room
      (Dr. Lucas . . .) . . . did not [sic] recognize, diagnose, or treat for angle
      closure glaucoma.
                                           27
       . . . .If the intraocular pressure is not reduced 30 minutes after the
second dose of pilocarpine, an osmotic agent must be considered. An
oral agent like glycerol can be administered in nondiabetics. Ms.
Heinzen is diabetic so oral isosorbide could be used to avoid the risk of
hyperglycemia associated with glycerol. Patients who are unable to
tolerate oral intake or do not experience a decrease in intraocular
pressure despite oral therapy are candidates for intravenous mannitol to
lower the pressure. This was not done by Dr. Lucas . . . .
       When medical therapy proves to be ineffective, corneal
indentation (CI) can be used as a temporizing measure to reduce IOP
until definitive treatment is available. As the cornea is indented,
aqueous humor is displaced to the periphery of the anterior chamber,
which serves to temporarily open the angle. This leads to immediate
reduction of IOP and occasionally may completely abort the attack.
After applying topical anesthetic, any smooth instrument can be used
to perform this procedure, including a gonioprism (ideal, if available),
or a cotton-tipped applicator. Obviously, a concern with performing CI
is the possibility for damage to the corneal epithelium, which may
complicate the patient’s course.
       Laser peripheral iridotomy or LPI, performed 24-48 hours after
IOP is controlled, is the standard of care therapy and considered the
definitive treatment for angle closure glaucoma. . . . Lens extraction
may also be considered by some to help reduce the intraocular pressure
if cataracts may be blocking the angle.
       The ophthalmologist should decide after testing including
gonioscopy with complete visualization and inspection of the angle
which therapy will be most beneficial to the patient. If ophthalmologic
consultation is not immediately available, the standard of care is that
the emergency department physician must begin pharmacologic
therapy as described previously above. Therapy should reduce
intraocular pressure and ophthalmologic evaluation must be quickly
obtained either within the emergency room or by transferring the
patient to a facility or emergency room with an ophthalmologist who
can immediately treat the patient. If the IOP is unchanged or increased,
with appropriate pharmacologic therapy, a laser iridotomy must be
done immediately. Because outcome is adversely affected by the
duration of symptoms, expeditious evaluation by an ophthalmologist is
required. Ocular massage through a closed eyelid may be performed

                                     28
      while waiting for ophthalmology if no other treatment reduces IOP.
      None of this was done by the emergency room doctors . . . .
      We conclude that Dr. Tasker not only adequately explained the role of an
ophthalmologist, but also sufficiently described the care that an emergency-room
physician must render while awaiting an ophthalmologist’s evaluation, and which
Dr. Lucas failed to perform.

      2.     Causation

      Dr. Tasker opined that if Heinzen had been properly treated in the emergency
room, the damage to her vision likely would have been minimal and reversible, and
that the damage to her vision increased each hour that her acute angle-closure
glaucoma remained untreated. Dr. Lucas contends that this causation opinion is
deficient in that Dr. Tasker does not state how Dr. Lucas should have treated Heinzen
and how that treatment would have stopped or reversed the damage.

      Here, too, Dr. Lucas’s arguments rely solely on the content of Dr. Tasker’s
second report, but as we have just seen, Dr. Tasker’s first report details the treatment
Dr. Lucas should have provided. Dr. Tasker further explained how the delay in
diagnosis and treatment allowed the damage to Heinzen’s eyes to progress:

      Angle-closure glaucoma (ACG) may be reversible and may be caused
      by mechanical blockage or by adhesions called synechia which close
      the anterior-chamber angle. The angle closure may occur in an acute or
      chronic form. In the acute form, the IOP rises rapidly as a result of
      relatively sudden blockage of the trabecular meshwork by the iris via
      papillary block mechanism. The chronic form may develop after acute
      angle closure where synechial closure of the angle persists, or it may
      develop over time as the angle closes from prolonged or repeated
      contact between the peripheral iris and the TM, which often leads to
      peripheral anterior synechiae (PAS) and functional damage to the
      angle. Time is of the essence. . . . It is well known that prolonged
      elevation of intraocular pressure leads anatomically to glaucomatous
      changes in the optic nerve head and loss of optic nerve axons and leads

                                          29
      to a progressive loss of the visual field. This is what happened in all
      medical probability to Ms. Heinzen.
                                          ...
      Ms. Heinzen’s ocular status began to deteriorate from the time she
      arrived in the emergency room until days later when she was finally
      seen by Dr. Wycoff. In my opinion, earlier intervention (proper
      diagnosis and treatment) in all of these areas would have in medical
      probability have [sic] saved her peripheral vision, optic nerve, nerve
      fiber layer, and other such ocular damage. . . . The patient kept getting
      worse and the eye pain and ocular symptoms got worse. . . . No one
      addressed the fact that Ms. Heinzen’s conditioning was worsening . . . .
      As with the physician’s expert report in Abshire, Dr. Tasker’s report in this
case draws a line directly from Dr. Lucas’s breach of the standard of care, to the
delay in diagnosis and treatment, and thence to the ultimate injury. See Abshire, 563
S.W.3d at 225. We conclude that Dr. Tasker’s reports satisfied the statutory
requirements, and we overrule Dr. Lucas’s second issue.

                                 VII. CONCLUSION

      Having affirmed the trial court’s overruling of the Providers’ dispositive
objections to Dr. Tasker’s first and second expert reports, we affirm the denial of the
Providers’ respective motions to dismiss.




                                        /s/     Tracy Christopher
                                                Justice


Panel consists of Justices Christopher, Hassan, and Poissant.




                                          30
