                                  COURT OF APPEALS
                               EIGHTH DISTRICT OF TEXAS
                                    EL PASO, TEXAS

                                                 §
TENET HOSPITALS LIMITED, A                                          No. 08-13-00290-CV
TEXAS LIMITED PARTNERSHIP                        §
D/B/A PROVIDENCE MEMORIAL                                             Appeal from the
HOSPITAL,                                        §
                                                                    168th District Court
                              Appellant,         §
                                                                 of El Paso County, Texas
v.                                               §
                                                                  (TC# 2012-DCV-03529)
LUZ DE LA ROSA AND GILBERT                       §
DE LA ROSA,
                                                 §
                              Appellees.
                                                 §

                                           OPINION

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

See TEX.CIV.PRAC. & REM.CODE ANN. §74.001-.507 (West 2011 & Supp. 2015). Luz De La

Rosa and Gilbert De La Rosa (collectively referred to as the De La Rosas) brought a medical

malpractice action against several defendants, including Tenet Hospitals Limited, a Texas

Limited Partnership d/b/a Providence Memorial Hospital (Providence). The trial court denied

Tenet’s challenge to the expert reports served by De La Rosa. We affirm.

                                   FACTUAL SUMMARY

       The following facts are drawn from the De La Rosas’ pleadings and the expert reports.

On January 25, 2010, Luz De La Rosa was transported by ambulance to Providence Memorial
Hospital for severe back pain radiating down her right leg. David Gillett, M.D., an emergency

room physician, examined her and ordered laboratory studies, morphine for pain, and Levaquin.

No radiologic studies were ordered. Luz was admitted to the hospital under the care of Salvador

Molina, M.D., a hospitalist, and Mark Landeros, M.D., a surgeon who had recently performed

surgery on Luz for breast cancer. Dr. Molina examined Luz on January 26, 2010 and found that

she had what he described as “right flank and abdominal pain.” That same day, Dr. Landeros

ordered a CT scan of the abdomen and pelvis which showed bladder and bowel distention. At 9

p.m., a nurse noted that Luz had weakness in her lower extremities. This information was not

reported to any of her physicians.

       The following day Luz continued to have severe back pain. Around noon, a nurse

notified Dr. Molina that Luz was complaining of “numbness and tingling in her right leg.”

Dionicio Alvarez, M.D., a kidney specialist, examined her a short time later and noted that she

had weakness in her lower right leg. Dr. Landeros noted at 4:41 p.m. that he had been called

because Luz was complaining of “severe back pain” and “right leg numbness.” Dr. Landeros

observed that her pain was most likely related to nerve compression. At 5:35 p.m., Dr. Molina

ordered an MRI of the thoracic and lumbar spine with contrast, but he did not require that the

MRI be done immediately.

       The following morning, a nurse found that Luz could not move her legs. Dr. Landeros

examined her at 8:10 a.m. and found that she could not feel pain or move her legs. He wrote

orders to make the MRI “stat” and a neurologist was consulted. Even though Dr. Landeros

ordered that the MRI be performed stat, it was not begun until 11 a.m. and it was completed at

12:45 p.m. A radiologist interpreted the MRI at around 1:42 p.m. The MRI showed that a




                                             -2-
hematoma had caused spinal cord compression. Luz had surgery to remove the clot around 6:30

p.m. that same day, but sadly she is now a paraplegic.

       The De La Rosas filed suit against Providence Memorial Hospital, four of the treating

physicians, a physician assistant, and a hospitalist group. This appeal concerns only the suit

against Providence.    The De La Rosas’ original petition alleged the following theories of

liability: (1) Providence is vicariously liable for the nurse’s negligence in failing to inform Dr.

Molina, Dr. Landeros, and the physician assistant of leg weakness; (2) Providence is vicariously

liable for the nurse’s negligence in failing to expedite the stat MRI; (3) Providence was negligent

for failing to have policies and procedures that required the nurses to inform physicians and

physician assistants of significant changes in the patient’s condition; and (4) Providence was

negligent for failing to have policies and procedures for the expediting of emergency radiological

studies.

       The De La Rosas served the defendants with four expert reports and curriculum vitae of

Dr. Laurence Huffman, Dr. J. Martin Barrash, Michael Van Buren Calvin, PA-C, MPAS, and

Jodi C. Avalos, R.N., M.S.N. Providence objected to the reports on the grounds the experts were

not qualified, the reports did not reference any direct conduct of Providence, and the experts’

opinions on the vicarious liability claims were speculative and conclusory. The trial court

granted Providence’s objections, but it also permitted the De La Rosas to cure deficiencies in

their expert reports as to the vicarious liability claims addressed by Dr. Huffman, Dr. Barrash,

and Nurse Avalos.

       The De La Rosas amended their pleadings to remove their claims for direct liability

against Providence. In the Second Amended Original Petition, the De La Rosas alleged that

Providence is vicariously liable through respondeat superior for the nurses’ negligent failure to



                                               -3-
inform the patient’s physicians and physician assistant of her leg weakness and failure to

expedite the stat MRI. The De La Rosas submitted supplemental expert reports of Dr. Huffman,

Dr. Barrash, and Nurse Avalos. Providence again objected to the expert reports and moved to

dismiss the suit against it. The trial court denied the motion to dismiss.

                         ADEQUACY OF THE EXPERT REPORTS

       In its sole issue, Providence contends that the trial court abused its discretion by denying

the motion to dismiss because the experts are unqualified and their reports are insufficient, both

individually and in combination, with respect to the relevant standard of care, breach, and

causation.

                                        Standard of Review

       We review a trial court’s ruling on a motion to dismiss under Section 74.351 for an abuse

of discretion. Tenet Hospitals Ltd. v. Barnes, 329 S.W.3d 537, 540 (Tex.App.--El Paso 2010, no

pet.), citing American Transitional Care Centers of Texas, Inc.v. Palacios, 46 S.W.3d 873, 875

(Tex. 2001). An abuse of discretion occurs when the trial court rules in an unreasonable or

arbitrary manner without reference to any guiding rules or principles. Van Ness v. ETMC First

Physicians, 461 S.W.3d 140, 142 (Tex. 2015); Barnes, 329 S.W.3d at 540-41. When applying

the abuse of discretion standard, we are required to defer to the trial court’s factual

determinations if they are supported by the evidence, but we review the legal determinations de

novo. Van Ness, 461 S.W.3d at 142; Tenet Hospitals Limited v. Bernal, 482 S.W.3d 165, 169

(Tex.App.--El Paso 2015, no pet.).

                     Expert Report Requirements and the Standard of Review

       Section 74.351(a) requires a plaintiff asserting a health care liability claim to serve an

expert report for each physician or health care provider against whom a liability claim is



                                                -4-
asserted. TEX.CIV.PRAC. & REM.CODE ANN. §74.351(a). A valid expert report under the TMLA

must provide: (1) a fair summary of the applicable standards of care; (2) the manner in which the

physician or health care provider failed to meet those standards; and (3) the causal relationship

between that failure and the harm alleged. TEX.CIV.PRAC. & REM.CODE ANN. §74.351(r)(6)

(defining expert report as a written report by an expert that provides a fair summary of the

expert’s opinions as of the date of the report regarding applicable standards of care, the manner

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

and the causal relationship between that failure and the injury, harm, or damages claimed); TTHR

Ltd. Partnership v. Moreno, 401 S.W.3d 41, 44 (Tex. 2013); Bernal, 482 S.W.3d at 169. A

challenge to the sufficiency of the report must be sustained if it does not amount to an objective

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

§74.351(l).

       In considering this issue, we must bear in mind that an appellate court’s review of an

expert report is limited to the four-corners of the report. See Bowie Memorial Hospital v.

Wright, 79 S.W.3d 48, 52 (Tex. 2002); Barnes, 329 S.W.3d at 541. It is not necessary for an

expert report to include a full statement of the standard of care and how the standard of care was

breached, but it must explain what care was expected but not given. Barnes, 329 S.W.3d at 541.

An expert report must represent a good-faith effort to provide a fair summary of the expert’s

opinions. Id. A report is a good faith effort if it (1) provides adequate information to inform the

defendant of the specific conduct the plaintiff has called into question; (2) provides a basis for

the trial court to conclude that the claims have merit; and (3) does not contain a material

deficiency. Bernal, 482 S.W.3d at 169, citing Van Ness, 461 S.W.3d at 141-42.

                       Failure to Notify of Change in Patient’s Condition



                                               -5-
       We beginning by examining the experts’ reports as they apply to the claim based on the

nurses’ alleged failure to verbally notify the doctors and physician assistant that Luz was

experiencing lower extremity weakness. The expert reports of Dr. Huffman and Nurse Avalos

address this claim. Section 74.351(i) permits a claimant to utilize separate expert’s reports

regarding different issues, such as liability and causation, arising from the conduct of a health

care provider. TEX.CIV.PRAC. & REM.CODE ANN. §74.351(i); Iqbal v. Rash, 346 S.W.3d 827,

835 (Tex.App.--El Paso 2011, no pet.). In our review of the trial court’s ruling, we will read

multiple reports together to determine whether they adequately address the standard of care,

breach of the standard, or causation. Iqbal, 346 S.W.3d at 835; Barnes, 329 S.W.3d at 542.

                               1. The Nursing Standard of Care

       Providence first asserts that Dr. Huffman is not qualified by training or experience to

offer an expert opinion on nursing standards of care in a hospital inpatient setting. An expert

who gives opinion testimony regarding whether a health care provider departed from accepted

standards of health care must be qualified to testify under Section 74.402 of the Civil Practice

and Remedies Code. TEX.CIV.PRAC. & REM.CODE ANN. §74.351(r)(5)(B). To testify about the

accepted standards of care, a person must: (1) be practicing in a field of practice that involves the

same type of care or treatment as that delivered by the defendant health care provider; (2)

possess knowledge of accepted standards of care for the diagnosis, care, or treatment of the

illness, injury, or condition involved in the claim; and (3) be qualified on the basis of training or

experience to offer an expert opinion regarding those accepted standards of health care.

TEX.CIV.PRAC. & REM.CODE ANN. §74.402(b); Wissa v. Voosen, 243 S.W.3d 165, 170

(Tex.App.--San Antonio 2007, pet. denied).




                                                -6-
       Dr. Huffman is board certified in family practice, emergency medicine, and geriatric

medicine, and he also has a Masters degree in health care administration. His supplemental

expert report reflects that he taught nurses a course entitled “The Health Care System” at the

College of the Ozarks, and the course work included nursing standards of care. Dr. Huffman,

who began practicing medicine in 1973, has been caring for hospitalized patients for most of his

career and he interacts with nurses on a regular basis regarding the care of his patients. Dr.

Huffman states in his supplemental report that a physician relies on the nurses to keep him

informed of the hospitalized patient’s condition because the physician cannot be with the patient

the entire day, and nurses are expected to make a timely notification of a significant change in

the patient’s condition. His supplemental report specifically states that “[t]imely notification is

the standard of care.” Although a physician is not automatically qualified to offer an opinion on

the standard of care a nurse must follow, a physician can be qualified to offer an opinion on the

nursing standard of care if he is familiar with the nursing standard of care because he has taught

courses to nurses and he has worked with and interacted with nurses. See Baylor Medical Center

v. Wallace, 278 S.W.3d 552, 558 (Tex.App.--Dallas 2009, no pet.). This is especially true in this

case because the nursing standard of care directly involves the interaction between a nurse and

physician in the hospital inpatient setting and the communication expected by a physician from a

nurse regarding a hospitalized patient. A physician who regularly cares for hospitalized patients

can be expected to be familiar with this particular nursing standard of care We conclude that the

trial court did not abuse its discretion by finding Dr. Huffman qualified to offer an opinion on the

nursing standard of care because Dr. Huffman’s curriculum vitae, expert report, and

supplemental report demonstrate that he is familiar with the applicable nursing standard of care

in a hospital inpatient setting, he has taught courses to nurses, and he has worked with and



                                               -7-
interacted with nurses in the hospital inpatient setting. See Hall v. Huff, 957 S.W.2d 90, 100

(Tex.App.--Texarkana 1997, pet. denied)(physician was qualified to testify as expert about

nursing standards of care where he had taught nursing courses, including management of critical

care patients, and had testified about nursing standard).

       Even if we agreed with Providence and found Dr. Huffman unqualified to testify about

the nursing standard of care, Nurse Avalos addressed the standard of care in her expert report:

       The standard of care required that the nurse personally inform one of Mrs. De la
       Rosa’s physicians or the physician assistant of Mrs. De la Rosa’s lower extremity
       weakness as this weakness is an ominous sign in a patient like Mrs. De la Rosa
       with severe back pain. All nurses should understand that lower extremity
       weakness in a patient with back pain could be a sign of compression of a spinal
       nerve or of the spinal cord itself. The standard of care requires that the nurse
       speak with one of Mrs. De la Rosa’s physicians or the physician assistant shortly
       (sic) as soon as practical after the weakness is detected. Speaking as soon as
       practical after the weakness is detected is required to assure that the information is
       timely passed on and not lost as the nurse’s attention is focused on another
       problem. The standard of care requires that the nurse document that the physician
       or physician assistant was informed of Mrs. De la Rosa’s lower extremity
       weakness and the response. There is no documentation that the nurse who
       detected Mrs. De la Rosa’s lower extremity weakness informed anyone of his/her
       findings. Thus, the nurse who detected Mrs. De la Rosa’s lower extremity
       weakness breached the standards of care.

       Providence concedes in its brief that Nurse Avalos was qualified to offer an opinion on

the nursing standard of care, but it maintains that her report and Dr. Huffman’s report regarding

the standard of care are conclusory and speculative because they fail to distinguish between the

standard of care for a doctor, who is responsible for diagnosing a patient, with that of a nurse,

who has no statutory duty to engage in any acts of medical diagnosis. We disagree. The reports

clearly identify the standard of care as requiring a nurse to timely and personally notify the

physician or physician assistant of a significant change in the patient’s condition. In this regard,

the reports are neither conclusory nor speculative because they provide a fair summary of the

care that was expected but not given. See Barnes, 329 S.W.3d at 542-43 (expert reports of

                                                -8-
doctor and nurse adequately articulated standard of care where doctor’s report stated that

patient’s physician should have been notified immediately by nurse and efforts should have been

made to stabilize patient following angiogram, and nurse’s report stated that nurse should have

immediately notified physician of a significant change in patient’s condition where patient’s

blood pressure was low following angiogram).

                         2. Breach of the Nursing Standard of Care

       Providence next contends that the reports of Dr. Huffman and Nurse Avalos are

conclusory and speculative with respect to the nurses’ alleged breach of the standard of care.

Nurse Avalos’s supplemental report sets forth the facts on which she based her conclusion that

the nurses who noted Luz’s lower extremity weakness did not personally report it to the

physicians or physician assistant. She stated the following in Paragraphs H through K of her

supplemental report:

       H. In my review of Mrs. De La Rosa’s medical records for her admission to
       Providence Memorial Hospital on January 26, 2010, I could find no
       documentation that a physician was called about the lower extremity weakness
       noted by the nurse on January 26th, no documentation that a physician called
       back, no documentation of orders being given, no documentation of no orders
       being given and no documentation of additional attempts to contact a physician.
       I. Based on the total absence of any of the documentation described above in ¶¶B
       and C, I am certain that the nurse who found weakness in Mrs. De La Rosa’s
       lower extremities on January 26th, did not notify the physician as the standard of
       care required and thus, breached the standard of care.
       J. In my review of Mrs. De La Rosa’s medical records for her admission to
       Providence Memorial Hospital on January 26, 2010, I could find no
       documentation that a physician was called about her lower extremity weakness
       noted by the nurse on January 27th, no documentation that a physician called
       back, no documentation of orders being given, no documentation of no orders
       being given and no documentation of additional attempts to contact a physician.
       K. Based on the total absence of any of the documentation described above in ¶¶
       B and C, I am certain that the nurse who found weakness in Mrs. De La Rosa’s
       lower extremities on January 27th at 10:15 p.m., did not notify the physician as
       the standard of care required and thus, breached the standard of care.




                                               -9-
Nurse Avalos’s report is neither speculative nor conclusory as it pertains to the alleged breach of

the nursing standard of care. We conclude that the expert reports submitted by the De La Rosas

adequately addressed the breach of the nursing standard of care applicable to this claim because

they demonstrate the care that was expected but not given. See Barnes, 329 S.W.3d at 542-43.

                                               3. Causation

        The next issue is whether the expert reports sufficiently addressed causation. An expert

report cannot be conclusory and it must provide a fair summary of the causal relationship

between the failure of a health care provider to meet the standards of care and the injury, harm,

or damages claimed. Estorque v. Schafer, 302 S.W.3d 19, 27 (Tex.App.--Fort Worth 2009, no

pet.). The report must explain the basis of the expert’s statements regarding causation and link

the expert’s conclusions to the facts. Tenet Hospitals Ltd. v. De La Riva, 351 S.W.3d 398, 403

(Tex.App.--El Paso 2011, no pet.); Estorque, 302 S.W.3d at 27-28. A causal relationship is

established by proof that the negligent act or omission was a substantial factor in bringing about

the harm and that absent said act or omission, the harm would not have occurred. De La Riva,

351 S.W.3d at 403; Barnes, 329 S.W.3d at 543. There can be no analytical gap between a breach

of the standard of care and the ultimate harm. Barnes, 329 S.W.3d at 543. An appellate court is

not permitted to fill in gaps in a report by drawing inferences or guessing what the expert meant

or intended. De La Riva, 351 S.W.3d at 404.

        Dr. J. Martin Barrash, a board certified neurosurgeon, addressed causation in his original

and supplemental reports.1 In his original report, Dr. Barrash stated that it was his opinion, based

on reasonable medical certainty, that if an MRI had been taken of the patient’s spine during the

emergency room visit and examination, a spinal cord hematoma would have been detected early


1
   It is unnecessary to address Providence’s argument that Dr. Huffman was unqualified to offer an opinion on
causation.

                                                   - 10 -
and she would have made a complete recovery, suffering no permanent injury to her spinal cord

with timely surgery. He explained that once spinal cord compression begins to cause symptoms,

the damage usually progresses from reversible to minimal to substantial. Dr. Barrash stated in

his supplemental report that the nurses’ failure to personally notify one of the physicians or

physician assistant of lower extremity weakness on January 26, 2010, and then again on January

27, 2010, caused a delay in the diagnosis of the spinal cord compression. In his opinion, Luz

would not have become paraplegic if an MRI had been performed on January 26 or 27 because

the hematoma would have been discovered and surgery could have been performed to remove

the hematoma causing pressure on the spinal cord. Dr. Barrash opined that lower extremity

weakness in a patient like Ms. De La Rosa is an ominous sign which requires that an MRI be

performed within “a very few hours.”

       Providence argues that Dr. Barrash’s report “is speculative because it improperly

presupposes that a phone call from the nurses about leg weakness would have caused the

physicians to immediately reach a correct diagnosis and to then successfully treat Mrs. De La

Rosa.” It also asserts that Dr. Barrash’s opinion that the nurses caused a substantial delay in

diagnosis is not supported by an adequate link to the facts. We disagree. Dr. Barrash’s opinion

on causation must be considered in light of his opinion that the physicians were required by the

applicable standard of care to order an MRI upon learning that Luz had developed lower

extremity weakness. The nurses observed that she had lower extremity weakness on January 26

and January 27, but they did not personally inform any of her doctors or the physician assistant

of this significant finding. Dr. Barrash concluded after reviewing the medical records that none

of the physicians were aware that the patient had been experiencing lower extremity weakness

until January 28 when she developed paraplegia. Dr. Barrash’s conclusion that the nurses’



                                             - 11 -
failure to inform the physicians of the lower extremity weakness caused a delay in ordering an

MRI is adequately linked to the facts. We conclude that Dr. Barrash’s expert report is sufficient

as it pertains to the element of causation on this claim. See Barnes, 329 S.W.3d at 543-44

(expert report supplied requisite causal relationship between the breach -- failure to notify the

patient’s physician -- and the patient’s death).

                                  Failure to Expedite the Stat MRI

          Providence also challenges the sufficiency of the expert reports on the De La Rosas’

claim based on the nurses’ failure to expedite the stat MRI.

                          1. The Nursing Standard of Care and Breach

          Nurse Avalos’s original and supplemental reports address the nursing standard of care as

it applies to the claim based on the nurses’ alleged failure to expedite the stat MRI. In paragraph

6 of her original report, Nurse Avalos stated that the patient’s development of paraplegia was an

emergency situation and there should have been no delay in obtaining the MRI of her spine. The

standard of care required that the nursing staff make every effort to obtain the MRI stat, and this

effort would include speaking with radiology and explaining the emergency. If radiology was

unwilling or unable to receive the patient on a stat basis, the standard of care would have been

for the nursing staff to inform Dr. Landeros so that he could intervene. Based on the absence of

any documentation of any effort made by the nursing staff to send Luz to radiology as a stat

patient, Nurse Avalos concluded that the nursing staff breached this standard of care. Nurse

Avalos’s expert report is sufficient with regard to the standard of care and breach of the standard.

See Barnes, 329 S.W.3d at 542-43. Because Nurse Avalos’s report is sufficient, it is unnecessary

to address the sufficiency of Dr. Barrash’s expert report as it pertains to the standard of care and

breach.



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                                          2. Causation

        In his supplemental report, Dr. Barrash stated that the failure to obtain a timely MRI and

timely perform surgery was the cause of the patient’s paraplegia. He added that:

        The delay (failure) to obtain the stat MRI on January 28th, after Mrs. De La Rosa
        was found to have no movement in her lower extremities, was unconscionable as
        every effort should have been made by her physicians and nurses to get her
        immediately to radiology. At that point, time was of the essence. In my opinion
        the physicians and nurses were equally responsible for the delay, as it seems no
        one was making any effort to expedite the process.

Providence maintains that Dr. Barrash fails to explain how the hospital staff delayed the MRI or

what they could have done to expedite it. This complaint goes to the standard of care and its

breach rather than causation. While Nurse Avalos cannot offer an opinion on causation, her

report related to the standard of care and breach sets forth the pertinent facts. As already noted,

Nurse Avalos described what the nurses should have done, but failed to do, to expedite the MRI.

Dr. Barrash’s report indicates that the hospital staff did nothing to expedite the MRI, and the

delay in obtaining the MRI caused permanent spinal injury. Dr. Barrash’s opinion on causation,

as set forth in his original and supplemental reports, is an adequate preliminary report because it

describes the causal relationship between the breach -- failure to expedite the stat MRI -- and the

patient’s paraplegia. See Barnes, 329 S.W.3d at 543-44. Because the trial court did not abuse its

discretion by denying Providence’s motion to dismiss, we overrule the sole issue presented and

affirm the trial court’s order.


                                             ANN CRAWFORD McCLURE, Chief Justice
June 8, 2016

Before McClure, C.J., Rodriguez, J., and Chew, C.J. (Senior Judge)
Chew, C.J. (Senior Judge), sitting by assignment, not participating




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