            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



LEONARD T. GLINSKI and BARBARA                                     UNPUBLISHED
GLINSKI,                                                           April 30, 2019

              Plaintiffs-Appellants,

v                                                                  No. 342046
                                                                   Oakland Circuit Court
CARDIOVASCULAR CLINICAL                                            LC No. 2016-154440-NH
ASSOCIATES, PC and MARK A. RASAK, D.O.,

              Defendants-Appellees.


Before: TUKEL, P.J., and SHAPIRO and GADOLA, JJ.

PER CURIAM.

       Plaintiffs, Leonard T. and Barbara Glinski, appeal as of right the trial court’s order
granting summary disposition in favor of defendants, Cardiovascular Clinical Associates, PC and
Mark A. Rasak, D.O., pursuant to MCR 2.116(C)(10). We affirm.

                                           I. FACTS

        This case arose from allegations of medical malpractice after plaintiff, Dr. Leonard
Glinski, suffered a stroke on February 26, 2015. Dr. Glinski has a history of cardiac problems.
In 1989, he had a heart attack and was treated at Garden City Hospital. Years later, on January
21, 2000, Glinksi was first treated by Dr. Rasak, a cardiologist working with Cardiovascular
Clinical Associates, PC, who implanted an arterial stent. On May 7, 2009, Glinski experienced a
transient ischemic attack (TIA) and was treated at Botsford Hospital. He was prescribed Plavix,
an antiplatelet medication, and was again referred to Rasak, who placed another arterial stent on
June 2, 2009.




                                               -1-
        In 2012, Glinski underwent an electrophysiology (EP) test to investigate whether he was
experiencing atrial fibrillation (AFib).1 The EP test produced an occurrence of AFib, and as a
result Rasak prescribed Glinski an anticoagulant medication while he underwent additional tests.
According to Rasak, however, Glinski strongly objected to the anticoagulant because it was
expensive and was, in Glinski’s opinion, “rat poison.” Glinski took the anticoagulant for three to
four months while undergoing further testing. Rasak determined that Glinski was having no
additional occurrences of AFib. Rasak testified that based on the non-recurrence of the AFib,
and taking into consideration Glinski’s strong objection to the medication, Rasak stopped the
anticoagulant and instead prescribed antiplatelet therapy. Rasak testified that he was not
concerned about Glinski discontinuing the anticoagulant because the AFib had been an isolated
episode, and that antiplatelet medication therefore was the optimal therapy.

       On January 4, 2014, Glinski had a second TIA, and was treated at Garden City Hospital.
Neurologist Anne Pawlak diagnosed plaintiff with vascular disease. In consultation with Rasak,
Pawlak prescribed Aggrenox, another antiplatelet medication. On August 14, 2014, Rasak had
Glinski undergo a “stress echo” test, which revealed no evidence of AFib.

         Glinski saw Rasak on December 17, 2014, complaining of chest discomfort. Rasak
testified that he recommended that Glinski undergo tests to verify that the existing medication
was working to prevent exercise-induced AFib. According to Rasak, Glinski told him that he
was leaving for Florida and would do the tests when he returned. After the December 17, 2014
appointment, Rasak stated in a letter to Glinski’s physician as follows:

       Assessment: Abnormal EKG, bruit, chest pain, other inferior wall/unspecified,
       ischemic heart disease, mixed hyperlipidemia, PVD, dizziness or lightheadedness,
       chest discomfort, pressure or tightness, obesity, dyspnea, palpitations, s/p PTCA,
       atherosclerotic heart disease, atrial fibrillation, paroxysmal[2], dyslipidemia, and
       hypertension.

       Plan: Medications reviewed-patient brought a list. Aggressive risk factor
       modification, as always, has been strongly reinforced including careful control of
       cholesterol, blood pressure and diet activity level. We should follow NCEP
       guidelines regarding the patient’s cholesterol. The patient should be on a low
       cholesterol, low sodium diet. Continue current cardiac medical regimen. Weight
       loss through diet and exercise.                  Bilateral Carotid Dopplers-
       lightheaded/dizzy/bruit, stress echocardiogram-chest pain/shortness of



1
  Atrial fibrillation is described as an irregular heartbeat that can increase the risk of stroke, heart
failure, and other heart-related health problems. See Mayo Clinic, Atrial fibrillation
<https://www.mayoclinic.org/disease-conditions/atrial-fibrillation/symptoms-causes/syc-
20350624> (accessed March 29, 2019).
2
   Paroxysm is a fit, attack, or sudden increase                    or   recurrence    of   symptoms.
<https://www.merriam-webster.com/dictionary/paroxysm>.


                                                  -2-
       breath/coronary artery disease, and current cardiac medications for now. May
       change pending the cardiac testing. (Emphasis added).

        On January 30, 2015, while in Florida, Glinski discovered hematuria (blood in the urine),
and contacted his urologist, Dr. Mark Arnkoff. Arnkoff advised Glinski to stop taking his
antiplatelet medication and to return to Michigan for surgical procedures. The parties do not
dispute that Arnkoff did not consult Rasak about discontinuing the antiplatelet medication, nor
did he inform Rasak about the hematuria or the planned surgeries.3 Glinski returned to Michigan
and Arnkoff performed a cauterization procedure on February 5, 2015. Afterwards, Arnkoff
recommended a second procedure known as transurethral resection of the prostate (TURP) to be
performed two weeks later. Arnkoff instructed Glinski not to resume his antiplatelet medication
until after the procedure. The TURP was performed on February 19, 2015, and on February 23,
2015, Arnkoff informed Glinski that he could resume taking his antiplatelet medication. On
February 26, 2015, Glinski suffered a stroke, resulting in ongoing impairments.

         Plaintiffs brought this action, contending that Glinski’s stroke and resulting impairments
were caused by Rasak’s failure to prescribe anticoagulation therapy for Glinski in 2014. During
discovery, the parties deposed Dr. Daniel Wohlgelernter, a cardiologist who testified as an expert
witness on behalf of plaintiffs. He testified that his opinion, as stated in the Affidavit of Merit,
was that because Glinski had a history of AFib and TIAs, together with his age and health
factors, he should have been prescribed anticoagulants in December 2014 to prevent a stroke.
Wohlgelernter further testified that despite what Glinski’s neurologist told Rasak after Glinski’s
TIA in 2014, Rasak should have made certain that Glinski was not experiencing AFib along with
the vascular disease diagnosed by the neurologist because Glinski had a history of paroxysmal
atrial fibrillation. Wohlgelernter conceded, however, that the only verified incident of AFib that
Glinski had ever experienced was in 2012 during the EP test.

       Wohlgelernter testified that if Glinski had been prescribed anticoagulants, he would have
needed to discontinue the medication after developing gross hematuria. He further testified,
however, that the need to discontinue the anticoagulants would have caused Arnkoff to consult
with Rasak to assess the risk involved. Wohlgelernter opined that, despite the hematuria
developed by Glinski in January 2015, it was likely that anticoagulation medication prescribed in
December 2014 would have minimized the risk of stroke from AFib.

         Dr. Louis Cannon, a cardiologist who was deposed by the parties as an expert witness on
behalf of defendants, testified that when Rasak saw Glinski in December 2014, there was no
evidence that Glinski had AFib and thus, Rasak had no reason to prescribe anticoagulants.
Cannon testified that he, like Rasak, would have trusted the neurologist with Glinski’s diagnosis
and treatment of vascular disease after the January 2014 TIA. Cannon noted that Rasak ordered
a “stress echo” test on August 14, 2014, which revealed no evidence of AFib. Cannon further
testified that it is possible for an individual to have both vascular disease and AFib at the same
time, and that either can cause a TIA. Cannon testified that in such a situation, he would be


3
  Plaintiff Barbara Glinski testified that after Glinski developed hematuria while in Florida, he
called Rasak and left a message. She did not know whether he eventually spoke with Rasak.


                                                -3-
reluctant to put a patient on both antiplatelet and anticoagulation drugs because of the high risk
of hemorrhage. He noted that Rasak ordered a second stress echo after Glinski’s visit in
December, which Cannon testified was reasonable given Glinski’s continued complaints of chest
pain despite the normal results of the first stress echo. Glinski, however, did not complete the
ordered test.

       According to Cannon, it was appropriate to take Glinski off of his antiplatelet medication
when he developed hematuria in January 2015, and it would have been appropriate at that time to
stop anticoagulant medication had it been prescribed. Both medications have blood-thinning
properties and should not be taken by individuals experiencing bleeding. Cannon testified that
because of the more serious nature of anticoagulants, however, it would have been appropriate to
“bridge” anticoagulant medication had Glinski been taking it, to avoid the risk of stroke.
However, Cannon did not believe that it would have been appropriate for Rasak to prescribe
Glinski anticoagulants based upon the information available in December 2014.

        Dr. Richard C. Davi, a urologist testifying on behalf of plaintiffs, testified that on
occasion he oversees surgical or other procedures that conflict with anticoagulant or antiplatelet
therapy. Davi testified that it would be inappropriate for a urologist to instruct someone with
hematuria to discontinue their anticoagulant or antiplatelet treatment without contacting the
prescribing physician because the treatments are outside the realm of a urologist’s practice.
However, while most urologists would not unilaterally discontinue antiplatelet therapy, a
urologist absolutely would not discontinue a patient’s anticoagulant medication without
contacting the prescribing physician. Davi belived that if Glinski had been prescribed
anticoagulants, Arnkoff would not have discontinued the medication without speaking with
Rasak.

        Dr. Frank Moser specializes in neuroradiology, and testified that, due to the blood
thinning properties of anticoagulants and antiplatelet treatments, he would ordinarily instruct
patients to discontinue use of the treatments if he were going to perform any type of invasive
procedure. With anticoagulants, Moser generally bridges the treatments by putting the patients
on Heparin until six hours before the procedure. Moser would then start the patients back on
Heparin a few hours after the procedure before transitioning them back to the long-acting
anticoagulant. Moser testified that he will stop the antiplatelet treatment unilaterally without
contacting the prescribing physician. Moser opined that Glinski’s stroke was “almost certainly”
the result of AFib.

        Defendants moved for summary disposition pursuant to MCR 2.116(C)(10), contending
that plaintiffs had failed to establish causation between Glinski’s injuries and any actions taken
or not taken by defendants. The trial court granted defendants’ motion, concluding that although
a genuine issue of material fact existed as to whether Rasak breached the standard of care by not
treating Glinski with anticoagulant medication in 2014, plaintiffs had failed to establish
proximate cause, specifically, that the failure to prescribe anticoagulants was a but-for cause of
the stroke. The trial court further found that even if causation had been established, Glinski’s
hematuria, which would have caused a “mandatory cessation of hypothetical anti-coagulation
therapy,” was an unforeseeable intervening cause. Plaintiffs now appeal to this Court.

                                       II. DISCUSSION

                                               -4-
                                  A. STANDARD OF REVIEW

        We review de novo a trial court’s order granting summary disposition. Graham v Foster,
500 Mich 23, 28; 893 NW2d 319 (2017). When reviewing an order granting summary
disposition under MCR 2.116(C)(10), this Court considers all documentary evidence submitted
by the parties in the light most favorable to the nonmoving party. Dawoud v State Farm Mut
Auto Ins Co, 317 Mich App 517, 520; 895 NW2d 188 (2016). Summary disposition under MCR
2.116(C)(10) is warranted when there is no genuine issue as to any material fact and the moving
party is entitled to judgment as a matter of law. Id. When a motion is made and supported under
MCR 2.116(C)(10), the burden shifts to the nonmoving party to show, by affidavits or other
documentary evidence, that there is a genuine issue of material fact. MCR 2.116(G)(4); Quinto v
Cross & Peters Co, 451 Mich 358, 362; 547 NW2d 314 (1996). If the nonmoving party does not
make such a showing, summary disposition is properly granted. Id. at 363.

                                         B. CAUSATION

       The trial court concluded that plaintiffs failed to create a genuine issue of material fact
that Rasak’s actions proximately caused Glinski’s stroke.4 We agree.

        A medical malpractice claim is one that arises during the course of a professional medical
relationship and hinges upon a question of medical judgment. Lockwood v Mobile Med
Response, Inc, 293 Mich App 17, 23; 809 NW2d 403 (2011). To establish medical malpractice,
the plaintiff bears the burden of proving “(1) the applicable standard of care, (2) a breach of that
standard by the defendant, (3) an injury, and (4) proximate causation between the alleged breach
of duty and the injury.” Rock v Crocker, 499 Mich 247, 255; 884 NW2d 227 (2016). Thus, a
plaintiff must not only demonstrate that a defendant breached the applicable standard of care, the
plaintiff must also demonstrate proximate causation of the plaintiff’s alleged injuries from that
breach. See id. at 255.

        “ ‘Proximate cause’ is a legal term of art that incorporates both cause in fact and legal (or
‘proximate’) cause.” Craig v Oakwood Hosp, 471 Mich 67, 86; 684 NW2d 296 (2004). A court
is required to first determine whether a defendant’s negligence was a cause in fact of the
plaintiff’s injuries before determining whether the defendant’s negligence was the legal cause of
those injuries. Ray v Swagger, 501 Mich 52, 64; 903 NW2d 366 (2017). To establish cause in
fact, the plaintiff must present substantial evidence from which the jury could conclude that, but
for the defendant’s conduct, the plaintiff’s injuries would not have occurred. Weymers v Khera,
454 Mich 639, 647; 563 NW2d 647 (1997). A plaintiff establishes cause in fact sufficient to
create a genuine issue of material fact if the plaintiff establishes “a logical sequence of cause and
effect, notwithstanding the existence of other plausible theories, although other plausible theories
may also have evidentiary support.” In a medical malpractice action, expert testimony is
required to prove causation, as well as standard of care. Kalaj v Khan, 295 Mich App 420, 429;


4
  The trial court concluded that there was a genuine issue of material fact that Rasak breached the
standard of care by not treating Glinski with anticoagulant medication in December 2014.
Because this finding is not challenged on appeal, we decline to address it.


                                                -5-
820 NW2d 223 (2012). However, the deposition testimony of an expert witness must still be
read fairly and in context. See Mate v Wolverine Mut Ins Co, 233 Mich App 14, 21; 592 NW2d
379 (1999) (deposition testimony read in context did not raise a genuine issue of material fact).
Patrick v Turkelson, 322 Mich App 595, 617; 913 NW2d 369 (2018) (quotation marks and
citation omitted). “Circumstantial evidence can be sufficient to establish a genuine issue of
material fact, but mere conjecture or speculation is insufficient.” McNeill-Marks v MidMichigan
Med Ctr-Gratiot, 316 Mich App 1, 16; 891 NW2d 528 (2016).

        In this case, plaintiffs’ evidence of causation is based entirely on speculation. Plaintiffs’
theory is that if Rasak had prescribed anticoagulants in 2014, Glinski likely would still have
experienced hematuria, and likely would have consulted a urologist, but the urologist likely
would have consulted Rasak before discontinuing the anticoagulants, which likely would have
led to Rasak prescribing a bridging anticoagulant during the surgical procedures, and then
Glinski likely would have resumed the anticoagulant after the surgeries, and the anticoagulant
likely would have prevented the stroke. This is a lengthy chain of causation, to say the least, and
appears to involve more than a fair amount of speculation that each of these events would have
occurred in the order listed.

        Indeed, a review of the record indicates that the evidence does not support that scenario.
Based on the evidence in the record that Glinski was strongly opposed to taking an anticoagulant,
had Rasak prescribed an anticoagulant in 2014 without further evidence of AFib, it is by no
means certain that Glinski would have consented to taking the medication. This is supported by
the fact that when in December 2014 Rasak proposed further cardiac testing to determine if
different medication was necessary, Glinski declined to undergo the tests at that time. Similarly,
as the trial court noted, plaintiffs did not provide evidence that Arnkoff would have contacted
Rasak about discontinuing Glinski’s anticoagulation medication had Glinski been prescribed the
same, only that it was likely that a urologist in that circumstance would do so. Davi, plaintiffs’
expert urology witness, testified that a urologist should contact the cardiologist when
discontinuing antiplatelet or anticoagulation medication. Because Arnkoff did not follow the
expected protocol in discontinuing the antiplatelet medication in this case, it is not supported that
he would have followed established protocol in plaintiffs’ theoretical scenario.5 Compounding
this speculation is the further speculation that the anticoagulant would have been bridged
successfully during the surgeries, that Glinski would have agreed to the eventual resumption of
anticoagulants, and that the anticoagulants would have successfully averted the stroke.




5
  It is remarkable to say the least that Arnkoff failed to consult with Rasak before performing two
surgical procedures on Glinski, despite Glinski’s lengthy and complex cardiac history. This fact
alone does not inspire confidence that he would have consulted with Rasak under different
conditions, and it is speculative at best to say that he would have done so. Arnkoff did not
advise Rasak he was performing not one but two surgeries on Rasak’s patient, but Rasak is now
held to account for the unfortunate outcome in this case. There would appear to be something
wrong with that picture.


                                                -6-
        A plaintiff must prove that the defendant’s act or omission was a cause of his injuries.
Craig, 471 Mich at 87. “Mere speculation or conjecture is insufficient to establish reasonable
inferences of causation.” Sniecinski v Blue Cross & Blue Shield of Mich, 469 Mich 124, 140;
666 NW2d 186 (2003). It is not enough that a plaintiff demonstrate a mere possibility of
causation, and an expert opinion regarding causation that is based only upon a hypothetical
situation is not enough to demonstrate a valid causal connection between the alleged actions and
the injury. Teal v Prasad, 283 Mich App 384, 394-395; 772 NW2d 57 (2009). In sum, “litigants
do not have any right to submit an evidentiary record to the jury that would allow the jury to do
nothing more than guess.” Skinner v Square D Co, 445 Mich 153, 174; 516 NW2d 475 (1994),
overruled in part on other grounds Smith v Globe Life Ins Co, 460 Mich 446, 455 n 2; 597 NW2d
28 (1999). Based on a review of the record, we conclude that the trial court correctly determined
that defendants were entitled to summary disposition of plaintiffs’ claim.

       Affirmed.



                                                           /s/ Jonathan Tukel
                                                           /s/ Douglas B. Shapiro
                                                           /s/ Michael F. Gadola




                                               -7-
