                                   COURT OF APPEALS
                                EIGHTH DISTRICT OF TEXAS
                                     EL PASO, TEXAS

                                                §
 TENET HOSPITALS LIMITED, A
 TEXAS LIMITED PARTNERSHIP                      §
 D/B/A PROVIDENCE MEMORIAL
 HOSPITAL,                                      §               No. 08-09-00093-CV

                   Appellant,                   §                    Appeal from
 v.
                                                §            County Court at Law No. 5
 RICHARD BARNES, JAMES BARNES,
 KATHLEEN HALE, KIMBERLEY                       §             of El Paso County, Texas
 VANDAGRIFF, AND
 KAREN CASTILLO, INDIVIDUALLY                   §                 (TC # 2007-4558)
 AND AS PERSONAL
 REPRESENTATIVE OF THE ESTATE                   §
 OF EARLINE W. BARNES, DECEASED,
                                                §
                   Appellees.
OPINION

       This appeal stems from a health care liability claim against Tenet Hospitals Limited, a Texas

Limited Partnership d/b/a Providence Memorial Hospital (Providence). Providence moved to

dismiss the lawsuit based on the plaintiffs’ failure to timely serve an expert report authored by a

qualified expert in compliance with Chapter 74 of the Texas Civil Practice and Remedies Code. The

trial court denied the motion. For the reasons that follow, we affirm.

                                 FACTUAL BACKGROUND

       The health care liability claim was brought by Richard Barnes, James Barnes, Kathleen Hale,

Kimberley Vandagriff, and Karen Castillo, individually and as personal representative of the Estate

of Earline W. Barnes (Appellees) for injuries allegedly sustained by Barnes and her subsequent

death. Appellees claim that Barnes, a 79-year-old woman with congestive heart failure who had

been admitted to Providence, suffered from complications of shock and died on October 31, 2005
because of the hospital’s negligence.

          Appellees filed suit on October 12, 2007 and their time in which to file expert reports expired

on February 9, 2008. In an effort to comply with Chapter 74, Appellees submitted three reports and

curriculum vitae from: (1) Michael P. Koumjian, M.D., (2) Juan U. Contin, M.D., and (3) Angelica

Tyler, R.N. Providence objected to the reports, alleging that the authors are not qualified to render

expert opinions against Providence and that their reports are inadequate. Providence also argued that

Dr. Contin’s report is not an expert report at all. No additional or supplemental expert reports were

served.

                                      STANDARD OF REVIEW

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

of discretion. See 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 acts in an unreasonable or

arbitrary manner without reference to any guiding rules or principles. Walker v. Gutierrez, 111

S.W.3d 56, 62 (Tex. 2003). A trial court will be deemed to have acted arbitrarily and unreasonably

if the trial court could have reached only one decision, yet reached a different one. See Teixeira v.

Hall, 107 S.W.3d 805, 807 (Tex.App.--Texarkana 2003, no pet.). To that end, a trial court abuses

its discretion when it fails to analyze or apply the law correctly. In re Southwestern Bell Telephone

Co., L.P., 226 S.W.3d 400, 403 (Tex. 2007), citing In re Kuntz, 124 S.W.3d 179, 181 (Tex. 2003).

An abuse of discretion does not occur merely because the appellate court may have decided a

discretionary matter in a different way than the trial court. Downer v. Aquamarine Operators, Inc.,

701 S.W.2d 238, 241-42 (Tex. 1985). However, to the extent resolution of the issues presented

requires interpretation of the statute, we review the ruling de novo. See Buck v. Blum, 130 S.W.3d

285, 290 (Tex.App.--Houston [14th Dist.] 2004, no pet.).
                                       EXPERT REPORTS

        In Points of Error One and Two, Providence complains that the reports of Dr. Contin and Dr.

Koumjian fail to meet the statutory requirements of Section 74.351.

                         Can the Expert Reports be Considered Together?

        Providence attacks the sufficiency of both Dr. Contin’s autopsy report and Dr. Koumjian’s

expert report. It raises numerous arguments addressing why an autopsy report does not qualify as

an expert report. It also challenges Dr. Koumjian’s report as wholly inadequate because it does not

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

Section 74.351(r)(6). Appellees respond that the three reports must be considered together and that

collectively they fulfill the procedural requirements of Section 74.351.

        In assessing the adequacy of an expert report necessary to sustain a medical malpractice suit,

the trial court must look only within the four corners of the report. Hutchinson v. Montemayor, 144

S.W.3d 614, 617 (Tex.App.--San Antonio 2004, no pet.). Although an expert report need not

include a full statement of the standard of care and how the standard of care was breached, it

must explain what care was expected but not given. Gallardo v. Ugarte, 145 S.W.3d 272, 278

(Tex.App.--El Paso 2004, pet. denied). An expert report must represent a good-faith effort to

provide a fair summary of the expert’s opinions. Ehrlich v. Miles, 144 S.W.3d 620, 626 (Tex.App.--

Fort Worth 2004, pet. denied). To constitute a good-faith effort, the report must discuss the standard

of care, breach thereof, and causation with sufficient specificity to inform the defendant of the

conduct the plaintiff has called into question and to provide a basis for the trial court to conclude

that the claims have merit. Chandler v. Singh, 129 S.W.3d 184, 188 (Tex.App.--Texarkana 2004,

no pet. h.).

        With regard to serving separate expert reports, Section 74.351(i) provides:
        Notwithstanding any other provision of this section, a claimant may satisfy any
        requirement of this section for serving an expert report by serving reports of separate
        experts regarding different physicians or health care providers or regarding different
        issues arising from the conduct of a physician or health care provider, such as issues
        of liability and causation. Nothing in this section shall be construed to mean that a
        single expert must address all liability and causation issues with respect to all
        physicians or health care providers or with respect to both liability and causation
        issues for a physician or health care provider.

TEX .CIV .PRAC.&REM .CODE ANN . § 74.351(i)(Vernon 2005).

        In Regent Care Center of Laredo, Ltd. Partnership v. Abrego, the plaintiff filed three expert

reports. No. 04-07-00320-CV, 2007 WL 3087211, at *1 (Tex.App.--San Antonio 2007, no pet.).

The issue on appeal was whether the expert reports (read separately or together) established the

casual relationship between a breach of the standard of care and the death of the plaintiff for

purposes of a wrongful death claim. Id. at *5. The defendant hospital argued that the reports were

deficient as to causation on the part of the administrator of the nursing home facility because the

expert only addressed the hospital’s negligence and how its acts and omissions caused the

plaintiff’s death. Id. at *6. The court looked to Martin v. Abilene Regional Medical Center,

No. 11-04-00303-CV, 2006 WL 241509, *4 (Tex.App.--Eastland 2006, no pet.) for guidance.

        In Martin, the hospital argued that the nursing expert’s report was deficient as to causation

because the expert only addressed the nursing standard of care and the breach of that standard while

the physician expert addressed only the negligence of the defendant physician and how that

negligence was a proximate cause of the plaintiff’s injuries. The court of appeals rejected the

hospital’s argument and read the reports of the nursing expert and the physician expert together since

causation--how the failure to prescribe medicine caused the injuries--applied to the conduct of both

the nurse and the physician who were allegedly at fault for the failure to prescribe. Id. at *4-5. “To

the extent that the trial court may have reviewed [the physician expert’s] report in isolation, the trial
court abused its discretion because Section 74.351(i) expressly provides that a claimant may satisfy

any requirement of the Act by providing expert reports of separate experts.” Id. at *4. Relying on

Martin, the Abrego court concluded that the two expert reports, read together, addressed the

standards of care for the nursing home and the hospital, fulfilling the statute’s causation requirement.

2007 WL 3087211, at *6.

        Based on the language in Section 74. 351(i) and the analysis in both Abrego and Martin, we

conclude that the three expert reports must be read together. We next consider whether the reports

combined provide a sufficient discussion of the standard of care, breach of the applicable standard,

and causation. TEX .CIV .PRAC.&REM .CODE ANN . § 74.351(r)(6).

                                    Standard of Care and Breach

        An expert report need not marshal the plaintiff’s proof, but it must include the expert’s

opinions on all three statutory elements. Gray v. CHCA Bayshore L.P., 189 S.W.3d 855, 859

(Tex.App.--Houston [1st Dist.] 2006, no pet.). Although it is not sufficient for an expert simply to

state that he knows the standard of care and assert it was not met, a fair summary is something less

than a full statement of the applicable standard of care and how it was breached. Palacios, 46

S.W.3d at 880. A fair summary need only set out what care was expected but not given. Id.

        Dr. Koumjian’s report references the applicable standard of care and subsequent breach of

that standard:

        Instead of going ahead with the transfer, Mrs. Barnes’ physician should have been
        immediately notified by the nurse and efforts made to stabilize Mrs. Barnes with
        vasopressors (medications to raise the blood pressure), intra-venous fluids, and
        oxygen. Since she had chest pain an EKG should have been immediately obtained.
        If notified of Mrs. Barnes’ condition her physician would have been able to meet the
        standard of care, which was, attempt to stabilize her as above; make an immediate
        effort to determine the cause of her hypotension (low blood pressure) and make an
        immediate effort to locate the source of her bleeding. . . . Instead the nurses of
        Providence Memorial Hospital and the ambulance personal [sic] decided to transfer
        Mrs. Barnes to Sierra Medical Center.

Dr. Koumjian’s expert report is corroborated by the report submitted by Nurse Tyler, who opines that

the nursing standard of care when a patient undergoes an angiogram is to monitor the patient looking

for evidence of bleeding. If there is a sign of blood loss, the standard of care would require the nurse

to notify a physician who would be responsive. While waiting for the responding physician, the

nurse may give supplemental oxygen if the patient is in extremis or put the patient in a

Trendelenburg position to increase blood flow. The standard of care also requires that vital signs

be taken and recorded at the time the patient leaves the nursing unit. Here, however, the medical

records indicate that the last vital signs were taken two hours before Barnes was transferred. Tyler’s

report faults Barnes’ nurse for:

        •failing to call the physician once there was a significant change in the patient’s condition
        and she destablilized;

        •failing to provide supplemental oxygen while she was waiting for the physician;

        •allowing a patient who had not been stabilized to be moved to Sierra Medical Center; and

        •failing to notify the nursing staff at Sierra of Barnes’ deteriorating condition.


        We conclude that the trial court acted within its discretion in finding that the expert reports

adequately complied with the statutory requirements for articulating the standard of care and the

breach thereof.

                                              Causation

        An expert report must provide a fair summary of the expert’s opinions on the causal

relationship of a breach from a standard of care to the harm claimed, with enough specificity to allow

the trial court to conclude that the plaintiff’s claims have merit. Palacios, 46 S.W.3d at 878; see

TEX .CIV .PRAC.&REM .CODE ANN . § 74.351(r)(6). Applying this standard, an expert report is
insufficient when it contains only a series of repetitious, conclusory statements regarding causation.

See Jones v. King, 255 S.W.3d 156, 160 (Tex.App.--San Antonio 2008, pet. denied)(mem.

op.)(adding that an expert must “explain the basis of his statements to link the conclusions to the

facts”). As is true in other types of negligence cases, causation is established by proof that the

negligent act or omission was a substantial factor in bringing about the harm and without which the

harm would not have occurred. Costello v. Christus Santa Rosa Health Care Corp., 141 S.W.3d

245, 249 (Tex.App.--San Antonio 2004, no pet.). Mere reference to general concepts regarding

assessment, monitoring, and interventions are insufficient as a matter of law. Regent Health Care

Center of El Paso, L.P. v. Wallace, 271 S.W.3d 434, 441 (Tex.App.--El Paso 2008, no pet.h.). There

can be no analytical gap between a breach of the standard of care and the ultimate harm. Clark v.

HCA, Inc., 210 S.W.3d 1, 11 (Tex.App.--El Paso 2005, no pet.).

       We have reviewed the four corners of Dr. Koumjian’s report and disagree with Providence

that it is conclusory. The report supplies the requisite causal relationship between the breach--the

failure to notify Barnes’ physician--and Barnes’ death. As to causation, the report contains the

following information:

       4. Instead the nurses of Providence Memorial Hospital and the ambulance personal
       [sic] decided to transfer Mrs. Barnes to Sierra Medical Center. In my opinion,
       Mrs. Barnes probably could have been stabilized at Providence if the nurse had
       contacted her physician at 3:20 p.m. This opinion is based upon the fact that Mrs.
       Barnes had not been hypotensive much more than an hour and her blood pressure
       would probably respond to intravenous fluids and medications. It is also my opinion
       that within reasonable medical probability the tear in Mrs. Barnes’ artery could have
       been located and repaired and she would have survived the event with no significant
       sequelae.

                                           .      .       .

       13. She expired on October 31, 2005 from complications of her hypotension in spite
       of intensive care and the input and expertise of many specialists. In all reasonable
       medical probability Mrs. Barnes fate was doomed shortly upon arrival at Sierra
       Medical Center as she had been documented as having the signs and symptoms of
       significant blood loss since 2:00 p.m. and had shown the signs and symptoms of
       having had hypotension that had existed for more than 30 minutes as of 3:20 p.m.

                                            .      .       .

       19. I reviewed the entire medical records concerning Mrs. Barnes hospitalization at
       Sierra Medical Center searching for other explanations of her death. In my opinion,
       based on reasonable medical probability, Mrs. Barnes died from the complications
       of shock.

                                            .      .       .

       22. Thus, in my opinion the transfer process resulted in a delay in the diagnosis and
       treatment of Mrs. Barnes’ hypotension caused by bleeding from a torn femoral artery
       and probably increased her blood loss. The delay in diagnosis and treatment caused
       by the transfer exceeded two hours and in all probability caused irreversible damage
       which led to multi-organ failure and then to death.

       The two-fold purpose of an expert report is to inform the defendant of the specific conduct

the plaintiff has called into question, and to provide the trial court with a basis to determine whether

the plaintiff’s claims have merit. Patel v. Williams ex rel. Estate of Mitchell, 237 S.W.3d 901, 906

(Tex.App.--Houston [14th Dist.] 2007, no pet.h.). Pursuant to this standard, we conclude that

Dr. Koumjian’s report sufficiently addresses the element of causation, linking the alleged breaches

of the standard of care to Barnes’ subsequent death. Bearing in mind that expert reports are a

preliminary method to demonstrate that a plaintiff has a viable cause of action that is not frivolous

or without expert support, we hold the trial court acted within its discretion in concluding that the

expert report complied with the statute’s causation requirement.

       Finding that the requirements of Section 74.351 are met by the reports of Dr. Koumjian and

Nurse Tyler, we need not address whether Dr. Contin’s autopsy report qualifies as an expert report

under Section 74.351. Accordingly, we overrule Points of Error One and Two.

                                  EXPERT QUALIFICATIONS
       In Points of Error Three through Six, Providence challenges the qualifications of the three

experts.

                                   License to Practice Medicine

       Before addressing whether Dr. Koumjian must be licensed in Texas in order to opine on

causation, we address the hospital’s argument that neither Dr. Koumjian’s report nor his

curriculum vitae indicate that he is licensed to practice medicine in any state. In support of this

argument, Providence directs us to Li v. Billingsley, No. 05-08-00436-CV, 2009 WL 242523, at *1

(Tex.App. --Dallas 2009, no pet. h.). There, the expert was a chiropractor who was licensed to

practice chiropractic, not to practice medicine. The court found that nothing in his report or

curriculum vitae suggested that he was licensed to practice medicine. Id. at 2. Here, the report and

curriculum vitae indicate that Dr. Koumjian is licensed to practice medicine in California. In his

report, Dr. Koumjian states that he is a board certified cardiovascular surgeon presently practicing

in San Diego, California. In his curriculum vitae, he lists his current position as a private

practitioner in cardiovascular and thoracic surgery in San Diego, California. We need not look

beyond the four corners of the report or curriculum vitae to determine his qualifications. Palacios,

46 S.W.3d at 878.

                             Must the Experts be Licensed in Texas?

       In Point of Error Three, Providence argues that Dr. Koumjian is not qualified to opine on

causation. The crux of the argument is that a physician licensed in another state may opine as to the

applicable standard of care and any breaches thereof, but only a physician licensed in Texas may

opine as to causation. We recently addressed this very issue in Tenet Hospitals Limited, a Texas

Limited Partnership, d/b/a Providence Memorial Hospital v. Boada, 304 S.W.3d 528 (Tex.App.--

El Paso 2009, pet. denied) and disagreed with the hospital’s statutory interpretation. We will not
revisit that holding here. We overrule Point of Error Three.

                                    Dr. Contin’s Qualifications

       In Point of Error Four, Providence argues that Dr. Contin lacks the requisite qualifications

to opine on the applicable standard of care. Having found that the expert reports of Dr. Koumjian

and Nurse Tyler meet the requirements of Section 74.351,we need not address Dr. Contin’s

qualifications. We overrule Point of Error Four.

                                 Qualifications/ Standard of Care

       In Points of Error Five and Six, Providence argues that neither Dr. Koumjian nor Nurse Tyler

is qualified to opine on the applicable standard of care.

                                            Dr. Koumjian

       Providence argues that even though Dr. Koumjian is a board certified cardiovascular surgeon,

he does not claim to be knowledgeable or experienced on the standards of care applicable to

hospitals or nurses. It suggests that merely working as a surgeon in a hospital is not analogous to

experience in specialized nursing care or hospital policies and procedures.

       Section 74.402(b) establishes that, in a suit involving a health care liability claim against a

health care provider, a person may qualify as an expert witness on the issue of whether the health

care provider departed from accepted standards of medical 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.
TEX .CIV .PRAC.&REM .CODE ANN . § 74.402(b)(Vernon 2005).

        Section 74.402(b) makes it clear that different standards of care apply to physicians and

health care providers. See Simonson v. Keppard, 225 S.W.3d 868, 872 (Tex.App.--Dallas 2007, no

pet.). When a physician fails to state in his expert report that he has knowledge of the standard of

care applicable to the specific types of health care providers involved in the claim, or that he has ever

worked with or supervised the specific types of health care providers involved in the claim, the

physician is not qualified on the issue of whether the health care provider departed from the accepted

standards of care for health care providers. See id. at 872-74. But if the physician states he is

familiar with the standard of care for both nurses and physicians, and for the prevention and

treatment of the illness, injury, or condition involved in the claim, the physician is qualified on the

issue of whether the health care provider departed from the accepted standards of care for health care

providers. See San Jacinto Methodist Hosp. v. Bennett, 256 S.W.3d 806, 814 (Tex.App.--Houston

[14th Dist.] 2008, no pet.)(distinguishing Simonson ). Further, if a physician states he is familiar

with the standard of care and responsibilities and requirements for physician’s assistants, and he has

worked with, interacted with, and supervised physician’s assistants, the physician is qualified on the

issue of whether the health care provider departed from the accepted standards of care for health care

providers. See Cook v. Spears, 275 S.W.3d 577, 582-84 (Tex.App.--Dallas 2008, no pet.)

(distinguishing Simonson ). A physician is not required to state he is familiar with the core standards

for nurse practitioners or physician’s assistants. See id.

        In Simonson, the Dallas Court of Appeals concluded the trial court abused its discretion when

it denied a nurse practitioner’s motion to dismiss because “[n]owhere in his affidavit does [the

medical expert] state that he either has knowledge of the standard of care applicable to nurse

practitioners or that he has ever worked with or supervised nurse practitioners.” Simonson, 225
S.W.3d at 872. Such is not the case here. Dr. Koumjian’s report states his personal experience: “I

have been involved in the care of about 250 patients with problems similar to Mrs. Barnes.” He

continues:

        10. I am a board certified cardiovascular surgeon presently practicing in San Diego,
        California. As a cardiovascular surgeon I am frequently involved in the surgical
        repair of injured blood vessels. I am also involved in the resuscitation and
        stabilization of patients with vascular injuries, blood loss and hypotension. The repair
        of injured blood vessels and stabilization of patients with hypotension was part of my
        training as a cardiovascular surgeon. I remain current with the literature in the field
        of cardiovascular surgery and attend medical education courses in the area of
        cardiovascular surgery.

His curriculum vitae also indicates that he is currently “Chief of Surgery” at Sharp Grossmont

Hospital. His report coupled with his curriculum vitae adequately establish his qualifications to state

the standard of care applicable to Providence in relation to the health care provider’s care of Barnes.

Not only has Dr. Koumjian demonstrated he has specific knowledge about the claim involved in this

case, his position as Chief of Surgery necessarily entails supervision of and interaction with the

requisite health care providers. Because Dr. Koumjian is qualified to opine on the applicable

standard of care, we overrule Point of Error Five. And even if we were to find that Dr. Koumjian’s

report and curriculum vitae do not sufficiently show his qualifications to opine on the applicable

standard of care, we may look to Nurse Tyler’s report to meet this requirement. TEX .CIV .PRAC.&

REM .CODE ANN . § 74.351(i).

                                             Nurse Tyler

        As with Dr. Koumjian, Nurse Tyler must show she qualifies as an expert witness on the issue

of whether the health care provider departed from accepted standards of medical care by showing

that she:

        (1) is practicing health care in a field of practice that involves the same type of care
        or treatment as that delivered by the defendant health care provider, if the defendant
       health care provider is an individual, at the time the testimony is given or was
       practicing that type of health care at the time the claim arose;

       (2) has knowledge of accepted standards of care for health care providers for the
       diagnosis, care, or treatment of the illness, injury, or condition involved in the claim;
       and

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

TEX .CIV .PRAC.&REM .CODE ANN . § 74.402(b). The definition of “practicing health care” includes:

       (1) training health care providers in the same field as the defendant health care
       provider at an accredited educational institution; or

       (2) serving as a consulting health care provider and being licensed, certified, or
       registered in the same field as the defendant health care provider.

TEX .CIV .PRAC.&REM .CODE ANN . § 74.402(a). In her report, Nurse Tyler states:

       My opinions in this case are based on my education, training and experience. 1 am
       a registered nurse and have spent most of my nursing career evaluating nursing care.
       In October 2005 I was practicing in the Office of the New Mexico Attorney General
       as a medical care investigator. My position required that I be a licensed, registered
       nurse. My job entailed reviewing complaints of substandard nursing care. As such,
       I was obligated to be familiar with nursing standards of care. From July 2002 to May
       2005 I practiced as a Surveyor/Reviewer for the State of New Mexico. In this
       position I evaluated hospitals for quality of care and quality of nursing care. I was
       also employed as an investigator with The Board of Nurse Examiners for the State
       of Texas - January 1999-2001. This position required me to evaluate nursing conduct
       to determine if the conduct met the nursing standard of care.

       I keep current by reading several nursing journals. My training and years of
       experience as a reviewer and as an investigator in the field of nursing, along with my
       reading and continuous nursing education have made me an expert regarding nursing
       standards of care. None of the standards of care I have described in this report would
       be considered highly specialized or esoteric. Rather these standards or care are basic
       standards of care taught in nursing school.

       Nurse Tyler’s resume also states she has been a registered nurse since 1990 and holds a

National Certification as an Investigator/Inspector. Based upon her report and resume, she clearly

possesses the requisite qualifications to opine on the applicable standard of care with regards to the
health care providers in this case. Nurse Tyler has demonstrated that she has the education,

certifications, and eight and a half years of experience in many areas of nursing. She meets the

definition of “practicing health care” because her investigator position is synonymous with a

consulting health care provider who licensed, certified, or registered in the same field as the

defendant health care provider. TEX .CIV .PRAC.&REM .CODE ANN . § 74.402(a)(2). We perceive no

abuse of discretion in the trial court’s finding that Nurse Tyler was qualified to opine on the

applicable standard of care. We overrule Point of Error Six and affirm the judgment of the court

below.



July 28, 2010
                                                      ANN CRAWFORD McCLURE, Justice

Before Chew, C.J., McClure, J., and Antcliff, Judge
Antcliff, Judge, sitting by assignment
