                         COURT OF APPEALS
                          SECOND DISTRICT OF TEXAS
                                FORT WORTH


                               NO. 2-07-353-CV


MALCOLM BARBER AND LEANN                                            APPELLANTS
BARBER

                                        V.

WILLIAM F. DEAN, M.D., MIKKO                                          APPELLEES
PETER TAURIAINEN, M.D., AND
CARDIOVASCULAR AND
THORACIC SURGICAL GROUP
OF WICHITA FALLS, P.A.

                                    ------------

         FROM THE 30TH DISTRICT COURT OF WICHITA COUNTY

                                    ------------

                                   OPINION

                                    ------------

                                 I. INTRODUCTION

      In three issues, appellants Malcolm Barber and Leann Barber appeal the

trial court’s order dismissing their health care liability claims against Appellees

William F. Dean, M.D., Mikko Peter Tauriainen, M.D., and Cardiovascular and
Thoracic Surgical Group of Wichita Falls, P.A. (“CTSG”). See Tex. Civ. Prac.

& Rem. Code Ann. § 74.351(b) (Vernon Supp. 2009). We will affirm in part

and reverse and remand in part.

                   II. F ACTUAL AND P ROCEDURAL B ACKGROUND

      According to Appellants’ original petition and the expert report of Jeffrey

Alan Wagner, M.D., M.B.A., in January 2004, Malcolm underwent a multivessel

coronary artery bypass graft procedure involving the harvesting of his left radial

artery, left saphenous vein, and left internal mammary artery. The surgery

lasted over six hours.    A “three team approach” was utilized during the

harvesting procedure, and all three harvests were performed simultaneously.

Dr. Tauriainen performed the harvest of the left internal mammary artery; Leo

Mercer, M.D. performed the harvest of the left saphenous vein; and Shellie

Barnett-Wright, PA-C performed the harvest of the left radial artery from

Malcolm’s left forearm. Dr. Dean, who was present in the operating room for

a portion of Malcolm’s surgical procedure, provided “medical/surgical” services

to Malcolm. Following the harvesting, Malcolm’s left arm was “tucked” by

anesthesiologist Robert Moss, M.D., assisted by a couple of nurses.

      Following the bypass graft procedure, Malcolm experienced difficulties

with his left hand and arm, including pain, burning, numbness, inability to grip,

stiffness, stinging, swelling, and weakness.     He attempted to relieve these

                                        2
difficulties through medical management and occupational therapy, but the

treatments proved to be unsuccessful.        An orthopedic surgeon diagnosed

Malcolm with a left ulnar nerve lesion and ulnar cubital syndrome and

recommended surgery to treat the conditions.           Surgery to relieve these

conditions was unsuccessful, and Malcolm continues to experience pain,

weakness, grip difficulties, and other problems with his left arm and hand.

      Appellants sued Appellees and others 1 alleging, among other things, that

Malcolm’s postsurgical problems were caused by Appellees’ negligence in

failing to provide medical or surgical care regarding Malcolm’s left upper

extremity condition during and after the surgical procedures. Throughout his

report, Dr. Wagner characterizes Appellees’ conduct as a failure to provide for

the proper positioning and padding of Malcolm’s arms and body to prevent

perioperative peripheral neuropathies.      Appellants alleged both direct and

vicarious theories of liability against CTSG. They tendered Dr. Wagner’s expert

report within 120 days of suit.



      1
        … The other defendants included Dr. Mercer; Barnett-Wright; Dr. Moss,
who placed Malcolm under general anesthesia for the procedure; and United
Regional Health Care System, Inc., the hospital at which the surgery occurred.
Dr. Mercer was the appellee in a separate appeal in which Appellants challenged
the trial court’s dismissal of their claim against Dr. Mercer for failure to comply
with the civil practice and remedies code expert report requirements. See
Barber v. Mercer, No. 02-08-00079-CV, 2009 WL 3337192 (Tex. App.—Fort
Worth Oct. 15, 2009, no pet. h.).

                                        3
      Dr. Dean timely filed his objections to Dr. Wagner’s report on the

following grounds:

      (1) Dr. Wagner is not qualified to render an opinion about the
      accepted and applicable standard of care relevant to Appellants’
      claim; and

      (2) the report fails to sufficiently set forth (i) the applicable
      standard of care and (ii) how Dr. Dean failed to meet that standard
      of care.

Dr. Tauriainen timely filed his objection to Dr. Wagner’s report on the ground

that Dr. Wagner, an anesthesiologist, is not qualified to render an opinion about

the standard of care applicable to a cardiovascular and thoracic surgeon. CTSG

timely filed its objections to Dr. Wagner’s report on the following grounds:

      (1) Dr. Wagner is not qualified to render an opinion as to whether
      CTSG breached any applicable standard of care; and

      (2) the report is insufficient to set forth (i) the applicable standard
      of care, (ii) how CTSG breached the standard of care, and (iii) how
      CTSG’s alleged negligence caused Malcolm’s alleged injuries.

      Appellees also filed civil practice and remedies code section 74.351(b)

motions to dismiss. After a hearing on Appellees’ objections to Dr. Wagner’s

report and motions to dismiss, the trial court sustained Appellees’ objections

and dismissed Appellants’ claims against Appellees with prejudice.2



      2
       … The trial court also denied Appellants’ request for a thirty-day grace
period to provide an amended expert report as to Appellees, but Appellants
have not appealed that portion of the trial court’s order.

                                        4
                            III. S TANDARD OF R EVIEW

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

liability claim for an abuse of discretion. 3 Jernigan v. Langley, 195 S.W.3d 91,

93 (Tex. 2006). A trial court abuses its discretion if it acts in an arbitrary or

unreasonable manner or if it acts without reference to any guiding rules or

principles.   Bowie Mem'l Hosp. v. Wright, 79 S.W.3d 48, 52 (Tex. 2002)

(citing Downer v. Aquamarine Operators, Inc., 701 S.W.2d 238, 241–42 (Tex.

1985), cert. denied, 476 U.S. 1159 (1986)).         We may not substitute our

judgment for the trial court’s judgment. Id. Nor can we determine that the trial

court abused its discretion merely because we would have decided the matter

differently. Downer, 701 S.W.2d at 242.

                IV. E XPERT R EPORT R EQUIREMENTS AND S TANDARDS

      Civil practice and remedies code section 74.351 provides that, within 120

days of filing suit, a plaintiff must serve expert reports for each physician or

health care provider against whom a liability claim is asserted. Tex. Civ. Prac.




      3
       … In their first issue in this appeal, Appellants ask this court to conclude
that abuse of discretion continues to be the proper standard of review following
the recodification of the Texas Medical Liability Act in 2003. Appellees agree
that the standard of review is abuse of discretion. In the absence of supreme
court authority instructing otherwise, we have continued to apply the abuse of
discretion standard and do so here. See, e.g., Maris v. Hendricks, 262 S.W.3d
379, 383 (Tex. App.—Fort Worth 2008, pet. denied).

                                        5
& Rem. Code Ann. § 74.351(a). An expert report is a written report by an

expert that provides a fair summary of the expert’s opinions regarding the

applicable standard of care, the manner in which the care rendered by the

physician or health care provider failed to meet the standard, and the causal

relationship between that failure and the injury, harm, or damages claimed. Id.

§ 74.351(r)(6). If a claimant timely furnishes an expert report, a defendant may

file a motion challenging the report’s adequacy. See id. § 74.351(a), (c), (l).

A trial court must grant a motion to dismiss based on the alleged inadequacy

of an expert report only if it finds, after a hearing, “that the report does not

represent an objective good faith effort to comply with the definition of an

expert report” in the statute. Id. § 74.351(l).

      The information in the report does not have to meet the same

requirements as evidence offered in a summary judgment proceeding or at trial,

and the report need not marshal all the plaintiff’s proof, but it must include the

expert’s opinions on each of the elements identified in the statute—standard of

care, breach, and causation.     Am. Transitional Care Ctrs. of Tex., Inc. v.

Palacios, 46 S.W.3d 873, 878–79 (Tex. 2001); Thomas v. Alford, 230 S.W.3d

853, 856 (Tex. App.—Houston [14th Dist.] 2007, no pet.). In detailing these

elements, the supreme court has made clear that an expert report must provide

enough information to fulfill two purposes if it is to constitute a good faith

                                        6
effort: the report must (1) inform the defendant of the specific conduct the

plaintiff has called into question and (2) provide a basis for the trial court to

conclude that the plaintiff’s claims have merit. Palacios, 46 S.W.3d at 879;

Gray v. CHCA Bayshore L.P., 189 S.W.3d 855, 859 (Tex. App.—Houston [1st

Dist.] 2006, no pet.). A report does not fulfill these two purposes if it merely

states the expert’s conclusions or if it omits any of the statutory requirements.

Palacios, 46 S.W.3d at 879. In assessing the report’s sufficiency, the trial

court may not draw any inferences; it must rely exclusively on the information

contained within the report’s four corners. Bowie Mem’l Hosp., 79 S.W.3d at

52; Palacios, 46 S.W.3d at 878.

      Regarding qualifications, the civil practice and remedies code provides in

relevant part that “expert” means the following:

      (A)   with respect to a person giving opinion testimony regarding
            whether a physician departed from accepted standards of
            medical care, an expert qualified to testify under the
            requirements of Section 74.401;

      (B)   with respect to a person giving opinion testimony regarding
            whether a health care provider departed from accepted
            standards of health care, an expert qualified to testify under
            the requirements of Section 74.402; [and]

      (C)   with respect to a person giving opinion testimony about the
            causal relationship between the injury, harm, or damages
            claimed and the alleged departure from the applicable
            standard of care in any health care liability claim, a physician



                                        7
            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)(A)–(C).

      Under section 74.401, a person may qualify as an expert witness on the

issue of whether a 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.

Id. § 74.401(a) (Vernon 2005). In determining whether a witness is qualified

on the basis of training or experience under section 74.401(a)(3), 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. Id. § 74.401(c).




                                        8
      Under section 74.402, a person may qualify as an expert witness on the

issue of whether a 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.

Id. § 74.402(b) (Vernon 2005). In determining whether a witness is qualified

on the basis of training or experience under section 74.402(b)(3), 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 related

services relevant to the claim. Id. § 74.402(c).

      Under rule of evidence 702, “[w]hat is required is that the offering party

establish that the expert has ‘knowledge, skill, experience, training, or



                                        9
education’ regarding the specific issue before the court which would qualify the

expert to give an opinion on that particular subject.” Broders v. Heise, 924

S.W.2d 148, 153 (Tex. 1996); see also Tex. Civ. Prac. & Rem. Code Ann.

§ 74.403 (Vernon 2005).

                       V. D R. W AGNER’S Q UALIFICATIONS

      In their second issue, Appellants argue that the trial court abused its

discretion by ruling that Dr. Wagner is not qualified to render an expert opinion

as to whether Dr. Dean, Dr. Tauriainen, and CTSG departed from accepted

standards of medical care regarding the positioning and padding of Malcolm’s

arm during the January 2004 multivessel coronary artery bypass graft

procedure.

      A.     Dr. Dean’s Objection

      Dr. Dean did not object in the trial court that Dr. Wagner does not meet

the criteria identified in section 74.401(a), (b), or (c). Instead, Dr. Dean based

his objection to Dr. Wagner’s qualifications on only one ground, stating as

follows:

      [Dr.] Wagner’s curriculum vitae (“CV”) fails to show that he has
      any training or experience as a cardiovascular surgeon. Since
      Dr. Dean is a cardiovascular surgeon, Dr. Wagner is not and cannot
      be familiar with the standard of care applicable to a physician like
      or similar to Dr. Dean.




                                       10
Dr. Dean’s objection to Dr. Wagner’s qualifications is without merit for more

than one reason.

      In delineating the statutory qualifications for a chapter 74 expert, the

statute does not merely focus on the defendant physician’s area of expertise

but also on the condition involved in the claim. See Tex. Civ. Prac. & Rem.

Code Ann. § 74.401(a)(2) (requiring expert to have “knowledge of accepted

standards of medical care for the diagnosis, care, or treatment of the illness,

injury, or condition involved in the claim” (emphasis added)), § 74.401(c)(1), (2)

(recognizing an expert may be qualified on the basis of training or experience

if he or she is board certified or is practicing “in an area of medical practice

relevant to the claim” (emphasis added)). That is, the applicable “standard of

care” and an expert’s ability to opine on it are dictated by the medical condition

involved in the claim and by the expert’s familiarity and experience with that

condition. See Granbury Minor Emergency Clinic v. Thiel, No. 02-08-00467-

CV, 2009 WL 2751026, at *4 (Tex. App.—Fort Worth Aug. 27, 2009, no

pet.); McKowen v. Ragston, 263 S.W.3d 157, 162 (Tex. App.—Houston [1st

Dist.] 2007, no pet.) (permitting infectious disease physician to opine on

standard of care for treating infection stemming from AV graft even though

defendant doctor was cardiothoracic surgeon); Blan v. Ali, 7 S.W.3d 741,

746–47 & n.3 (Tex. App.—Houston [14th Dist.] 1999, no pet.).

                                       11
      Here, according to Dr. Wagner’s fourteen-page, single-spaced report, he

specializes in anesthesiology and he has substantial personal knowledge and

experience in the care and treatment of patients undergoing general anesthesia

for cardiac surgical procedures. He is also familiar with how such procedures

are managed.      Included in the management of such procedures is the

positioning and padding of the patient and the patient’s extremities. 4

Appellants claim that Malcolm’s postsurgical problems were caused by

Appellees’ negligence in failing to provide for the proper positioning and padding

of his arm. Thus, Dr. Wagner has familiarity and experience with the specific

medical condition involved in the claim, which is the focus of chapter 74.

      Further, though not every physician automatically qualifies as an expert

in every area of medicine, it is well established that a physician need not be a

practitioner in the same specialty as the defendant to be qualified as an expert

in a particular case. Broders, 924 S.W.2d at 152–53. If a particular subject

is substantially developed in more than one medical field, a qualified physician

in any of those fields may testify. Id. at 154; see Rittger v. Danos, No. 01-08-

00588-CV, 2009 WL 1688099, at *7 (Tex. App.—Houston [1st Dist.] June



      4
      … Dr. Wagner additionally states, “Anesthesiology may also be defined
as continuity of patient care involving preoperative evaluation, intra-operative
and postoperative care and the management of systems and personnel that
support these activities.” [Emphasis added.]

                                       12
18, 2009, no pet. h.) (stating that when a particular subject of inquiry is

common to and equally developed in all fields of practice and the prospective

medical expert witness has practical knowledge of what is usually and

customarily done by a practitioner under circumstances similar to those that

confronted the practitioner charged with malpractice, the witness is qualified

to testify).

      Here, the proper positioning and padding of Malcolm’s arm during the

cardiac surgical procedure is not a subject exclusively within the knowledge or

experience of a physician specializing in cardiovascular or thoracic surgery

because Dr. W agner, a physician who specializes in anesthesiology, is

experienced in and familiar with how cardiac surgical procedures—including the

positioning and padding of patients’ extremities—are managed. Contrary to

Dr. Dean’s objection, Dr. Wagner’s specialization in the field of anesthesiology

instead of cardiovascular or thoracic surgery does not disqualify him from

rendering an expert opinion as to whether Dr. Dean departed from accepted

standards of medical care regarding the proper positioning and padding of

Malcolm’s arm.5 See Broders, 924 S.W.2d at 153–54. We hold that the trial



      5
       … To the extent Dr. Dean argues that Dr. Wagner is not qualified to
render an opinion for reasons other than the ground addressed above, we do
not consider those waived objections because they were not raised in the trial
court within twenty-one days after the date Dr. Dean was served with Dr.

                                      13
court abused its discretion by ruling that Dr. Wagner is not qualified to render

an expert opinion as to whether Dr. Dean departed from the accepted standards

of medical care regarding the positioning and padding of Malcolm’s arm. We

sustain this part of Appellants’ second issue.

      B.    Dr. Tauriainen’s Objection

      Dr. Tauriainen made the following objection in the trial court to

Dr. Wagner’s qualifications:

      [Dr. Tauriainen] objects to the qualifications of Dr. Wagner for the
      reason that they fail to meet the criteria, delineated in § 74.401(a),
      (b) and (c), that would permit him to offer expert testimony on the
      issue of whether Dr. Tauriainen departed from the accepted
      standards of medical care in this matter.

Dr. Wagner’s report satisfies each of the section 74.401(a) requirements.

      Dr. Wagner has been actively engaged in the practice of medicine from

1982 to the present, and he was practicing medicine as of the date of the




Wagner’s report implicating Dr. Dean’s conduct. See Tex. Civ. Prac. & Rem.
Code Ann. § 74.351(a); Maris, 262 S.W.3d at 384.

                                       14
report and when the claim arose in January 2004.6 Dr. Wagner thus satisfies

the requirement of civil practice and remedies code section 74.401(a)(1).

      As mentioned above, Dr. Wagner states that he has substantial personal

knowledge and experience in the care and treatment of patients undergoing

general anesthesia for cardiac surgical procedures. He is also familiar with the

management of such procedures, which includes positioning and padding

patients and patients’ extremities in order to prevent perioperative peripheral

neuropathies.    Dr. Wagner consequently states that he has substantial

knowledge of the reasonable, prudent, and accepted standards of care

applicable to cardiovascular and cardiothoracic surgeons, general and traumatic

surgeons, registered nurses, and physician assistants, among others, for “the

diagnosis, assessment, care, and treatment of patients undergoing general

anesthesia for cardiac surgical procedures,” which includes the positioning and

padding of the patient and the patient’s extremities in order to prevent




      6
       … According to Dr. Wagner’s curriculum vitae, which he fully
incorporated by reference into his report, he has been the President and
Managing Partner of Anesthesia Associates since 1986, he was the chairperson
for the Department of Anesthesia at a Connecticut hospital, he was on the
faculty of the Yale School of Medicine, he was an Assistant Professor of
Anesthesia at the Yale School of Medicine, he was the CEO of Pain Therapy
Consultants, and he was the director of an intensive care unit at a Connecticut
hospital.

                                      15
perioperative peripheral neuropathies.       Dr. Wagner’s knowledge of the

applicable standards of care is based upon the following:

      (1) his education, training, and experience;

      (2) his familiarity with applicable medical literature;

      (3) his familiarity with the applicable standards of medical and
      health care developed among anesthesiologists, cardiovascular and
      cardiothoracic surgeons, general and traumatic surgeons, nurses,
      and physician assistants in the positioning and padding of patients
      and the patients’ extremities for the prevention of perioperative
      peripheral neuropathies under circumstances like Malcolm’s;

      (4) his familiarity with the minimum standards of reasonable,
      prudent, and accepted medical practices for the assessment, care,
      and treatment of surgical patients like or similar to Malcolm
      regarding the prevention of perioperative peripheral neuropathies;
      and

      (5) his familiarity with the standards of reasonable, prudent, and
      accepted standards of medical care and treatment of surgical
      patients like Malcolm regarding the prevention of perioperative
      peripheral neuropathies that were applicable to all cardiovascular
      and thoracic surgeons, general or traumatic surgeons, nurses, and
      physician assistants as of 2004.

In light of his substantial knowledge of the reasonable, prudent, and accepted

standards of care for Malcolm’s condition, Dr. Wagner demonstrated that he

“has knowledge of accepted standards of medical care for the diagnosis, care,

or treatment of the illness, injury, or condition involved in the claim,” as

mandated by civil practice and remedies code section 74.401(a)(2). See Tex.

Civ. Prac. & Rem. Code Ann. § 74.401(a)(2).

                                       16
      As for the section 74.401(a)(3) requirement, Dr. Wagner states in his

report that he became board certified in anesthesiology in 1985. He has been

a Diplomate and Consultant to the American Board of Anesthesia since 1985

and a Diplomate to the National Board of Medical Examiners since 1982.

Dr. Wagner’s certification is relevant to Appellants’ claim because Dr. Wagner

is experienced in and familiar with how cardiac surgical procedures, including

the proper positioning and padding of a patient’s extremities, are managed. See

id. § 74.401(c)(1).

      Additionally, Dr. Wagner states that since 1982, he has administered and

managed medical anesthesia care and treatment to over 10,000 patients

undergoing surgeries in a supine position and to between 300 and 400 patients

undergoing cardiac surgery. He also states that he has “extensive experience

working cooperatively with nurses and physician[] assistants in the nursing and

physician assistant care and treatment of patients undergoing general

anesthesia for cardiac surgical procedures.” Further, Dr. Wagner states that he

has   substantial   knowledge   of   the   causal   relationship   regarding   an

anesthesiologist’s, cardiovascular and cardiothoracic surgeon’s, and physician

assistant’s failures to meet the reasonable, prudent, and accepted standards of

care and supervision in the diagnosis, care, and treatment of patients

undergoing general anesthesia for cardiac surgical procedures.        In light of

                                      17
Dr. Wagner’s substantial relevant experience, he has “other substantial training

or experience in an area of medical practice relevant to” Appellants’ claim.

See id.

      In considering section 74.401(c)(2), Dr. Wagner has specialized in the

field of anesthesiology since 1983 and is actively engaged in the practice of

medicine as the term is defined in section 74.401. We have already explained

that Dr. Wagner’s practice of anesthesiology is relevant to Appellants’ claim.

Thus, Dr. Wagner is actively practicing medicine in rendering medical care

services relevant to Appellants’ claim. See id. § 74.401(c)(2). Accordingly,

considering that Dr. Wagner is board certified or has other substantial training

or experience in an area of medical practice relevant to the claim and that he

is actively practicing medicine in rendering medical care services relevant to the

claim, he showed that he is “qualified on the basis of training and experience

to offer an expert opinion regarding” the accepted and applicable standards of

medical care in this case. See id. § 74.401(a)(3).

      To the extent Dr. Tauriainen’s objection based on section 74.401

implicates section 74.351(r)(5)(C), considering the totality of Dr. Wagner’s

report, he has knowledge, skill, experience, training, or education that qualifies

him to give an opinion about whether Dr. Tauriainen’s departure from accepted

standards of medical care regarding the positioning and padding of Malcolm’s

                                       18
arm before, during, and after the surgical procedure had a causal relationship

to Malcolm’s injury because (1) he has substantial personal knowledge and

experience in the care and treatment of patients undergoing general anesthesia

for cardiac surgical procedures; (2) he has substantial knowledge of the

reasonable,   prudent,   and   accepted    standards   of   care   applicable   to

cardiovascular and cardiothoracic surgeons and other professionals for the care

and treatment of patients undergoing general anesthesia for cardiac surgical

procedures; (3) he has specialized in the field of anesthesiology since 1983 and

has been board certified in anesthesiology since 1985; and (4) he has

administered and managed medical anesthesia care and treatment to between

300 and 400 patients undergoing cardiac surgery. See Broders, 924 S.W.2d

at 153. Dr. Wagner’s report establishes that he is qualified to opine on the

issue of causation because he is qualified to render such an opinion under the

rules of evidence. See Tex. Civ. Prac. & Rem. Code Ann. §§ 74.351(r)(5)(C),

74.403(a).

      Like Dr. Dean, Dr. Tauriainen argues that Dr. Wagner is not qualified to

address the accepted standard of care in this case because he is an

anesthesiologist, not a cardiovascular and thoracic surgeon. This argument is

unpersuasive for the same reasons that it was unpersuasive for Dr. Dean. We

hold that the trial court abused its discretion by ruling that Dr. Wagner is not

                                      19
qualified to render an expert opinion as to whether Dr. Tauriainen departed from

the accepted standards of medical care regarding the positioning and padding

of Malcolm’s arm. We sustain this part of Appellants’ second issue.

       C.     CTSG’s Objection

       CTSG challenged Dr. Wagner’s qualifications to render an expert opinion

as to whether it departed from the accepted standards of medical care relevant

to Appellants’ claims. Appellants alleged both direct and vicarious theories of

liability against CTSG. 7   We construe CTSG’s objection as a challenge to

Dr. Wagner’s qualifications to render an expert opinion as to CTSG’s direct

liability.8

       As a professional association, CTSG is a “health care provider” as defined

by section 74.001. Id. § 74.001(a)(12)(A). Thus, Dr. Wagner’s report must

demonstrate that he is qualified pursuant to section 74.402 to render an expert

opinion as to CTSG’s alleged departure from the applicable standard of care.

See id. § 74.351(r)(5)(B). Unlike Dr. Wagner’s report as to Dr. Dean and Dr.


       7
       … Regarding Appellants’ direct liability claims, they alleged that CTSG
negligently failed to supervise the quality of medical and health services for
Malcolm.
       8
        … To the extent CTSG challenges Dr. Wagner’s report as to Appellants’
allegations that CTSG is vicariously liable for the actions and inactions of
Dr. Tauriainen and Dr. Dean, we have already ruled above that the report was
sufficient to demonstrate Dr. Wagner’s qualifications to render an expert
opinion as to Dr. Tauriainen and Dr. Dean.

                                       20
Tauriainen, Dr. Wagner’s report as to CTSG does not provide any information

regarding his background, training, or experience from which it can be

concluded that he has expertise about the standards of care generally applicable

to professional associations. Dr. Wagner generally asserts that he is qualified

to render an expert opinion on CTSG’s conduct, but this alone is insufficient in

the absence of any information within the report itself indicating any experience

or training regarding the standards of care applicable to professional

associations.   We hold that the trial court did not abuse its discretion by

sustaining CTSG’s objection that Dr. Wagner’s report failed to show that he is

qualified under section 74.402 to opine regarding Appellants’ direct liability

claim against CTSG. We overrule this part of Appellants’ second issue.

                   VI. S UFFICIENCY OF D R. W AGNER’S R EPORT

      In their third issue, Appellants argue that the trial court abused its

discretion by ruling that Dr. Wagner’s report is insufficient to represent an

objective good faith effort to comply with the definition of an expert report in

section 74.351(r)(6).   Dr. Tauriainen did not object in the trial court that

Dr. Wagner’s report was insufficient as to any of the section 74.351(r)(6)

requirements. But Dr. Dean objected that Dr. Wagner’s report was insufficient

regarding the applicable standard of care and how Dr. Dean failed to meet that




                                       21
standard of care, and CTSG challenged each requirement of section

74.351(r)(6).

      A.    Standard of Care

      Dr. Wagner states the following regarding the accepted and applicable

standards of care in this case:

      The applicable reasonable, prudent and accepted standards of care
      for . . . Dr. [Tauriainen] [and] Dr. Dean . . . involved a shared
      responsibility on the part of each of these surgeons, the physician
      assistant, and nurses to properly position and pad [Malcolm’s] left
      and right upper extremities before the start of the CABG surgical
      procedure, during the left radial artery harvest, after the left radial
      [artery] harvest and during the remainder of the surgery in order to
      prevent peripheral neuropathies to [Malcolm’s] upper extremities.
      Of the major nerves in the upper extremities, the ulnar nerve and
      brachial plexus nerves are and were the most common nerves to be
      at risk of injury and to become symptomatic and lead to major
      disability of a patient during and after the perioperative period.
      Improper surgical patient positioning and padding of upper
      extremities were well known causative factors in the development
      of surgical patients’ ulnar neuropathies as of 2004 and such risks
      had been known by the surgical, physician assistants, hospital, and
      operating room nursing communities in the United States for many
      years.     As of 2004, reasonably prudent anesthesiologists,
      cardiovascular and cardiothoracic surgeons, general and traumatic
      surgeons, physician’s professional associations, registered nurses,
      and physician[] assistants were or should have been aware that
      surgical patients in supine positions were at risk of developing ulnar
      nerve injuries and neuropathies during surgery due to external ulnar
      nerve compression or stretching caused by malpositioning and
      improper or inadequate padding during surgery. Prevention of
      perioperative peripheral neuropathies to [Malcolm], including his left
      upper extremity, was preventable by proper positioning and
      padding of his left arm and hand. Dr. Moss, with the cooperation
      of nurses Alexander and Syptak, should have positioned

                                        22
      [Malcolm’s] right and left upper extremities in a manner to decrease
      pressure on the postcondylar groove of the humerus or ulnar
      groove. When his arms were tucked at the side the neutral forearm
      position with elbows padded would have been appropriate. When
      his left upper extremity was abducted on an arm board, that
      extremity should have been either in supination or a neutral forearm
      position. His arm should have been extended to less than ninety
      degrees. They should have applied padding materials such as foam
      sponges, eggcrate foam or gel pads, to protect exposed peripheral
      nerves in [Malcolm’s] left arm, particularly at the site of his elbow
      and left ulnar groove. Thus, after Drs. [Tauriainen] [and] Dean . . .
      harvested [Malcolm’s] left radial artery from his left upper extremity
      extended on an armboard, they, together with Dr. Moss, and
      nurses Alexander and Syptak, should have assured that [Malcolm’s]
      left upper extremity was returned to his side in a neutral forearm
      position and padding of his left elbow and any bony prominences
      should have been performed to protect his left ulnar nerve and
      prevent the risk of a left upper extremity neuropathy to the nerve.
      Also, Drs. [Tauriainen] and Dean . . . should have assured and
      followed procedures so that [Malcom’s] left upper extremity was
      positioned in a neutral forearm position and properly padded to
      prevent the risk that any of the surgeons or assistants could come
      in contact or lean on his left arm during the surgical procedure.
      [Emphasis added.]

      The report thus includes Dr. Wagner’s opinions on the element of

standard of care. See id. § 74.351(r)(6). Dr. Dean and CTSG, however, cite

Taylor v. Christus Spohn Health System Corp., 169 S.W.3d 241 (Tex.

App.—Corpus Christi 2004, no pet.), and argue that Dr. Wagner’s report is

insufficient because it fails to state with specificity the applicable standard of

care for each defendant.      Taylor has been thoroughly scrutinized by the

appellate courts, and it does not expressly prohibit applying the same standard



                                       23
of care to more than one health care provider if they all owe the same duty to

the patient.   See Springer v. Johnson, 280 S.W.3d 322, 332–33 (Tex.

App.—Amarillo 2008, no pet.); Livingston v. Montgomery, 279 S.W.3d 868,

871–73 (Tex. App.—Dallas 2009, no pet.); Sanjar v. Turner, 252 S.W.3d 460,

466–67 (Tex. App.—Houston [14th Dist.] 2008, no pet.). Dr. Wagner’s report

provides that Appellees all shared a responsibility to properly position Malcolm’s

arm. The report is not insufficient for “grouping” Appellees together because

Dr. Wagner specifically states that they all owed the same duty to ensure the

proper positioning and padding of Malcolm’s arm. See Springer, 280 S.W.3d

at 332; Livingston, 279 S.W.3d at 873; Sanjar, 252 S.W.3d at 466; In re

Stacy K. Boone, 223 S.W.3d 398, 405–06 (Tex. App.—Amarillo 2006, no pet.)

(holding that a single standard of care applicable to physicians and physician

assistant was sufficient because all participated in administering treatment); cf.

Polone v. Shearer, 287 S.W.3d 229, 235 (Tex. App.—Fort Worth 2009, no

pet.) (holding report that set forth single standard of care applicable to

physician and physician assistant insufficient to represent a good faith effort

because “[a]lthough the standards of care might be the same for both [the

physician and physician assistant], the report does not specifically state as

much”). We hold that Dr. Wagner’s report constitutes a good faith effort to

identify and set forth the applicable standards of care in this case and that the

                                       24
trial court abused its discretion by ruling otherwise. We sustain this part of

Appellants’ third issue.

      B.    Breach of Standard of Care and Causation

      Dr. Wagner’s report states the following regarding how Appellees failed

to meet the applicable standards of care and the causal relationship between

that failure and the injury, harm, or damages claimed:

      It is my opinion that Dr. [Tauriainen] [and] Dr. Dean . . . failed to
      meet the applicable reasonable, prudent and accepted standards of
      medical care . . . for each of them in that they did not properly and
      adequately perform procedures to assure that [Malcolm’s] left
      upper extremity was positioned and padded to decrease pressure
      on his left postcondylar groove of the humerus or ulnar groove in
      order to protect him from a serious and permanent left ulnar nerve
      injury and neuropathy to his left upper extremity. During the
      surgery, [Malcolm] was asleep under the effects of general
      anesthesia and he was unable to care for himself and protect
      himself from a left upper extremity ulnar nerve injury and
      neuropathy. According to the hospital’s intraoperative record[,] a
      left radial artery harvest was performed by Ms. Barnett-Wright,
      under the supervision of Dr. [Tauriainen] and Dr. Dean. After this
      harvest procedure, [Malcolm’s] right arm was placed in a tucked
      and padded position on his right side, his left arm was placed on an
      olympic table for the left radial artery harvest procedure, and then
      his left arm was placed in a “tucked” position on his left side by
      Dr. Moss, with the cooperation of nurses Alexander and Syptak.
      Dr. [Tauriainen] [and] Dr. Dean . . . had a shared responsibility with
      the anesthesiologist . . . to assure that [Malcolm’s] left upper
      extremity was properly positioned and padded for the remainder of
      the CABG surgery. However, Dr. [Tauriainen] [and] Dr. Dean . . .
      improperly failed to position [Malcolm’s] left arm and apply padding
      or adequate padding such as foam sponges, eggcrate foam, or gel
      pads to protect his exposed peripheral left ulnar nerve at the site of
      his elbow and left ulnar groove.             Dr. [Tauriainen] [and]

                                       25
Dr. Dean . . . should have directed Ms. Barnett-Wright to place
[Malcolm’s] left arm in a neutral forearm position and apply padding
of his left elbow to protect his left ulnar nerve, and Dr. [Tauriainen]
[and] Dr. Dean . . . should have checked the site of [Malcolm’s] left
arm and elbow to assure that these procedures had been properly
followed, or Dr. [Tauriainen] [and] Dr. Dean should have performed
these procedures themselves. It appears from the hospital record
that Dr. [Tauriainen] [and] Dr. Dean . . . did not adequately direct
Ms. Barnett-Wright in the positioning and placement of [Malcolm’s]
left arm to protect his left ulnar nerve following the left radial artery
harvest, and that they did not adequately perform these procedures
themselves nor assure that Ms. Barnett-Wright had done so to
protect [Malcolm’s] left ulnar nerve. . . . These standard of care
failures by Dr. [Tauriainen] [and] Dr. Dean . . . very likely resulted
in the exposure of [Malcolm’s] left ulnar peripheral nerve to
excessive external pressure or stretching, or both, over a prolonged
period of approximately four hours during the surgical procedure
and this prolonged pressure and/or stretching most likely resulted
in a serious and permanent left ulnar nerve injury and neuropathy
to [Malcolm’s] left arm and hand, and [Malcolm’s] physical
impairments in the use of his left hand consisting of pain,
numbness, stiffness, impaired use of his left hand and two fingers
involved. My opinion in this regard is based upon the facts that
[Malcolm] did not have any preoperative history of left upper
extremity neuropathy, the hospital intraoperative records indicate
that his left upper extremity was inappropriately and inadequately
positioned and padded during the surgery, [and] he awoke from
general anesthesia in the ICU and immediately perceived painful
throbbing, burning and swelling of his left arm and hand. . . . If
Dr. [Tauriainen] [and] Dr. Dean . . . with the cooperation of
Ms. Barnett-Wright, had properly positioned and padded
[Malcolm’s] left arm, and particularly the area of his elbow and
ulnar groove, his ulnar nerve would not have been exposed to
prolonged pressure throughout the remainder of the surgery, and in
all reasonable medical probability, he would not have suffered
permanent left upper extremity ulnar nerve injury and neuropathy
for the reasons which I have discussed above. [Emphasis added.]




                                   26
      The report thus includes Dr. Wagner’s opinions on the elements of the

manner in which the care rendered by Appellees failed to meet the applicable

standards of care and the causal relationship between that failure and the

injury, harm, or damages claimed.     See Tex. Civ. Prac. & Rem. Code Ann.

§ 74.351(r)(6).   The report also links Appellees’ purported breach of the

applicable standards of care to Malcolm’s alleged injuries. See Bowie Mem’l

Hosp., 79 S.W.3d at 52 (requiring expert to explain the basis of his statements

regarding causation and link his conclusions to the facts).       We hold that

Dr. Wagner’s report represents an objective good faith effort to identify and set

forth how Appellees breached the applicable standards of care and the causal

relationship between that failure and the injuries claimed. Dr. Wagner’s report

indisputably informs Appellees of the specific conduct Appellants have called

into question and provides a basis for the trial court to conclude that the

Appellants’ claims have merit. See Palacios, 46 S.W.3d at 879. We hold that

the trial court’s ruling otherwise was arbitrary or unreasonable, or without

reference to any guiding rules or principles, and, thus, an abuse of discretion.

We sustain the remainder of Appellants’ third issue.

                                VII. C ONCLUSION

      Having overruled part of Appellants’ second issue, we affirm the part of

the trial court’s order sustaining CTSG’s objection that Dr. Wagner’s report

                                       27
failed to show that he is qualified under section 74.402 to render an expert

opinion as to CTSG’s direct liability and dismissing Appellants’ direct liability

claims against CTSG. Having sustained the remainder of Appellants’ second

issue and all of their third issue, we reverse the trial court’s order sustaining

each of Appellees’ other objections to Dr. Wagner’s report and dismissing

Appellants’ claims against Dr. Dean and Dr. Tauriainen and their vicarious

liability claims against CTSG. We remand the case to the trial court for further

proceedings.




                                            BILL MEIER
                                            JUSTICE

PANEL: CAYCE, C.J.; LIVINGSTON and MEIER, JJ.

DELIVERED: October 29, 2009




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