Opinion issued August 30, 2018




                                       In The

                                  Court of Appeals
                                      For The

                          First District of Texas
                             ————————————
                               NO. 01-17-00898-CV
                            ———————————
                     DILEEP PUPPALA, M. D., Appellant
                                         V.
                        JAMES REID PERRY, Appellee


                    On Appeal from the 270th District Court
                            Harris County, Texas
                      Trial Court Case No. 2017-012732


                                    OPINION

      This is an interlocutory appeal from the trial court’s order denying Dr.

Puppala’s motion to dismiss James Perry’s health care liability claims for failure to

serve adequate expert reports.1


1
      See TEX. CIV. PRAC. & REM. CODE §§ 51.014(a)(9), 75.351.
      In three issues, Puppala contends that the trial court abused its discretion in

denying his motion to dismiss Perry’s claims because the opinions of Perry’s two

experts on the element of causation were conclusory and because the two experts

were not qualified to offer causation opinions.

      We affirm.

                                   Background

      Perry’s two expert reports provide the background facts in this case, and we

accept the factual statements in the reports for the limited purpose of this appeal.

See Bowie Mem’l Hosp. v. Wright, 79 S.W.3d 48, 53 (Tex. 2002) (review of

Chapter 74 report is limited to four corners of report). Perry’s medical records are

not before us.

      Perry arrived at the emergency room just before 11:00 am on August 22,

2015, complaining of weakness in his left leg, difficulty walking, and poor

balance. He was admitted to the hospital and seen by physicians who are not

parties to this appeal.

      The next day, on Sunday, August 23, Puppala saw Perry for the first time.

Puppala noted that Perry’s symptoms had worsened; Perry had “weakness in the

legs in the lower extremities when he came in” the day before, but now, on August

23, he “has no sensation in both lower extremities, ribs down” and “is not able to

move” either lower extremity. Puppala also noted that CT scans were ordered but


                                         2
were “unremarkable.” Puppala ordered an MRI to diagnose Perry’s neurological

condition. Either the same day or the next, the medical staff determined that

Perry’s size prevented a successful MRI evaluation using the MRI equipment

available onsite.

      On August 24, Puppala ordered that Perry be transferred to another medical

facility to have an MRI. Six medical facilities (identified by name in the expert

report) were contacted, but each responded that its MRI equipment could not

accommodate Perry’s size either. Puppala wrote: “Will continue working on

transferring him to a place where he can safely get an MRI of the spine.”

      The next day, on August 25, Puppala’s notes state they “tried every which

way to get his MRI done” but could not due to his size and that transfer to another

facility “did not materialize.”

      On the fifth day, August 26, Perry was transferred to another medical

facility, and an MRI was successfully performed. Perry was diagnosed with an

epidural abscess on his lumbar spine that was placing increasing pressure on his

spinal cord. The neurosurgeon who evaluated the MRI suspected that the abscess

size and sustained pressure had damaged the spinal cord to the point that the

paralysis had become permanent. This was confirmed with surgery. Perry has

remained paralyzed from the chest down.




                                         3
      Perry sued the various physicians involved in his care during the period of

delayed imaging. As to Puppala, Perry submitted expert reports from two

physicians: Dr. Alex Lechin, a board-certified pulmonologist, and Dr. Derek

Riebau, a board-certified neurologist. Dr. Lechin opined that the standard of care

generally requires physicians to timely diagnose and treat patients. More

specifically, it requires physicians to initiate an immediate work-up and diagnosis

when a patient presents with the inability, or compromised ability, to move their

lower extremities so that the chances of recovery are maximized. According to

Lechin, the standard of care required Puppala to timely ensure Perry underwent a

MRI. Lechin stated that Puppala could have met this standard in multiple ways,

including by “communicating the importance of a timely imaging study to outside

hospital staff,” “articulating the need to transfer the patient to an outside facility

and bring the patient back, given that the admitting facility cannot provide the

required services,” “contacting stand-alone imaging centers,” and “personally

telephoning hospitals and/or accepting physicians at other facilities.” Lechin

opined that Puppala breached the standard of care when he failed to ensure a

timely MRI.

      Lechin’s report states that the partial or complete inability to use one’s lower

extremities is a medical emergency. According to Lechin, when a patient presents

with compromised ability to move a lower extremity, the standard of care requires


                                          4
an “immediate work up” to determine the cause. If an extrinsic etiology is

discovered, “the standard of care requires immediate removal, usually surgically.”

This is because an extrinsic force to the spinal cord applies pressure to the cord and

causes damage to the spinal cord. “Recovery and preservation are dependent upon

timely diagnosis and treatment of extrinsic forces to the spinal cord that are

causing damage.”

      Thus, Lechin opines that the standard of care required Puppala “to timely

ensure Mr. Perry underwent a MRI study” and that Puppala breached this standard

“when he failed to ensure Mr. Perry underwent a timely MRI to diagnose” his

condition. Riebau agreed.

      Regarding causation, Lechin opined that Puppala’s breach caused a delay in

obtaining the necessary MRI and a delay in diagnosing Perry’s abscess.

Meanwhile, Perry’s condition worsened as the abscess “continued to grow and

apply pressure.” “As a result of Dr. Puppala’s failure to appropriately ensure a

timely MRI was performed, Mr. Perry’s abscess progressed and caused complete

paralysis.” Moreover, had an MRI been performed timely, “Mr. Perry would not

have suffered permanent paralysis.”

      Riebau agreed. He noted that Perry presented to the ER on August 22 with

weakness in the left lower extremity only. Thereafter, “there was a deterioration in

his neurological condition whereby he developed loss of sensation from the chest


                                          5
down . . . .” Riebau opined that “it is more likely than not that the abscess would

have been visible on appropriate imaging on 8/22/15,” the day Perry presented

with left-leg weakness. Riebau opined that it also is “more likely than not that had

an epidural lesion been timely diagnosed based upon emergent imaging, . . . Mr.

Perry’s outcome of paraplegia could have been prevented.” Finally, according to

Riebau, Puppala’s failure to “emergently recognize, evaluate and manage acute

spinal cord injury secondary to an extra-axial lesion more likely than not lead to

permanent neurological injury. As a result of Dr. Puppala’s failure to appropriately

ensure appropriate imaging was immediately arranged,” Perry’s abscess grew and

“progressed and caused complete paralysis.”

      Puppala moved to dismiss Perry’s health care liability claims against him,

arguing that the two reports were inadequate as to the element of causation and that

the two experts were not qualified to opine on causation. The trial court denied

Puppala’s motion. Puppala appeals.

                                Motion to Dismiss

      Dr. Puppala contends that the trial court abused its discretion by denying his

motion to dismiss Perry’s health care liability claims for failure to serve adequate

expert reports because (1) the causation opinions of Perry’s two experts were

conclusory and (2) those two experts were not qualified to opine on causation.




                                         6
A.    Standard of review

      We review a trial court’s ruling on a motion to dismiss a health care

liability claim for an abuse of discretion. Van Ness v. ETMC First Physicians, 461

S.W.3d 140, 142 (Tex. 2015) (per curiam). We “defer to the trial court’s factual

determinations if they are supported by evidence,” but we review its legal

determinations de novo. Id. “A trial court abuses its discretion if it rules without

reference to guiding rules or principles.” Id.

B.    Health care liability expert report requirements

      Under the Medical Liability Act, a plaintiff asserting health care liability

claims must timely serve each defendant physician and health care provider with

one or more expert reports and a curriculum vitae of each expert whose opinion is

offered to substantiate the merits of the claims. TEX. CIV. PRAC. & REM. CODE

§ 74.351(a), (i); see Mangin v. Wendt, 480 S.W.3d 701, 705 (Tex. App.—

Houston [1st Dist.] 2015, no pet.). The standard for serving an adequate expert

report is well established. The expert report must provide a “fair summary” of the

expert’s opinions regarding the (1) applicable standards of care, (2) manner in

which the care rendered by the physician or health care provider failed to meet the

standards, and (3) causal relationship between that failure and the injury, harm, or

damages claimed. TEX. CIV. PRAC. & REM. CODE § 74.351(r)(6); Miller v. JSC

Lake Highlands Operations, LP., 536 S.W.3d 510, 513 (Tex. 2017) (per curiam).


                                           7
For standard of care and breach, the expert report must explain what the physician

or health care provider should have done under the circumstances and what the

physician or health care provider did instead. Am. Transitional Care Ctrs. of Tex.,

Inc. v. Palacios, 46 S.W.3d 873, 880 (Tex. 2001). For causation, the expert report

must explain how and why the physician’s or health care provider’s breach

proximately caused the plaintiff’s injury. Columbia Valley Healthcare Sys., L.P.

v. Zamarripa, 526 S.W.3d 453, 459–60 (Tex. 2017).

      When the plaintiff timely serves an expert report, and the defendant timely

files a motion to dismiss to challenge the adequacy of the report, the trial court

may take one of three actions. Mangin, 480 S.W.3d at 705. First, if the trial court

concludes that the report is adequate, it must deny the motion. Id. Second, if the

trial court concludes that the report does not constitute an objective good faith

effort to comply with the statute, it must grant the motion. Id.; see TEX. CIV.

PRAC. & REM. CODE § 74.351(l). Third, if the trial court concludes that the report

is an objective good faith effort to comply with the statute but is nevertheless

deficient in some way, it may grant the plaintiff one 30-day extension to cure the

deficiency and must grant the extension if the deficiency is curable. Mangin, 480

S.W.3d at 705–06.

      A report qualifies as an objective good faith effort to comply if it discusses

each element with sufficient specificity to (1) inform the defendant of the specific

                                         8
conduct the plaintiff questions and (2) provide a basis for the trial court to

conclude that the plaintiff’s claims have merit. Baty v. Futrell, 543 S.W.3d 689,

693–94 (Tex. 2018); Mangin, 480 S.W.3d at 706. In determining whether an

expert report constitutes an objective good faith effort to address each element, “a

trial court may not draw inferences; instead, it must exclusively rely upon the

information contained within the four corners of the report.” Cornejo v. Hilgers,

446 S.W.3d 113, 123 (Tex. App.—Houston [1st Dist.] 2014, pet. denied); see

Baty, 543 S.W.3d at 693. And when the issue is the expert’s qualifications, the

court may also consider the four corners of the expert’s curriculum vitae. Mangin,

480 S.W.3d at 706.

      For causation, an expert report must explain “how and why” the physician’s

or health care provider’s breach proximately caused the plaintiff’s injury.

Zamarripa, 526 S.W.3d at 459–60. Proximate cause has two components: cause-

in-fact and foreseeability. Id. at 460. A physician’s breach was a cause-in-fact of

the plaintiff’s injury if the breach was a substantial factor in bringing about the

harm, and absent the breach (i.e., but for the breach), the harm would not have

occurred. Id. A physician’s breach was a foreseeable cause of the plaintiff’s injury

if a physician of ordinary intelligence would have anticipated the danger caused by

the negligent act or omission. See Price v. Divita, 224 S.W.3d 331, 336 (Tex.

App.—Houston [1st Dist.] 2006, pet. denied). “No particular words or formality


                                         9
are required, but bare conclusions will not suffice.” Scoresby v. Santillan, 346

S.W.3d 546, 556 (Tex. 2011). Thus, to provide more than a conclusory statement

on causation, an expert report must include an “explanation tying the conclusion to

the facts” and showing “how and why the breach caused the injury based on the

facts presented.” Jelinek v. Casas, 328 S.W.3d 526, 539–40 (Tex. 2010).

      The purpose of the expert-report requirement is not to determine the merits

of the claim but to rule out frivolous lawsuits at the onset of litigation, before the

parties have conducted full discovery. Ross v. St. Luke’s Episcopal Hosp., 462

S.W.3d 496, 502 (Tex. 2015); Mangin, 480 S.W.3d at 706. As we have explained:

      The requirement to serve an expert report arises at the outset of
      litigation and before the opportunity for the plaintiff to engage in
      significant discovery, including taking oral depositions of the
      defendants. As such, the statute itself contemplates that the amount
      and quality of evidence available at the time of drafting the expert
      reports will be less than that available at trial on the merits or even the
      summary-judgment stage.

Mangin, 480 S.W.3d at 713 (citations omitted). In reviewing the adequacy of an

expert report at this early stage of the litigation, a trial court may not consider an

expert’s credibility, the data the expert relies on, or the documents he relies on or

had failed to consider. See Mettauer v. Noble, 326 S.W.3d 685, 691 (Tex. App.—

Houston [1st Dist.] 2010, no pet.); Gonzalez v. Padilla, 485 S.W.3d 236, 245 (Tex.

App.—El Paso 2016, no pet.).




                                          10
      Additionally, an expert report “need not anticipate or rebut all possible

defensive theories that may ultimately be presented.” Owens v. Handyside, 478

S.W.3d 172, 187 (Tex. App.—Houston [1st Dist.] 2015, pet. denied). Nor must the

report “rule out every possible cause of the injury, harm, or damages claimed.”

Baylor Med. Ctr. at Waxahachie, Baylor Health Care Sys. v. Wallace, 278 S.W.3d

552, 562 (Tex. App.—Dallas 2009, no pet.).

      In determining whether the causation opinions are conclusory, we must

remain mindful that expert-report challenges are made at this early, pre-discovery

stage in the litigation, not when the merits of the health care liability claim are

being presented to the factfinder to determine liability. Cf. Baty, 543 S.W.3d at 697

& n.10 (rejecting argument that expert report was inadequate on standard of care,

breach, and causation; concluding that expert report sufficed “particularly in light

of the purposes the report is intended to serve” at early stage in litigation; and

stating that “additional detail is simply not required at this stage of the

proceeding”).

C.    Trial court did not err in concluding that experts’ causation opinions
      were not conclusory

      In his first and second issues, Puppala argues that the trial court abused its

discretion in denying his motion to dismiss because Lechin’s and Riebau’s expert

reports were conclusory on the element of causation.



                                         11
      Perry’s experts opined that Perry had an abscess on his spinal cord that was

growing. According to Riebau, the abscess was large enough to be identified

through MRI imaging on the day Perry arrived at the ER. On that day, Perry had

weakness in his left leg but no paralysis. An MRI was not possible at the location

where Perry was being treated, and, according to the experts’ opinions, Puppala

breached the standard of care by failing to ensure that an MRI was timely

performed at another facility. During the four-day delay in obtaining an MRI, the

abscess “continued to grow,” pressure on his spine was not relieved, there was a

“deterioration in [Perry’s] neurological condition,” and he became paralyzed from

the chest down. According to the experts, it is more likely than not that a timely

MRI would have revealed the cause of Perry’s worsening condition and avoided

the permanent paralysis that resulted from the four-day delay of imaging and

diagnosis. Their opinion is that Puppala breached the standard of care by not taking

certain, identified steps to ensure a timely MRI was performed.2 And their

causation opinion is that Puppala’s breach proximately caused the foreseeable

injury of permanent paralysis by allowing the natural and foreseeable progression

of the abscess’s growth and resulting damage through a failure to timely ensure

diagnostic imaging.


2
      Puppala does not challenge the expert reports on the elements of standard of care
      or breach. As such, we consider only whether the causation opinion meets the
      requirements of Section 74.351.
                                          12
      This causation opinion is in line with other illness- and injury-progression

cases in which causation opinions were held to be adequate to meet the

requirements of the Medical Liability Act. See Hayes v. Carroll, 314 S.W.3d 494,

507–08 (Tex. App.—Austin 2010, no pet.); Fagadau v. Wenkstern, 311 S.W.3d

132, 138–39 (Tex. App.—Dallas 2010, no pet.); see also TEX. CIV. PRAC. &

REM. CODE § 74.351. In these cases, the experts opined that, had the physician not

breached the standard of care, a proper diagnosis and medical intervention would

have been achieved, and the patient’s injuries would have been avoided; thus, the

physician’s breach in delaying diagnosis or treatment proximately caused the

injuries suffered. See Hayes, 314 S.W.3d at 507; Fagadau, 311 S.W.3d at 138–39.

The appellate courts held that the causation opinions were adequate and not

conclusory even when they did not specify when along the continuum of illness- or

injury-progression the plaintiff’s condition became irreversible so that, after that

point, any breach and related delay could not be said to have contributed to the

ultimate injury. See Hayes, 314 S.W.3d at 507 (stating that possibility that

factfinder might reject expert’s causation opinion and conclude instead that

damage “became irreversible at a point prior to the involvement of one or more” of

the medical providers did not render expert reports conclusory); Fagadau, 311

S.W.3d at 138–39 (rejecting physician’s argument that, by failing to specify exact

date patient suffered retinal detachment, expert failed to show causal link between


                                        13
failure to refer patient to retinal specialist and permanent injuries suffered when

retina detached).

      A challenge to an expert’s causation opinion was granted by the trial court

but later reversed by this court in Owens v. Handyside, 478 S.W.3d 172 (Tex.

App.—Houston [1st Dist.] 2015, pet. denied). There, the plaintiff went to the ER

on three separate occasions complaining of severe headaches, but the doctors did

not order any diagnostic tests. Id. at 175–76. On her fourth medical visit,

diagnostic tests were ordered, and they revealed that she had a “head bleed.” Id. at

176. The head bleed resulted in permanent blindness, and the patient sued the

doctors who failed to order diagnostic tests during her three initial visits. Id. The

patient’s expert opined that, had those physicians ordered diagnostic testing, it was

medically probable that her condition would have been diagnosed and treated in a

timelier manner, and she most likely would not have been permanently blinded. Id.

at 179. The physicians argued that the expert failed to explain “how and why” their

alleged breach caused the patient’s blindness, but we disagreed. Id. at 188–90.

      We held that the causation opinion was adequate because an “expert may

show causation by explaining a chain of events that begins with a defendant

doctor’s negligence and ends in injury to the plaintiff.” Id. at 189. The expert

explained that this type of injury progression was well known and opined that the

physicians’ failure to order diagnostic testing caused a delay in diagnosis and


                                         14
treatment and that the delay resulted in the patient’s blindness. Id. at 190. The

expert further opined that, in reasonable medical probability, early diagnosis would

have prevented the blindness. Id. We held that the expert report represented a

good-faith effort to inform the physicians of the causal relationship between their

failure to adhere to the standard of care and the injury, harm, or damages claimed

and that the expert’s report met the requirements of Section 74.351. Id. at 191.

      The Austin case, Hayes, presents a similar delay-in-diagnosis-and-treatment

scenario in which the patient’s condition deteriorated rapidly, and the patient’s

experts opined that the doctors’ failure to timely diagnose an emergent medical

issue proximately caused the patient’s permanent injuries. 314 S.W.3d at 507.

There, a woman receiving emergency medical care was given a large amount of IV

fluids that caused swelling. Id. at 497–98. None of her health care providers

realized that a bandage on her leg was becoming increasingly tight as her body

swelled. Id. at 499. After 28 hours, a nurse noticed the tight bandage and removed

it, but the “tourniquet-like effect” of the bandage had already caused necrosis that

could not be reversed, requiring the amputation of her leg. Id. at 497–98.

      The expert opined that, as a consequence of each health care provider’s

breach, “the extremity’s condition went unmonitored, and the impediment to

circulation was not removed until after the damage was done. Such actions caused

irreversible ischemia of the right lower extremity with resultant amputation.” Id. at


                                         15
507. The various health care providers sought dismissal on various grounds, the

trial court held that the expert’s report was adequate, and the health care providers

appealed. See id. at 499.

      The Austin court held that the trial court did not abuse its discretion in

concluding that the expert report was adequate because the report notified each

provider that, in the expert’s opinion, each was responsible for the harm caused by

the constrictive bandage in that each failed to notice, loosen, or remove the

bandage before permanent injury resulted. Id. at 507. At the pre-discovery stage of

the litigation, the plaintiff was not required to “marshal all of her evidence or prove

her case against a particular defendant. Rather, what the statute requires is that the

report constitute a good faith effort to provide a fair summary of the expert’s

opinions regarding causation.” Id. The expert report met that standard because it

informed each defendant of the conduct the plaintiff called into question and

provided a basis for the trial court to conclude that the claims have merit. Id. at

508. As the Austin court stated, “The expert report is not required to prove the

defendant’s liability, but rather to provide notice of what conduct forms the basis

for the plaintiff’s complaints.” Id. at 507.

      The Austin court further explained that, while the factfinder might ultimately

reject the expert’s causation opinion and determine, as to one or more defendant

health care providers, that the damage was already irreversible before that


                                           16
particular defendant provided any medical care, that possibility did not render the

expert’s causation opinion conclusory. Id.; see Adeyemi v. Guerrero, 329 S.W.3d

241, 244–46 (Tex. App.—Dallas 2010, no pet.) (in injury-progression case

involving delayed diagnosis, court held that expert report was not conclusory

because it stated what doctor should have done and what happened because she

failed to do it, and it provided “fair summary” of expert’s opinions on causal

relationship between breach and injury); Mosely v. Mundine, 249 S.W.3d 775,

780–81 (Tex. App.—Dallas 2008, no pet.) (holding that expert report constituted

good-faith effort to provide fair summary of expert’s causation opinion because

expert explained opinion that delayed diagnosis allowed disease to progress such

that more severe injuries resulted); see also Bay Oaks SNF, LLC v. Lancaster, No.

01-17-00982-CV, 2018 WL 3353009, at *12 (Tex. App.—Houston [1st Dist.] July

10, 2018, no pet. h.) (noting that possibility that expert is wrong about how alleged

breach caused harm is issue for summary judgment, not motion to dismiss under

Chapter 74 as conclusory opinion).

      Here, Perry’s expert reports explained the experts’ causation opinions,

including the “how and why” Puppala’s alleged breach caused Perry’s injury. See

Miller, 536 S.W.3d at 516–17 (concluding that expert’s report adequately explains

“how and why” radiologist’s breach in failing to detect “foreign body” that was

visible on patient’s x-ray proximately caused patient’s aspiration and subsequent


                                         17
death). The experts opined that meeting the identified standard of care through

identified acts would have detected the physical condition, that early detections are

remediable, that “delay in such treatment can cause significant disability,” and that

“the failure to timely diagnose and treat” the patient proximately caused the injury.

Thus, they constituted a good-faith effort to provide a fair summary of the experts’

opinions regarding causation and to describe the basis for liability. See Miller, 536

S.W.3d at 515–17; Adeyemi, 329 S.W.3d at 245–46.

      Puppala argues that the expert reports did not contain enough factual

assertions, reducing the experts’ opinions to assumptions untied to the specific

facts of the case. As an example, Puppala asserts that the reports are deficient

because they do not contain facts about stand-alone radiology centers’ ability to

perform MRIs under sedation. First, we note that Section 74.351 expert reports are

due before any discovery is conducted in a case. Second, the reports state that an

MRI actually was performed at a nearby facility once one was found that could

accommodate Perry’s size, though in the experts’ opinion it was not timely. We

fail to see how more detail about MRIs performed under sedation reduce these

experts’ causation opinions to mere conclusory statements.

      Puppala also argues that the experts’ opinions are conclusory because they

fail to identify when Perry’s abscess had grown and damaged his spinal cord to the

point that his paralysis was irreversible and they fail to compare the timing of that


                                         18
event to when an MRI could have been obtained had Puppala not breached the

applicable standard of care. But the absence of an opinion stating with specificity

at what point in the continuum of disease progression an intervention would have

proven timely does not cause these experts’ causation opinion to be conclusory at

this early stage of evaluation. See Hayes, 314 S.W.3d at 507 (holding that, while it

was possible that factfinder might ultimately reject expert’s causation opinion and

conclude that plaintiff’s injury had already become irreversible before doctor’s

alleged breach, that possibility did not render expert reports conclusory); Fagadau,

311 S.W.3d at 138–39 (rejecting physician’s argument that expert’s causation

opinion was conclusory because it failed to specify exact date patient suffered

retinal detachment and therefore failed to show causal link between failure to refer

patient to retinal specialist and permanent injuries suffered when retina detached).

      We conclude that the experts adequately tied their causation opinion to the

facts and explained how and why the alleged breach of the standard of care

proximately caused Perry’s permanent injuries. See Jelinek, 328 S.W.3d at 539–40.

In reaching this conclusion, we note that the context in which this these two

experts’ causation opinions are offered is distinguishable from that in other cases

involving multiple medical conditions and competing causal agents. See, e.g., id. at

540 (expert’s report identified breach of standard of care as failing to ensure that

renewal of prescription for hospitalized patient who had on-going infections,


                                         19
identified plaintiff’s injury as increased pain and longer hospital stay, and opined

that health care provider’s breach caused injury; however, report was inadequate

because it failed to link conclusion to relevant facts given that patient was

receiving medical treatment for multiple other conditions both during and after

short-term lapse in antibiotics and expert failed to link causation opinion to facts);

Shenoy v. Jean, No. 01-10-01116-CV, 2011 WL 6938538, at *6–10 (Tex. App.—

Houston [1st Dist.] Dec. 29, 2011, pet. denied) (expert’s report stated that

cardiologist breached standard of care by clearing patient for non-urgent surgery in

light of patient’s concurrent heart-health issues, identified plaintiff’s injuries as

post-operative respiratory arrest with oxygen deprivation and resulting death, and

opined that cardiologist’s breach caused patient’s injuries; however, report was

inadequate because it did not explain “how and why” breach caused plaintiff’s

injuries in that it did not identify any role pre-existing conditions played in

subsequent events, particularly given that patient was “prematurely” extubated,

suffered respiratory arrest, was reintubated, later self-extubated, and then suffered

second respiratory arrest).

      At this expert-report stage, an expert report “does not have to meet the same

requirements as the evidence offered in a summary-judgment proceeding or at

trial.” Miller, 536 S.W.3d at 517 (quoting Scoresby, 346 S.W.3d at 556 n.60).

Because Perry’s experts’ reports provided a fair summary of the experts’ opinions


                                         20
regarding the applicable standards of care, a statement identifying the manner in

which the care rendered by Puppala failed to meet the standards, and an

explanation of the causal relationship between that failure and the injury, harm, or

damages claimed, the trial court did not abuse its discretion in denying Puppala’s

motion to dismissal. See TEX. CIV. PRAC. & REM. CODE § 74.351(r)(6); Miller, 536

S.W.3d at 513; Mangin, 480 S.W.3d at 705.

      We overrule Puppala’s second issue.

D.    Qualifications

      In his third issue, Puppala contends that the trial court abused its discretion

by finding that Perry’s experts are statutorily qualified to provide causation

opinions.

      Whether an expert witness is qualified to offer an expert opinion under the

relevant statutes and rules lies within the sound discretion of the trial court.

Cornejo, 446 S.W.3d at 121. The expert’s qualifications must appear in the four

corners of the expert report or its accompanying curriculum vitae. Id. In a health

care liability suit, “a person may qualify as an expert witness on the issue of the

causal relationship between the alleged departure from accepted standards of care

and the injury, harm, or damages claimed only if the person is a physician and is

otherwise qualified to render opinions on that causal relationship under the Texas

Rules of Evidence.” TEX. CIV. PRAC. & REM. CODE § 74.403(a); see id.


                                         21
§ 74.351(r)(5)(C) (defining “expert” qualified to give opinion on causation as “a

physician who is otherwise qualified to render opinions on such causal relationship

under the Texas Rules of Evidence”); Cornejo, 446 S.W.3d at 120.

      Under the Rules of Evidence, an expert witness may be qualified on the

basis of “knowledge, skill, experience, training, or education” to testify on

scientific, technical, and other specialized subjects, if the testimony would “help

the trier of fact to understand the evidence or to determine a fact in issue.” TEX. R.

EVID. 702; see Cornejo, 446 S.W.3d at 121. “Thus, a plaintiff must show that her

expert has knowledge, skill, experience, training, or education regarding the

specific issue before the court that would qualify the expert to give an opinion on

that particular subject.” Cornejo, 446 S.W.3d at 121 (internal quotations omitted).

Not all licensed physician are qualified to testify on all medical questions; but, at

the other extreme, there is no requirement that a physician practice in the particular

field for which he is testifying. Id. What is required is that the physician

demonstrate that he is qualified to opine on the specific issue before the court. Id.

      Puppala does not challenge the qualifications of Perry’s two experts to

generally opine that an undetected epidural abscess will grow and apply increasing

pressure on a spinal cord and, if undetected and untreated, will cause irreversible

paralysis. Nor does he challenge their qualifications to opine that timely diagnosis

and treatment, in reasonable medical probability, would allow for successful


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medical intervention to remove the abscess and pressure and, in doing so, cause the

patient to obtain a more favorable result that does not include permanent paralysis.

Puppala agrees that Perry’s experts “may have experience in suspecting the

presence of an epidural abscess and obtaining the diagnostic tests (i.e. MRI) to

confirm the diagnosis.”

      Puppala’s causation-qualification challenge is more specific. He argues that

Perry’s pulmonology and neurology experts are unqualified to opine on two

particular aspects of causation: “(1) when would a surgery on [Perry]’s spine have

occurred if there was a ‘timely’ MRI” and “(2) when was [Perry]’s paraplegia

irreversible and beyond the point where surgery would likely restore his ability to

walk.” In other words, Puppala contends that Perry’s experts lack the qualifications

to identify the moment beyond which a causal link could no longer be established.

      But, as we already concluded, at this early stage in the litigation in a case

involving the natural progression of an illness or injury, Perry’s experts were not

required to identify when in the continuum of injury progression Perry’s paralysis

became irreversible to state a qualifying causation opinion in their pre-discovery

expert report. See Hayes, 314 S.W.3d at 507; Fagadau, 311 S.W.3d at 138–39.

Because the expert reports were not required to contain expert opinions on these

two specific temporal issues, the expert reports and accompanying CVs are not

inadequate for failing to establish a qualification to provide an unnecessary


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opinion. See TEX. CIV. PRAC. & REM. CODE §§ 74.403(a), 75.351(r)(5) (setting

forth requirements for expert qualifications).

      We overrule Puppala’s third issue and, with it, his first issue asserting that

the trial court erred in denying his motion to dismiss.

                                     Conclusion

      We affirm.




                                                 Harvey Brown
                                                 Justice

Panel consists of Chief Justice Radack and Justices Massengale and Brown.




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