           If this opinion indicates that it is “FOR PUBLICATION,” it is subject to
                revision until final publication in the Michigan Appeals Reports.




                           STATE OF MICHIGAN

                            COURT OF APPEALS



RONNIE WELBORN,                                                  UNPUBLISHED
                                                                 August 13, 2019
              Plaintiff-Appellee,

and

MARY WELBORN,

              Plaintiff,


v                                                                No. 342650
                                                                 Wayne Circuit Court
DR. AKASH R. SHETH, M.D.,                                        LC No. 16-009274-NH

              Defendant-Appellant,

and

SURGICAL SPECIALISTS OF MICHIGAN, P.C.
and WILLIAM BEAUMONT HOSPITAL a/k/a
WILLIAM BEAUMONT-GROSSE POINTE,

              Defendants.


Before: K. F. KELLY, P.J., and TUKEL and REDFORD, JJ.

PER CURIAM.

       Defendant, Dr. Akash R. Sheth, M.D., appeals by leave granted1 the trial court order
granting in part and denying in part his motion for summary disposition in this medical


1
 Welborn v Dr Akash R Sheth MD, unpublished order of the Court of Appeals, entered June 18,
2018 (Docket No. 342650).



                                             -1-
malpractice action. We reverse and remand for entry of an order granting summary disposition
in favor of defendant with regard to the claim of damages for prolonged dialysis.

                      I. BASIC FACTS AND PROCEDURAL HISTORY

        On January 25, 2014, plaintiff presented at William Beaumont Hospital2 with complaints
of nausea, vomiting, diarrhea, difficulty urinating, and a distended abdomen. Tests were
performed, and an evaluation indicated that plaintiff suffered from systemic inflammatory
response syndrome (SIRS), small bowel obstruction, and a ruptured appendix. Plaintiff alleged
that defendant, a surgeon, was consulted regarding his condition, but did not conduct a personal
review of his symptoms. Additionally, defendant did not meet with plaintiff until 11:00 a.m. on
January 26, 2014. Ultimately, plaintiff alleged that surgery was not performed until 18 hours
after his admission to the hospital. It was asserted that defendant committed medical malpractice
by failing to perform surgery within six to eight hours of the final diagnosis to prevent
complications, septic shock, and a continued need for dialysis.

        Following discovery, defendant moved for summary disposition pursuant to MCR
2.116(C)(10). Defendant alleged that the medical malpractice action failed as a matter of law
because plaintiff did not present expert testimony to support his theory that defendant caused
plaintiff to suffer from SIRS, permanent dialysis, and prolonged dialysis. Although plaintiff
claimed those three injuries as a result of defendant’s treatment, he presented two general
surgery experts, Dr. Elliott Goodman and Dr. Melanie Friedlander, and neither expert linked the
damage to treatment by defendant. Defendant submitted that plaintiff’s experts did not opine
that a breach of the standard of care by defendant caused plaintiff to develop SIRS. With regard
to the injuries for permanent and prolonged dialysis, both experts deferred to a nephrology
expert, but plaintiff had not retained such an expert. Rather, the only nephrology expert, Dr.
Jerry Yee, was retained by defendant, and Dr. Yee opined that the injuries that caused the need
for dialysis were sustained before plaintiff arrived at the emergency room for treatment.

        Plaintiff opposed the motion for summary disposition, alleging that defendant discussed
his case with hospital personnel, but failed to come to the hospital to conduct an independent
examination. Additionally, defendant did not appear at the hospital until 11:00 a.m. on January
26, 2014, and this delay between admission and surgery caused him to develop acute renal
failure, a need for dialysis, and the progression of his sepsis. Plaintiff alleged that his experts
opined that the delay between admission and surgery exacerbated the damage to his kidneys.
Alternatively, plaintiff requested the opportunity to amend the complaint to include allegations
regarding the elevation of SIRS to sepsis if the court concluded that summary disposition was
appropriate.




2
 The parties stipulated to dismiss plaintiff, Mary Welborn, and defendants, Surgical Specialist of
Michigan, P.C. and William Beaumont Hospital a/k/a William Beaumont – Grosse Pointe.
Accordingly, the singular plaintiff refers to Ronnie Welborn only, and the singular term
defendant refers to Dr. Akash R. Sheth, M.D.


                                                -2-
        At the hearing on the dispositive motion, the defense reiterated its position that plaintiff’s
experts deferred to a nephrology expert regarding whether the permanent and prolonged dialysis
was necessitated by defendant’s delay in treatment. However, plaintiff’s counsel opined that a
nephrology expert was unnecessary because his experts testified that prolonged delay caused
systemic failure. Upon questioning by the court, plaintiff’s counsel acknowledged that he had no
testimony to support the “question of permanency as it relates to the need for the dialysis.”
However, he would not make any concession with regard to the claim that defendant caused the
need for prolonged dialysis. Defense counsel noted that plaintiff failed to cite deposition
testimony to support a claim of prolonged dialysis, and a prolonged need for dialysis was
subsumed within a claim for permanent dialysis. Additionally, the defense asserted that even
plaintiff’s experts acknowledged that plaintiff had experienced SIRS that led to full blown shock
when he arrived at the hospital because plaintiff suffered from the condition for four days before
he arrived at the hospital. Plaintiff’s counsel asserted that his expert, Dr. Goodman, opined that
the longer the wait, the more damage there was to the kidneys, and he was pursuing amendment
to address the SIRS issue. After the court noted that there did not appear to be a genuine issue
on the SIRS claim, plaintiff’s counsel “accepted” the court’s conclusion. Ultimately, the court
granted summary disposition of plaintiff’s claims for damages premised on SIRS and permanent
dialysis, but allowed plaintiff to submit the claim for prolonged dialysis to a jury. Plaintiff
moved for reconsideration and attached an affidavit from Dr. Friedlander to support plaintiff’s
contention that he suffered from SIRS that progressed to sepsis as a result of defendant’s
malpractice, but the trial court denied the motion for reconsideration, holding that it presented
the same issues previously ruled on by the court.

                                    II. EXPERT TESTIMONY

        Plaintiff offered two experts to support his medical malpractice action. Dr. Elliott
Goodman, a board-certified general surgeon, testified that plaintiff had a four-day history of
abdominal pain, nausea, vomiting, and diarrhea. Because his condition had occurred for several
days, the appendix acted like a “bomb” that had exploded, and there was pus everywhere.
Plaintiff may not have been in septic shock when he arrived at the hospital, but he progressed to
the condition within a matter of hours. Dr. Goodman testified that if a patient arrived in sepsis or
sepsis shock, a doctor must control the source within 6 to 12 hours of the sepsis diagnosis and
use fluid resuscitation and antibiotics. It was alleged that defendant should not have relied on the
hospital’s resident opinion and should not have waited 18 hours after admission to examine
plaintiff in light of the symptoms and vitals. Rather, he should have conducted an evaluation of
the abdomen to determine the need for immediate surgery. With regard to his opinion regarding
injury and damage, Dr. Goodman testified:

               I think the failure to take the patient to the operating room on a timely
       basis within, let’s say, six to eight hours after the diagnosis was made, meaning to
       take him to surgery no later than around 3:00 or 4:00 o’clock in the morning of
       the 26th caused a delay of around, let’s say, 12 hours or so.

               And I think that that 12-hour delay was a proximate cause to a lot of the
       septic consequences of the sepsis and the peritonitis and the ruptured appendix
       and that that delay, for instance, meant that the patient developed intractable or


                                                 -3-
       irreversible acute kidney injury on top of whatever kidney insufficiency he had
       such that he is now dialysis dependent.

              And I think to a reasonable degree of medical certainty that had the patient
       been taken to the operating room those 12 hours earlier, then the septic course
       would have been truncated, would have been arrested.

              So that his acute kidney injury would have lessened to the point that he
       may have required dialysis for a short period of time. But I don’t think he would
       have ended up requiring permanent dialysis.

              I also think, for instance, he would not have been on the ventilator for so
       long because, again, his acute respiratory failure was a consequence of the sepsis
       and the septic shock, et cetera, and that he may not, for instance, or he would to
       reasonable degree of medical certainty, would not have ended up needing a trach
       on, I believe the whatever it was, the 12th of February – I’m sorry the 21st of
       February.

              So his septic course would have been much shorter, much less severe
       without the need for the trach and without the need for permanent dialysis had he
       been resuscitated and the source of sepsis controlled on a timely basis.

Dr. Goodman had reviewed 8 to 9 percent of the 11,000 page medical record to formulate his
standard of care opinion regarding the first 20 hours of plaintiff’s care, and his opinion regarding
the standard of care would not be augmented by additional information. However, he asked to
see the nephrology records to formulate complete causation opinions because plaintiff had some
degree of kidney disease before he arrived at the hospital. Therefore, to address the causal link
between the sepsis and now dependence on dialysis, he needed to see the nephrology outpatient
records to determine the condition of the kidneys before plaintiff became septic. Dr. Goodman
agreed that defendant performed the appropriate procedure in a successful manner, but took issue
with the timing of the procedure. When questioned about the degree of acute kidney injury, any
reversibility, and acute renal failure upon hospital admission, Dr. Goodman acknowledged that
he did not know plaintiff’s baseline kidney function because he did not have those medical
records. Dr. Goodman also acknowledged that the medical records indicated that plaintiff’s wife
initially refused to provide consent for surgery at 12:20 p.m. on January 26, 2014. However, he
opined that this 1 to 2 hour delay was a small or minor contribution to the septic complications
from not being taken to surgery 12 hours earlier. However, when asked to conclude whether the
12-hour delay in surgery rendered the acute renal failure irreversible, Dr. Goodman answered, “I
don’t think I can say.” He then agreed that a nephrologist was in a better position to address
functioning of the kidneys and acute renal failure and would defer to a nephrologist under those
circumstances.

        Dr. Melanie H. Friedlander, a board-certified general surgeon, reviewed plaintiff’s
medical file and opined that he arrived at the hospital with a ruptured appendix. Dr. Friedlander
reviewed the opinion by Dr. Goodman and was in agreement with it. She also opined that if a
surgeon consulted on a patient with an acute small bowel obstruction and signs of sepsis, the
patient should be seen at the time of consultation and not the next day. Dr. Friedlander testified

                                                -4-
that she reviewed the medical records and defendant’s deposition to conclude that plaintiff
should have been operated on the day he presented to the emergency room. She did not criticize
the type of surgery or its success, but opined that it should have been performed sooner. She
could not determine if plaintiff’s appendix ruptured three to four days before the surgery, but
acknowledged that it was perforated at least one day before he arrived at the emergency room.
Dr. Friedlander also concluded that defendant did not breach any standard of care following the
surgery. She opined that he breached the standard of care: (1) by not seeing plaintiff on the day
of the consult because it was known from the x-ray that there was an acute small bowel
obstruction even before the CAT scan results arrived; (2) he should have seen plaintiff first thing
the next morning, not at 11:00 a.m.; and (3) once the family agreed to the surgery, the surgery
should have occurred in a timely fashion even if the surgery schedule had to be altered. Dr.
Friedlander opined that “there’s a reasonable degree of medical probability that the patient’s
outcome was worse” as a result of the breaches.

        Dr. Friedlander was unsure if plaintiff arrived at the hospital with sepsis, but
acknowledged that minimally he had SIRS, a condition where the patient demonstrates
characteristics of sepsis, but does not meet the criteria for sepsis. A patient’s condition
proceeded from SIRS into sepsis with a showing of hypertension, tachycardia, and a known
source of infection. After examining plaintiff’s chart, Dr. Friedlander concluded that plaintiff
was in septic shock before defendant consulted on the case. According to his deposition,
defendant indicated that the surgery’s timing was influenced by plaintiff’s daughter because she
did not believe that he was medically stable for the surgery. Dr. Friedlander opined that a doctor
should not take medical advice from a patient’s family member and should not rely on the
physical examination by another hospital staff member. Because of the septic shock, Dr.
Friedlander concluded that defendant should have been at plaintiff’s bedside within 1 to 2 hours
because early intervention could mean the difference between life and death.

        When questioned regarding injuries resulting from the breaches of the standard of care,
Dr. Friedlander testified:

              Well, its’ difficult to know what his outcome would have been if he had
       had surgery on the night of admission. Nobody has a crystal ball to predict that.
       But there is a reasonable degree of medical probability that all of his multiple
       organ failure issues would have been less severe had he gone to surgery sooner
       because the underlining cause of sepsis would have been sooner and the fallout
       would have been less.

              So it’s difficult to say how much better things would have been. It’s
       possible that his kidney function would have improved sooner. It’s possible that
       he wouldn’t have needed long-term dialysis. I mean, when kidneys fail for sepsis,
       the kidney function usually returns and improves. And granted, [plaintiff] was
       already starting with some degree of renal dysfunction. But even with that, if it
       had been - - if his underlying cause of sepsis had been treated sooner, his multiple
       organ failure probably would not have been as severe. He may not have
       developed ARDS. His entire hospital course could have been shorter, simpler,
       less complication.


                                                -5-
However, Dr. Friedlander then stated that plaintiff did not suffer kidney failure because of
defendant’s breach of the standard of care, but rather, because of the sepsis. She acknowledged
that plaintiff arrived at the emergency room with acute kidney failure before defendant was
asked to consult on his care. Dr. Friedlander was asked to quantify how much worse plaintiff’s
kidney function was as a result of the breaches of the standard of care, she answered, “I cannot.”
She did not know how much better plaintiff would have been if defendant went to the hospital on
the night of the consult “or if it could have been better at all.” Dr. Friedlander acknowledged
that she did not manage chronic kidney failure patients and their need for permanent dialysis and
would defer to a nephrologist on those issues.

        Plaintiff also submitted testimony from Dr. James McQuiston.3 Dr. McQuiston, a general
surgeon, offered a meritorious defense, asserting that plaintiff represented that he believed he
had food poisoning and obtained relief of his discomfort following digestion of over the counter
medication. However, the x-ray showed a small bowel obstruction, and the scan taken later that
day revealed a ruptured appendix. Because he was ill and needed to be resuscitated, plaintiff was
cared for in the intensive care unit. Dr. McQuiston opined that there was no breach of the
standard of care because there were plenty of physicians caring for plaintiff and attempting to
stabilize his condition and avoid surgery. He testified that a recent study of 32,000 case records
demonstrated that there was no difference in final outcomes between an early and delayed
surgery. Dr. McQuiston opined that plaintiff was in septic shock when he arrived at the hospital,
and he suffered a perforation 1 to 2 days earlier. He testified that plaintiff would not have been
operated upon sooner because he was not stable enough for the surgery. Plaintiff was in renal
failure when he arrived at the hospital, and his kidneys shut down and never responded because
of the sepsis. He concluded it was reasonable to wait 12 to 24 hours to determine if the patient
would show signs of improvement.

        Finally, Dr. Jerry Yee, a senior staff nephrologist affiliated with Henry Ford Hospital,
reviewed plaintiff’s medical condition and treatment before the alleged January 2014 medical
malpractice by defendant. Plaintiff’s medical history revealed chronic kidney disease. When
plaintiff arrived at the hospital, he was in acute kidney failure and septic shock. The kidney
failure was caused by an infection, septic shock, low blood pressure, and the prior kidney
disease. The initial course of action was to treat plaintiff’s low blood pressure and repair the
infection. Counsel asked Dr. Yee, with regard to plaintiff’s condition, “[T]he longer the delay in
performing surgery, the more risk there is for damage to the kidneys?” Dr. Yee responded:

                  No, not necessarily. Kidney failure after it’s established, actually it’s
          protective; there are cytoprotective measures. So, this was observed as early as
          the seventies that if you have an insult to the kidney, like a turtle will cover itself
          up and won’t be injured again, the kidneys already in this case have been
          hammered, so to speak, and it’s not really going to get any worse. Kidney failure
          was clearly established, because even after they gave fluids which would
          normally dilute the serum creatinine, the creatinine continued to increase, so



3
    Plaintiff submitted this deposition with his answer to the dispositive motion.


                                                   -6-
       nothing that I could have done or anyone else could have done would have made
       the kidney better at that point. The kidney heals on its own. There’s no
       medication for the kidney. The dye [sic] was cast.

              In fact, he actually gave an excellent history, the patient, by saying, “I’m
       having trouble urinating,” but he already had a history of benign prostatic
       hypertrophy which probably injures his kidneys, which is why it was so silent,
       and also had a history of a urinary tract infection several years before, which
       showed that he already had problems with his urogenital plumbing, so to speak,
       which fostered him to have kidney problems, but he already had established
       kidney failure.

               It wasn’t going to matter what I did or anybody else, for that matter, so
       treating infection was to treat the infection, not to save the kidneys. Had nothing
       to do—one had nothing to do with each [sic] other. The most judicious problem
       or thought was picking the right antibiotics; that’s all at that point. They gave him
       the fluids . . . [T]here’s nothing to do for the kidneys at this point.

       Dr. Yee further stated that plaintiff had stage III acute kidney failure and that had he
gotten to the hospital earlier, it would have made little difference; he just would not have
suffered as much. “They could have dialyzed him, they could have done things, but it wouldn’t
have mattered.”

                         III. SUMMARY DISPOSITION STANDARD

        A trial court’s ruling on a motion for summary disposition is de novo. Bennett v Russell,
322 Mich App 638, 642; 913 NW2d 364 (2018). Summary disposition is appropriate pursuant
to MCR 2.116(C)(10) where there is “no genuine issue as to any material fact, and the moving
party is entitled to judgment or partial judgment as a matter of law.” MCR 2.116(C)(10). When
reviewing a motion for summary disposition challenged under MCR 2.116(C)(10), the court
considers the affidavits, pleadings, depositions, admissions, and other admissible documentary
evidence then filed in the action or submitted by the parties. MCR 2.116(G)(4), (G)(5); Puetz v
Spectrum Health Hosps, 324 Mich App 51, 68; 919 NW2d 439 (2018).

        The moving party has the initial burden to support its claim for summary disposition with
affidavits, depositions, admissions, or other documentary evidence. Quinto v Cross & Peters Co,
451 Mich 358, 362; 547 NW2d 314 (1996). The burden then shifts to the nonmoving party to
establish that a genuine issue of disputed fact exists for trial. McCoig Materials, LLC v Galui
Constr, Inc, 295 Mich App 684, 693; 818 NW2d 410 (2012). The nonmoving party may not rely
on allegations or denials in the pleadings, but must present admissible documentary evidence.
Id.

                     IV. APPLICATION OF THE LAW TO THE FACTS

        We conclude that the trial court erred in denying defendant’s motion for summary
disposition pertaining to the claim of prolonged dialysis.



                                               -7-
        To prevail on a claim for medical malpractice, a plaintiff must prove four requirements:
“(1) the appropriate standard of care governing the defendant’s conduct at the time of the
purported negligence, (2) that the defendant breached that standard of care, (3) that the plaintiff
was injured, and (4) that the plaintiff’s injuries were the proximate result of the defendant’s
breach of the applicable standard of care.” Craig v Oakwood Hosp, 471 Mich 67, 86; 684 NW2d
296 (2004). For medical malpractice, the plaintiff has the burden of proving that he suffered an
injury that more probably than not was proximately caused by the negligence of the defendant.
MCL 600.2912a(2). In Robins v Garg (On Remand), 276 Mich App 351, 362; 741 NW2d 49
(2007), this Court explained the principles of causation in the context of medical malpractice
actions:

       ‘Proximate cause’ is a term of art that encompasses both cause in fact and legal
       cause. Generally, an act or omission is a cause in fact of an injury only if the
       injury could not have occurred without (or ‘but for’) that act or omission. Cause
       in fact may be established by circumstantial evidence, but the circumstantial
       evidence must not be speculative and must support a reasonable inference of
       causation. All that is necessary is that the proof amount to a reasonable likelihood
       of probability rather than a possibility. The evidence need not negate all other
       possible causes, but such evidence must exclude other reasonable hypotheses with
       a fair amount of certainty. Summary disposition is not appropriate when the
       plaintiff offers evidence that shows that it is more likely than not that, but for
       defendant’s conduct, a different result would have obtained.

Thus, “a causal connection between a defendant’s breach of the applicable standard of care and a
plaintiff’s injuries is critical.” Rock v Crocker, 499 Mich 247, 255; 884 NW2d 227 (2016).
Generally, expert testimony is necessary in a malpractice action to establish the applicable
standard of care and to demonstrate that the medical professional breached the standard. Elher v
Misra, 499 Mich 11, 21; 878 NW2d 790 (2016).

       Because the deposition testimony offered by plaintiff failed to demonstrate a causal link
between defendant’s actions and plaintiff’s prolonged dialysis, summary disposition was
appropriate in favor of defendant.

        A review of the deposition testimony from plaintiff’s experts, Dr. Goodman and Dr.
Friedlander, reveals that both doctors claimed that the delay in treatment between plaintiff’s
admission and defendant’s performance of the surgery caused damage to plaintiff. However,
when questioned about the degree of kidney injury that plaintiff had when he was admitted to the
hospital and whether his kidneys would have recovered or if the injury would have been reversed
if surgery was performed sooner, both doctors indicated that they would defer to a nephrologist
regarding that determination. Although Dr. Goodman unequivocally concluded that defendant
breached the standard of care and additional information would not alter his opinion, Dr.
Goodman declined to address the causal link between the sepsis and dialysis dependency. He
noted that he did not have the nephrology records to determine any pre-existing kidney
conditions. Similarly, Dr. Friedlander was asked to determine how much worse plaintiff’s
kidney condition was as a result of defendant’s breach of the standard of care, and she could not
answer the question. Additionally, she could not opine how much better plaintiff’s condition
would be or if it would be better at all and also deferred to a nephrologist on those issues.

                                                -8-
        As defendant notes, the sole nephrologist offered was Dr. Yee. Dr. Yee examined
plaintiff’s medical records and was aware that he had a prior history of chronic kidney disease.
Dr. Yee opined that the prior history coupled with the symptoms that plaintiff presented at the
hospital demonstrated that there were no other measures to reverse the damage done to the
kidneys. Accordingly, plaintiff failed to meet his burden of demonstrating that he required
prolonged dialysis as a result of defendant’s breach of the standard of care, and the court erred in
denying summary disposition of this injury claim.4

        Accordingly, we reverse the trial court’s denial of the motion for summary disposition
pertaining to the claim of prolonged dialysis and remand for entry of an order granting summary
disposition of this claim. We do not retain jurisdiction.

                                                             /s/ Kirsten Frank Kelly
                                                             /s/ Jonathan Tukel
                                                             /s/ James Robert Redford




4
  In light of our holding that plaintiff failed to present expert testimony to support a claim for
injury premised on prolonged dialysis, we need not address defendant’s additional contention
that prolonged dialysis was subsumed within the claim premised on permanent dialysis.


                                                -9-
