                                           COURT OF APPEALS
                                        EIGHTH DISTRICT OF TEXAS
                                             EL PASO, TEXAS


    SCOTT A. PROTZMAN, M.D., EL PASO                        §
    ORTHOPAEDIC SURGERY GROUP,
    P.A., AND FRED UTTER, CRNA,                             §                  No. 08-15-00281-CV

                                     Appellants,            §                     Appeal from the

    v.                                                      §                   448th District Court

    MARIA T. GURROLA, INDIVIDUALLY                          §               of El Paso County, Texas
    AND ON BEHALF OF ALL
    WRONGFUL DEATH BENEFICIARIES,                           §                 (TC# 2014-DCV-3560)
    AND AS REPRESENTATIVE OF THE
    ESTATE OF OSCAR GURROLA,                                §
    DECEASED,
                                                            §
                                     Appellee.

                                                    OPINION

           This is a health care liability case subject to the Texas Medical Liability Act.

TEX.CIV.PRAC.&REM.CODE CH. 74 (West 2011). On November 9, 2012, Mr. Oscar Gurrola

underwent a non-surgical manipulation of his shoulder which was performed under anesthesia at

El Paso Specialty Hospital, was discharged, suffered cardiac arrest, and died. His wife, Maria

Gurrola, sued El Paso Specialty Hospital, Dr. Scott A. Protzman, El Paso Orthopaedic Surgery

Group (EPOSG), and Nurse Anesthetist Fred Utter, CRNA.1 Maria timely served Dr. Michael


1
    El Paso Specialty Hospital challenges the trial court’s ruling on the expert report as to the hospital in a separate
Koumjian’s expert reports on the defendants. The trial court heard the defendants’ objections to

the expert reports and denied their motion to dismiss Maria’s suit. TEX.CIV.PRAC.&REM.CODE

ANN. § 74.351(b)(West Supp. 2015).

        In this interlocutory appeal, Appellants ask us to determine whether the trial court abused

its discretion when it overruled their objections and denied their motion to dismiss.

TEX.CIV.PRAC.&REM.CODE ANN. § 51.014(a)(9)(West Supp. 2015). Appellants assert the expert

reports were inadequate because: (1) Dr. Michael Koumjian failed to establish his qualifications

to opine on the standard of care, breach of that standard, and causation in support of Maria’s health

care liability claims relating to the death of her husband, Oscar; and (2) the expert reports fail to

satisfy the TMLA requirements regarding causation based on the conduct of Dr. Scott A. Protzman

and Nurse Utter, and as to the standard of care and breach of that standard in relation to the conduct

of Nurse Utter. TEX.CIV.PRAC.&REM.CODE ANN. § 51.014(a)(10).

        We conclude the trial court did not abuse its discretion in denying the defendants’

objections and motion to dismiss Dr. Koumjian’s expert report regarding Dr. Protzman’s conduct,

and affirm the trial court’s ruling. However, Dr. Koumjian’s expert report regarding Nurse Utter

is inadequate to constitute an objective good faith effort to comply with TMLA’s statutory

requirements. TEX.CIV.PRAC.&REM.CODE ANN. § 74.351(l)(West Supp. 2015). We affirm in

part, reverse in part, and remand the case for further proceedings. TEX.R.APP.P. 43.2(a), (d).

                                            BACKGROUND

        The basis of Maria’s claim and the focus of Dr. Koumjian’s report involves Oscar’s

post-procedure tachycardia as well as the acts or omissions of the Hospital’s employees or agents


appeal. See El Paso Specialty Hospital, LTD v. Maria Gurrola, Individually and on Behalf of all Wrongful Death
Beneficiaries and as Representative of the Estate of Oscar Gurrola, Deceased, No. 08-15-00282-CV.
                                                      2
in relation thereto, specifically with regard to the failure to monitor, diagnose, care for and treat the

condition. Maria alleges that while Oscar was under the care of the defendants, he developed

symptoms of congestive heart failure but was discharged home where he suffered a cardiac arrest,

was cared for by emergency personnel, and transported to another medical facility where he was

pronounced dead. An autopsy revealed that Oscar died from severe coronary atherosclerosis.

                                           DISCUSSION
                                         Standard of Review

        We review the trial court’s ruling to determine whether it abused its discretion in ruling on

the adequacy of the expert report. Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46

S.W.3d 873, 877 (Tex. 2001); Tenet Hospitals Ltd. v. Boada, 304 S.W.3d 528, 533 (Tex.App.--El

Paso 2009, pet. denied). Under an abuse of discretion standard, the appellate court defers to the

trial court’s factual determinations if they are supported by evidence, but reviews the trial court’s

legal determinations de novo.         See Stockton v. Offenbach, 336 S.W.3d 610, 615 (Tex.

2011)(citing In re Labatt Food Serv., L.P., 279 S.W.3d 640, 643 (Tex. 2009)). A trial court

abuses its discretion if it rules without reference to guiding rules or principles. Samlowski v.

Wooten, 332 S.W.3d 404, 410 (Tex. 2011).

                                      I. Expert Qualifications

        Appellants present their complaints in four issues. In Issues One and Two respectively,

Appellants challenge Dr. Koumjian’s qualifications to render expert opinions on the standards of

care and breach of applicable standards, and his qualifications to opine regarding the causal nexus

between the alleged negligence and Oscar’s death. We first address Issue Two.

        To opine on whether a physician departed from accepted standards of medical care for

physicians, an expert must be a physician who:

                                                   3
       (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.

TEX.CIV.PRAC.&REM.CODE ANN. § 74.401(a)(West 2011); TEX.CIV.PRAC.&REM.CODE

ANN. § 74.351(r)(5)(A).     To opine on whether a health care provider other than a

physician departed from accepted standards of health care, an expert must be a person who:

           (1) is 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, if
               the defendant health care provider is an individual, at the time the testimony
               is given or was practicing that type of health care at the time the claim arose;

           (2) has 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

           (3) is 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); TEX.CIV.PRAC.&REM.CODE ANN.

§ 74.351(r)(5)(A). To opine on causation in any healthcare liability claim, an expert must

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

under the Texas Rules of Evidence. TEX.CIV.PRAC.&REM.CODE ANN. § 74.351(r)(5)(C).

       An expert report or its required accompanying curriculum vitae must show that the expert

is qualified to opine on the subject matter at issue. TEX.CIV.PRAC.&REM.CODE ANN. § 74.351(a);

In re McAllen Med. Center, Inc., 275 S.W.3d 458, 463 (Tex. 2008). The medical expert need not

practice in the same specialty as the defendant in order to qualify as an expert. Roberts v.

Williamson, 111 S.W.3d 113, 122 (Tex. 2003). However, not every licensed physician is always

                                                  4
qualified to testify on every medical question. Broders v. Heise, 924 S.W.2d 148, 152 (Tex.

1996).

         To determine whether an expert report is sufficient to demonstrate the qualifications of the

expert to opine, the trial court should focus on the medical expert’s “knowledge, skill, experience,

training, or education” concerning the specific issue before the court which would qualify the

expert to give an opinion on that particular subject. Broders, 924 S.W.2d at 153-54 (applying

Texas Rule of Evidence 702); see also Tenet Hospitals, Ltd. v. Garcia, 462 S.W.3d 299, 306

(Tex.App.--El Paso 2015, no pet.)(application of rules of evidence in assessing expert’s

qualifications to opine on causation as set forth in Section 74.351(r)(5)(C) pertains only to expert’s

qualifications and does not extend to expert’s opinion). The focus of the trial court should not be

on the specialty of the medical expert. Roberts, 111 S.W.3d at 122. A medical expert from one

specialty may be qualified to testify if he has practical knowledge of what is traditionally done by

medical experts of a different specialty under circumstances similar to those at issue in the case.

Pediatrix Med. Services Inc. v. De La O, 368 S.W.3d 34, 40 (Tex.App.--El Paso 2012, no pet.). If

the subject matter is common to and equally recognized and developed in all fields of practice, any

practitioner familiar with the subject may testify as to the standard of care. Id. at 40. The trial

court must ascertain that the expert does indeed possess the expertise on the subject for which he is

giving an expert opinion. Palafox v. Silvey, 247 S.W.3d 310, 316 (Tex.App.--El Paso 2007, no

pet.). The proffered medical expert’s qualifications must be evident from the four corners of his

expert report and curriculum vitae. See Palacios, 46 S.W.3d at 878. We cannot infer causation

either by filling in missing gaps or by guessing what an expert likely meant or intended. Tenet

Hosps. Ltd. v. Bernal, 482 S.W.3d 165, 171 (Tex.App.--El Paso 2015, no pet.); Tenet Hosps, Ltd.


                                                  5
v. Garcia, 462 S.W.3d 299, 310 (Tex.App.--El Paso 2015, no pet.)(citing Bowie Mem'l Hosp. v.

Wright, 79 S.W.3d 48, 52 (Tex. 2002)).

        The basis of Maria’s claim and the focus of Dr. Koumjian’s report involves Oscar’s

post-procedure tachycardia as well as the acts or omissions of Dr. Protzman and Nurse Utter in

relation thereto, specifically with regard to the failure to diagnose, care for and treat the condition.

Maria alleges that while Oscar was under the care of the defendants, he developed symptoms of

congestive heart failure but was discharged home where he suffered a cardiac arrest, was

transported to another medical facility, and was pronounced dead. An autopsy revealed that

Oscar had died from severe coronary atherosclerosis.

                     1. Qualifications to Opine on Standards of Care and Breach

        In Issue Two, Appellants complain Dr. Koumjian is not qualified to render expert opinions

regarding the standard of care or the breach of that standard by Dr. Protzman or Nurse Utter. As

to Protzman, Appellants contend that Dr. Koumjian has failed to demonstrate “how or why” he is

familiar with the standard of care, and assert that his failure to specify standards for post-procedure

care renders his report too ambiguous, vague, and overbroad to render him qualified to opine as to

the standards applicable to Dr. Protzman or Nurse Utter. They also complain that Dr. Koumjian

fails to explain how or why Dr. Protzman should have been aware of the severe nature of Oscar’s

cardiovascular disease or should have acted differently.

        Appellants argue that Dr. Koumjian has not shown that he is qualified to opine on the

standard of care and breach of the standard that is applicable to Nurse Utter because he fails to

show that he is practicing health care in a field of practice that involves the same type of care or

treatment as that delivered by Nurse Utter, providing anesthesia, or was practicing that type of


                                                   6
health care at the time Maria’s claim arose, or has knowledge of the accepted standards of care for

health care providers for the diagnosis, care, or treatment of the illness, injury, or condition

involved in the claim.

         We disagree with these assertions. In her petition, Maria asserts that: (1) Appellants

knew or should have known that Oscar was at risk for “developing a cardiac arrest because of

severe coronary disease;” (2) while Oscar was at the hospital, the standard of care included proper

assessment and treatment to prevent a patient like Oscar from “developing a cardiac arrest because

of severs coronary artery disease;” (3) Appellants violated the standard of care by failing to

provide proper assessment and treatment to prevent Oscar’s cardiac arrest and death; and (4) at all

relevant times, the Hospital and EPOSG acted by and through its employees and agents and are

vicariously liable for their negligent acts and omissions. 2 There is no question that Maria’s

complaint addresses Oscar’s status as an at-risk cardiac patient, and challenges the Hospital’s

compliance with the proper standard of care to be provided him as an at-risk cardiac patient.

Therefore, pursuant to Section 74.351(r)(5)(B), Dr. Koumjian must establish that he is qualified

under the requirements of Sections 74.401 and 74.402 to testify as an expert witness on the issue of

whether the physician and defendant health care provider departed from those applicable accepted

standards of care.         TEX.CIV.PRAC.&REM.CODE ANN. § 74.351(r)(5)(B); TEX.CIV.PRAC.&

REM.CODE ANN. §§ 74.401, 74.402.


2
  We analyze the sufficiency of the expert report only with respect to the actions of EPOSG’s employees and agents in
Maria’s vicarious liability claim. See Certified EMS, Inc. v. Potts, 392 S.W.3d 625, 626 (Tex. 2013)(defendant did
not challenge adequacy of expert report as to its vicarious liability); TTHR Ltd. Partnership v. Moreno, 401 S.W.3d
41, 45 (Tex. 2013)(expert report is analyzed as to physician’s actions, and plaintiff’s claims that hospital was
vicariously liable for the physician’s actions may proceed if expert report regarding physician’s actions adequately
address the standard of care, breach, and causation as to physician); see also Tenet Hosp. Ltd. v. Bernal, 482 S.W.3d
165, 174 (Tex.App.--El Paso 2015, no pet.)(expert must consider both the pleadings and the medical record in
formulating opinion, but is not required to address hospital’s vicarious liability for physician’s acts or omissions in
order for expert’s report to be adequate)(citing Loaisiga v. Cerda, 379 S.W.3d 248, 261 (Tex. 2012)).
                                                          7
                                          Applicable Law

       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:

       (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.

TEX.CIV.PRAC.&REM.CODE ANN. § 74.401(a).              For the purpose of this section, “practicing

medicine” or “medical practice” includes, but is not limited to, training residents or students at an

accredited school of medicine or osteopathy or serving as a consulting physician to other

physicians who provide direct patient care, upon the request of such other physicians.

TEX.CIV.PRAC.&REM.CODE ANN. § 74.401(b). 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(c)(1), (2). The court shall apply the criteria specified

in Subsections (a), (b), and (c) in determining whether an expert is qualified to offer expert

testimony on the issue of whether the physician departed from accepted standards of medical care,

but may depart from those criteria if, under the circumstances, the court determines that there is a

good reason to admit the expert’s testimony. TEX.CIV.PRAC.&REM.CODE ANN. § 74.401(d).

                                                  8
       In a suit involving a health care liability claim against a health care provider, a person may

qualify as an expert witness on the issue of whether the health care provider departed from

accepted standards of care only if the person:

       (1) is 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, if the defendant
       health care provider is an individual, at the time the testimony is given or was
       practicing that type of health care at the time the claim arose;

       (2) has 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

       (3) is qualified on the basis of training or experience to offer an expert opinion
       regarding those accepted standards of health care. [Emphasis added].

TEX.CIV.PRAC.&REM.CODE ANN. § 74.402(b). “Practicing health care” includes: (1) training

health care providers in the same field as the defendant health care provider at an accredited

educational institution; or (2) serving as a consulting health care provider and being licensed,

certified, or registered in the same field as the defendant health care provider.

TEX.CIV.PRAC.&REM.CODE ANN. § 74.402(a).

       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 certified by a licensing agency of one or more states of the United States or a

national professional certifying agency, or has other substantial training or experience, in the area

of health care relevant to the claim; and (2) is actively practicing health care in rendering health

care services relevant to the claim.        TEX.CIV.PRAC.&REM.CODE ANN. § 74.402(c).              In

determining whether an expert is qualified to offer expert testimony on the issue of whether the

defendant health care provider departed from accepted standards of medical care, the court shall


                                                  9
apply the criteria specified in Subsections (a), (b), and (c) but may depart from those criteria if,

under the circumstances, the court determines that there is a good reason to admit the expert’s

testimony.   TEX.CIV.PRAC.&REM.CODE ANN. § 74.401(d).                If it departs from the specified

criteria, the court shall state on the record its reason for admitting the testimony. Id.

                                               Analysis

        Maria filed Dr. Koumjian’s expert reports regarding Dr. Protzman and Nurse Utter on

March 23, 2015, and April 6, 2015, respectively. In each, Dr. Koumjian’s curriculum vitae

indicates that he has been licensed to practice medicine since 1978, is currently the Chief of

Surgery at Sharp Grossmont Hospital, has appointments as attending staff, consulting staff,

provisional staff, or transitional staff in cardiothoracic surgery at seven hospital facilities, is board

certified in Thoracic Surgery, and also conducts a private practice in cardiovascular and thoracic

surgery. Thus, he was licensed and practicing medicine as a cardiovascular and thoracic surgeon

and as Chief of Surgery at the time of his expert report and at the time Maria’s claim arose. He

has previously served as Chief of the Cardio-Thoracic Section of Scripps Mercy Hospital, and has

served as a District Counselor for the American College of Cardiologists. Dr. Koumjian has

completed residencies in general surgery and cardiothoracic surgery, as well as fellowships

involving cardiac surgery, cardiac transplantation, and cardiac “valve.” He has lectured on the

intra-operative use of inotropic agents during and immediately post-cardiopulmonary bypass, and

has served as an assistant clinical professor of surgery for the University of California at San

Diego’s Department of Cardiac Surgery.

        In his expert reports, Dr. Koumjian states that his medical practice involves the diagnosis

and treatment of coronary artery disease under the same or similar circumstances here, and that he


                                                   10
is familiar with the standard of care concerning the evaluation of both the risk and prevention of

death caused by severe coronary atherosclerosis under the same or similar circumstances in this

case. He is familiar with the evaluation, consultation, diagnosis, and treatment of patients who

are at risk for death caused by atherosclerosis, and notes that the standard of care for identifying

the risks and symptoms of severe coronary artery disease and obtaining cardiology consultation

under the same or similar circumstances in this case applies to all physicians, including

orthopaedic surgeons, and to nurse anesthetists. Dr. Koumjian works closely with nurses who

evaluate patients who are at risk and have symptoms associated with severe coronary artery

disease under the same or similar circumstances in this instance, and is familiar with the nursing

standard of care for reporting to physicians the symptoms associated with coronary artery disease,

the diagnosis, care, or treatment of which is involved in Maria’s claim.

       In his expert report, Dr. Koumjian notes that a cardiologist had determined ten days before

Oscar’s shoulder-manipulation procedure that although surgery was not contraindicated, Oscar

would need to be closely monitored due to his history of coronary artery disease. Oscar was at

risk of death due to severe coronary artery disease, and Dr. Koumjian states that Appellants knew

or should have known this as Oscar had a diagnosis of atherosclerotic disease, coronary artery

stents, uncontrolled diabetes, and hypertension, which are factors for tachycardia. Without

prompt diagnosis and treatment, tachycardia can lead to cardiac arrest. Dr. Koumjian claims

Appellants failed to properly diagnose and treat the signs and symptoms which Oscar presented

post-procedure. These symptoms included elevated blood pressure, elevated heart rate, pain, and

dizziness. He asserts that the applicable standard of care required the performance of a “STAT

cardiac workup.” This workup would have shown Oscar’s tachycardia and would have required


                                                11
immediate treatment such as defibrillation, intubation, and mechanical ventilation.             These

treatments, more likely than not, would have prevented Oscar’s cardiac arrest and death.

       According to Dr. Koumjian, in addition to the standard of care applicable to both

physicians and healthcare providers, the standard of care further required that Dr. Protzman as a

physician both closely monitor Oscar because of his high risk for cardiac arrest due to coronary

artery disease, and provide orders to staff to carefully monitor Oscar for any signs or symptoms

related to heart failure, such as a significant change in blood pressure, tachycardia, or dizziness,

and to notify him immediately if they occurred. Instead, Dr. Protzman failed to closely monitor

Oscar, and failed to provide orders to staff to carefully monitor Oscar for signs or symptoms of

heart failure such as changes in blood pressure, tachycardia, or dizziness. This breach of the

standard resulted in a failure to diagnose and treat Oscar’s ventricular tachycardia before he was

discharged from El Paso Specialty Hospital. Oscar experienced a significant change of blood

pressure, tachycardia, and dizziness while at the hospital but was sent home where he died that

same day. According to Dr. Koumjian, had the standard of care been followed, the hospital’s

nursing staff would have notified Dr. Protzman or a physician, Oscar more likely than not would

have been diagnosed with tachycardia and treated, and with such diagnosis and treatment, Oscar’s

ventricular tachycardia would have resolved and his cardiac arrest and death would have been

prevented.

       We do not find Dr. Koumjian’s recitations regarding his experience, training, knowledge,

or familiarity with the diagnosis, care, or treatment of the condition, injury, or harm in this case to

be vague, overbroad, or permitting of impermissible inferences as Appellants suggest.

Dr. Koumjian’s qualifications to opine on the standards of care and breach of those standards


                                                  12
regarding Maria’s claims in this case are evident from the four corners of his expert report and

curriculum vitae. See Palacios, 46 S.W.3d at 878. Consequently, we conclude the trial court did

not abuse its discretion in concluding that Dr. Koumjian is qualified to opine on the standard of

care and breach thereof as it applies to Dr. Protzman as a physician and to Nurse Utter as a health

care provider. Issue Two is overruled.

                                 2. Qualifications to Opine on Causation

         In Issue One, Appellants argue Dr. Koumjian has failed to explain his qualifications and

has therefore not demonstrated that he is qualified to render an expert opinion on causation. They

label as insufficient Dr. Koumjian’s assertion that his practice of medicine “involves the diagnosis

and treatment of coronary artery disease, under the same or similar circumstances as in this case.”

They specifically complain that Dr. Koumjian provides no insight regarding how his practice

involves matters confronted by either Dr. Protzman or Nurse Utter, fails to address whether he

treats patients like Oscar or is familiar with the issues presented in Maria’s claim, and fails to assert

that he is familiar with the consequences of the purported breaches of the standards of care.

Although acknowledging that Dr. Koumjian may be qualified to opine on causation, Appellants

assert his expert reports contain insufficient information, such as an explanation of his familiarity

with the non-surgical interventions that he claims were required and could have prevented Oscar’s

death.

         To opine on causation in any healthcare liability claim, an expert must be a physician who

is otherwise qualified to render opinions on such causal relationship under the Texas Rules of

Evidence.     TEX.CIV.PRAC.&REM.CODE ANN. § 74.351(r)(5)(C); TEX.CIV.PRAC.&REM.CODE

ANN. § 74.401(a). Rule of Evidence 702 provides that a witness who is qualified as an expert by


                                                   13
knowledge, skill, experience, training, or education may testify in the form of an opinion if the

expert’s scientific, technical, or other specialized knowledge will help the trier of fact to

understand the evidence or determine a fact issue.               See TEX.R.EVID. 702.         Section

74.351(r)(5)(C) incorporates the rules of evidence in the context of the expert’s qualifications, not

the substance of the opinion itself. Garcia, 462 S.W.3d at 306. Consequently, Rule 702’s

requirement that the witness must be qualified by “knowledge, skill, experience, training, or

education” applies here. Id.

       That an expert is qualified to opine on the subject matter at issue may be shown in the

expert’s report or its required accompanying curriculum vitae. TEX.CIV.PRAC.&REM.CODE ANN.

§ 74.351(a); In re McAllen Med. Center, 275 S.W.3d at 463. We have examined Dr. Koumjian’s

report and curriculum vitae, and find that he has adequately shown that he is qualified by

knowledge, skill, experience, training, or education to opine on causation on the matter at issue.

       To the extent we have addressed Dr. Koumjian’s qualifications by knowledge, skill,

experience, training, or education as presented within the four corners of his expert reports, we

need not repeat them here. However, in addition to stating that his “practice of medicine involves

the diagnosis and treatment of coronary artery disease, under the same or similar circumstances as

in this case,” Dr. Koumjian also notes his familiarity with the standard of care for the prevention of

death under the same or similar circumstances as those of Oscar.

       Dr. Koumjian’s qualifications to opine on the standards of care, breach of those standards,

and causation arising from such breach with regard to the claims in this case are evident within the

four corners of his expert report and curriculum vitae.         See Palacios, 46 S.W.3d at 878.

Consequently, because Dr. Koumjian’s expert report shows that he is a physician having


                                                 14
knowledge and experience concerning the subject of his opinion, we conclude the trial court did

not abuse its discretion in determining that Dr. Koumjian was qualified to offer an opinion on the

cause of Oscar’s cardiac arrest and death. Issue One is overruled.

                                II. Sufficiency of Expert Reports

       In Issues Three and Four respectively, Appellants complain the trial court abused its

discretion in overruling their objections to the adequacy of Dr. Koumjian’s expert reports and in

failing to dismiss Maria’s suit. Issue Three complains that Dr. Koumjian’s expert report fails to

provide a non-conclusory, factually-supported explanation of the causal link between

Dr. Protzman and Nurse Utter’s alleged negligence and Oscar’s death. Issue Four asserts that

Dr. Koumjian’s expert report fails to establish the standard of care applicable to Nurse Utter, and

Nurse Utter’s breach of that standard of care.

                                          Applicable Law

       A plaintiff asserting a health care liability claim must serve each defendant with an expert

report that includes “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 damage

claimed.” TEX.CIV.PRAC.&REM.CODE ANN. § 74.351(r)(6); Van Ness v. ETMC First Physicians,

461 S.W.3d 140, 141 (Tex. 2015); Bustillos v. Rowley, 225 S.W.3d 122, 130 (Tex.App.--El Paso

2005, pet. denied)(expert report need not include full statement of applicable standard of care and

how it was breached; fair summary must set out what care was expected, but not given)(citing Am.

Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 880 (Tex. 2001)). A challenge

to the sufficiency of a report must be sustained if the report does not represent an objective good


                                                 15
faith effort to comply with the statutory requirements.         TEX.CIV.PRAC.&REM.CODE ANN.

§ 74.351(l); Van Ness, 461 S.W.3d at 141. A report is a good faith effort if it provides adequate

information to inform the defendant of the specific conduct the plaintiff has called into question,

provides a basis for the trial court to conclude that the claims have merit, and does not contain a

material deficiency. Van Ness, 461 S.W.3d at 141-42.

       The evidence in the expert report need not be the same evidence as if the merits of the claim

are being litigated. Palacios, 46 S.W.3d at 879; Tenet Hosps. Ltd. v. Barajas, 451 S.W.3d 535,

540 (Tex.App.--El Paso 2014, no pet.). Rather, the expert’s report can be informal and the

information contained therein “does not have to meet the same requirements as the evidence

offered in a summary-judgment proceeding or at trial.” Palacios, 46 S.W.3d at 879; Barajas, 451

S.W.3d at 540. However, an expert must explain, based on facts set out in the report, how and

why the breach caused the injury. Van Ness, 461 S.W.3d at 142, citing Jelinek v. Casas, 328

S.W.3d 526, 539-40 (Tex. 2010). A bare expert opinion that the breach caused the injury will not

suffice. Van Ness, 461 S.W.3d at 142.

                                                 Analysis

       Dr. Koumjian set out the following facts in his report as those on which he based his

opinions. Oscar’s cardiologist, Dr. Gregorio J. Castillo, examined him on October 29, 2012.

Dr. Castillo noted that Oscar was scheduled for surgery the following week, that his blood sugars

were elevated after increasing the dose of medication, that his blood pressure was 110/70, and his

pulse was 63. Although Oscar had no symptoms of dizziness or syncope, Dr. Castillo observed

that Oscar had uncontrolled diabetes and atherosclerotic cardiovascular disease. He noted that

Oscar did not have a medical contraindication for surgery under general anesthesia for treatment of


                                                16
his right shoulder adhesive capsulitis, but indicated that Oscar would require close monitoring

because of his history of coronary artery disease.

        On November 9, 2012, Oscar went to El Paso Specialty Hospital for a right shoulder

therapeutic manipulation under general anesthesia and an injection of anesthetic, steroid, and

arthrogram. Dr. Scott Protzman, an orthopaedic surgeon, and Nurse Anesthetist Fred Utter

performed the orthopaedic procedure. Oscar’s pre-anesthesia blood pressure was 128/90, and his

heart rate was 84. The anesthesia was started at 9:05 a.m., and the procedure was commenced at

9:21 a.m. The procedure ended at 9:30 a.m., and Oscar was in the recovery room at 9:42 a.m. At

that time, his heart rate was 82, and his respirations were 18. Anesthesia was ended eight minutes

later at 9:50 a.m.

        In the recovery room, Oscar complained of increasing pain. He subsequently underwent a

block for post-operative pain, with anesthesia commending at 11:20 a.m. and ending at 11:45 a.m.

Dr. Koumjian’s expert report does not identify the person who administered this anesthesia to

Oscar. In the recovery room, Oscar’s blood pressure was 163/91, and his heart rate had increased

to 91. Oscar told the recovery room nurse that he was feeling dizzy and very sleepy. The nurse

informed Oscar that his symptoms were normal, and noted to Oscar and Maria that although

Oscar’s blood pressure was high, that was normal as well. The unidentified recovery room nurse

did not notify a physician about Oscar’s reported symptoms, and at approximately 12:50 p.m., “the

nurse” instructed Oscar and Maria to return home.

        As instructed, Oscar and Maria returned home. Maria assisted Oscar out of their car and

into their home, and at approximately 2 p.m., Maria left to run errands. When Maria returned

home, she found Oscar unresponsive and called 9-1-1. Emergency medical services arrived at


                                                17
4:30 p.m., initiated cardio-pulmonary resuscitation on Oscar, and transported him to a hospital,

arriving there at 4:47 p.m. Cardio-pulmonary resuscitation was discontinued at 4:59 p.m., and

Oscar was pronounced dead.         An autopsy report shows Oscar died from severe coronary

atherosclerosis, and the certificate of death identifies Oscar’s immediate cause of death was severe

coronary artery disease.

                                B. Expert Reports on Causation

       In Issue Three, Appellants complain that Dr. Koumjian fails to provide a factual

underpinning for his causation conclusions, and fails to explain how or why Oscar’s ventricular

tachycardia led to his fatal cardiac arrest, fails to discuss any connection between the ventricular

tachycardia and the severe coronary atherosclerosis found after autopsy, or how immediate

treatment consisting of defibrillation, intubation, and mechanical ventilation would have

prevented the fatal cardiac arrest “hours later.”

       In his five-page expert reports, Dr. Koumjian notes that Oscar’s post-procedure heart rate,

elevated blood pressure, and dizziness are signs and symptoms of ventricular tachycardia. He

states that untreated ventricular tachycardia can lead to cardiac arrest. There is no evidence noted

in the expert report that the recovery room nurse or any nurse ever notified Dr. Protzman or any

physician about Oscar’s tachycardia signs and symptoms. Rather, the recovery nurse informed

Oscar and Maria that Oscar’s symptoms were normal and instructed them to return home.

       Dr. Koumjian explains that Dr. Protzman breached the standard of care by failing to

closely monitor Oscar, by failing to provide orders that staff carefully monitor Oscar for any signs

and symptoms of heart failure such as a significant change in blood pressure, tachycardia, or

dizziness, and to notify him or a doctor of such signs and symptoms. This breach of the standard


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of care resulted in the failure to diagnose and treat Oscar’s ventricular tachycardia before he was

discharged and sent home.        Oscar experienced a significant change of blood pressure,

tachycardia, and dizziness post-procedure while at the hospital. Had the standard of care been

followed, the hospital’s nursing staff would have notified Dr. Protzman or a physician, and Oscar

more likely than not would have been diagnosed with ventricular tachycardia and immediately

treated with defibrillation, intubation, and mechanical ventilation. More likely than not, this

diagnosis and treatment would have prevented Oscar’s cardiac arrest and death.

       In his report regarding Nurse Utter, Dr. Koumjian explains that Nurse Utter breached the

standard of care by failing to carefully monitor Oscar for any signs and symptoms of heart failure

such as a significant change in blood pressure, tachycardia, and dizziness. He opines that had

Nurse Utter followed the standard of care, he would have assessed Oscar, found that Oscar had a

significant change of blood pressure, tachycardia, and dizziness, and would have reported these

findings to a physician. According to Dr. Koumjian, Nurse Utter’s breach of the standard of care

resulted in a failure to diagnose and treat Oscar’s ventricular tachycardia before he was discharged

and sent home. If Nurse Utter had followed the standard of care, more likely than not, Oscar

would have been treated for tachycardia by defibrillation, intubation, and mechanical ventilation.

This diagnosis and treatment, based on a reasonable medical probability, more likely than not

would have resolved Oscar’s ventricular tachycardia and prevented his cardiac arrest and death.

       Dr. Koumjian’s expert reports demonstrate that Dr. Protzman’s and Nurse Utter’s alleged

negligence are causally related to Oscar’s death. He reports that the signs and symptoms of

Oscar’s ventricular tachycardia were evident, detectable, and treatable, and that adherence to the

standard of care by providing proper monitoring and administration of treatment more likely than


                                                19
not would have resolved the tachycardia and prevented Oscar’s cardiac arrest and death. It was

incumbent upon the trial court to review the reports, sort out their contents, resolve

inconsistencies, and decide whether the expert reports demonstrated a good faith effort to show

that Maria’s claims have merit. See Van Ness, 461 S.W.3d at 144. Based on our review, the

reports provide a fair summary of Dr. Koumjian’s opinions as to the causal relationship between

Dr. Protzman’s and Nurse Utter’s alleged breaches and the harm claimed, inform the defendants of

the conduct being called into question, and provide a basis for the trial court to conclude that

Maria’s claims have merit. Consequently, we conclude the trial court did not abuse its discretion

by determining that the expert reports are not conclusory and constitute a good-faith effort to

comply with the TMLA’s requirements as to causation. Issue Three is overruled.

              1. Expert Report on Nurse Utter’s Standard of Care and Breach.

       In Issue Four, Appellants complain the trial court abused its discretion by overruling their

objections to the expert report regarding Nurse Utter on the basis that Dr. Koumjian’s report fails

to establish the standard of care applicable to Nurse Utter and his alleged breach of that standard.

According to Dr. Koumjian’s expert report, the standard of care for a nurse anesthetist, like that of

Dr. Protzman, required that Nurse Utter monitor Oscar for signs and symptoms associated with

heart failure and ventricular tachycardia, “such as a significant change in blood pressure,

tachycardia, and dizziness,” and report them to a physician, and alleges that Nurse Utter breached

the standard of care by failing to do so.

       Appellants counter that Dr. Koumjian’s report as to Nurse Utter is deficient in part because

it fails to place Nurse Utter in the recovery room with Oscar or explain the role of a nurse

anesthetist in providing post-procedure care. They contend the report is also deficient because it


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fails to identify or discuss Utter’s role in relation to that of the hospital’s nursing staff present in the

recovery room with Oscar, or the hospital nursing staff to whom Dr. Protzman should have issued

orders to closely monitor Oscar.3 Appellants note that Nurse Utter cannot be assumed to have

provided post-operative care to Oscar, and indicate that Dr. Koumjian’s report only links Nurse

Utter to Oscar during the administration of anesthesia between 9:05 and 9:50 a.m., during which

the report fails to claim that Oscar presented any observable symptoms of severe coronary artery

disease such as elevated blood pressure, heart rate, and dizziness. Those symptoms, Appellants’

argue, presented only after a second administration of anesthesia by an unnamed provider. For

these reasons, Appellants argue Dr. Koumjian’s expert report regarding Nurse Utter is speculative

and without foundation as no facts recited in the report connect Nurse Utter’s care to Oscar’s

post-procedure care.

           We agree with these assertions.             The facts recited in Dr. Koumjian’s expert report

regarding Nurse Utter do not adequately explain how or why Nurse Utter’s specific conduct

constitutes a breach of the standard of care for a nurse anesthetist. In his report, Dr. Koumjian

specifically identifies Nurse Utter as the person who provided general anesthesia to Oscar between

9:05 and 9:50 a.m. Oscar’s pre-anesthesia heart rate was 84, and when he was taken to the

recovery room at 9:42 a.m., eight minutes before anesthesia concluded at 9:50 a.m., his heart rate

was 82. However, the report does not identify Nurse Utter as the person who subsequently

administered the anesthesia to Oscar for a pain-control block, nor as a member of the nursing staff

of the hospital or its recovery room. The facts which Dr. Koumjian recites regarding Oscar’s

post-procedure complaints, signs, and symptoms, neither directly nor indirectly implicate any act



3
    Maria does not claim that Nurse Utter is an employee of the hospital.
                                                           21
or omission by Nurse Utter which indicates that he breached the standard of care for a nurse

anesthetist in this situation.

        The trial court’s factual determination of Nurse Utter’s alleged breach is not supported by

the facts recited in Dr. Koumjian’s expert report. See Stockton, 336 S.W.3d at 615. Because

Dr. Koumjian’s expert report does not provide adequate information to inform Nurse Utter of the

specific conduct Maria has called into question, it fails to provide a basis for the trial court to

conclude that Maria’s claims against Nurse Utter have merit, and does not constitute an objective

good faith effort to comply with the statutory requirements of an expert report. See Van Ness, 461

S.W.3d at 141-42. We conclude the trial court abused its discretion when it overruled Appellants’

objections to Dr. Koumjian’s expert report regarding Nurse Utter’s alleged breach of the standard

of care. Issue Four is sustained.

        The Supreme Court has determined that when an appellate court reverses a trial court’s

denial of a motion to dismiss a health care liability claim due to omission of any of the statutory

expert report requirements, the appellate court may remand the case to the trial court to consider

granting a thirty-day extension to cure the deficiencies in the report. Leland v. Brandal, 257

S.W.3d 204, 207–08 (Tex. 2008); see also Lewis v. Funderburk, 253 S.W.3d 204, 208 (Tex.

2008)(stating that a deficient report may be cured by amending the report or by serving a new

report from a separate expert that cures the deficiencies in the previously filed report); Regent

Health Care Center of El Paso, L.P. v. Wallace, 271 S.W.3d 434, 441 (Tex.App.--El Paso 2008,

no pet.). The trial court is in the best position to decide whether a cure for an inadequate expert

report is feasible. See Samlowski v. Wooten, 332 S.W.3d 404, 411–12 (Tex. 2011). Based on

these decisions, it is appropriate to remand the case to the trial court for consideration of whether


                                                 22
the deficiencies in the expert reports can be cured, and therefore, whether to grant an extension of

time.

                                         CONCLUSION

        The trial court’s order is affirmed in part, and reversed and remanded in part to the trial

court for further proceedings.



August 24, 2016
                                              YVONNE T. RODRIGUEZ, Justice

Before McClure, C.J., Rodriguez, and Hughes, JJ.




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