Case Title: Mobile Infirmary Association v. Robert E. Tyler, as administrator of the estate of Lida Mae Tyler, deceased

Citation: 

Docket Number: 1041484

State: alabama

Court: Alabama Supreme Court

Date: 2007-09-14T00:00:00Z

Document:
REL: 09/14/2007
Notice: This opinion is subject to formal revision before publication in the advance
sheets of Southern Reporter.  Readers are requested to notify the Reporter of Decisions,
Alabama Appellate Courts, 300 Dexter Avenue, Montgomery, Alabama 36104-3741 ((334) 229-
0649)), of any typographical or other errors, in order that corrections may be made before
the opinion is printed in Southern Reporter.
SUPREME COURT OF ALABAMA
SPECIAL TERM, 2007
____________________
1041484
____________________
Mobile Infirmary Association
v.
Robert E. Tyler, as administrator of the estate of Lida Mae
Tyler, deceased
Appeal from Mobile Circuit Court 
(CV-00-2202)
SMITH, Justice.
Mobile Infirmary Association ("the Infirmary") appeals
from a judgment, entered on a jury verdict, in favor of Robert
E. Tyler, as administrator of the estate of his mother, Lida
Mae Tyler, deceased.  We affirm conditionally.
1041484
"Atrial fibrillation is an irregular heart
1
rhythm--arrhythmia--experienced by many
Americans.  It can develop at any time in
a person's life but is primarily found in
the older population.  It occurs when a
person's atrium, an upper chamber in the
heart, begins to flutter and fibrillate
instead 
of 
efficiently 
expanding 
and
contracting 
in 
conjunction 
with 
the 
heart's
other chambers.  This flutter prevents
efficient blood transfer to the ventricle
for pumping to the other parts of the body
and often causes a person to feel fatigued,
nervous, and as though he or she has a
'racing heartbeat.'"
(Robert's brief, p. 14 n.4 (summarizing expert medical
testimony).)
2
Facts and Procedural History
On Friday, June 4, 1999, Lida Mae Tyler, who was 72 years
old, complained to her daughter-in-law, 
Teresa 
Tyler, that 
she
felt dizzy and tired and that her heart felt like it was
"racing."  Teresa took Lida to the office of Dr. Steven Donald
in Chatom.  Dr. Donald examined Lida and concluded she was
suffering from a heart arrhythmia called atrial fibrillation,1
and he advised her to go to the Infirmary, where she could be
examined by a cardiologist.
Dr. Mir Wail Hashimi, a cardiologist employed by
Cardiology Associates of Mobile, P.C. ("CAM"), examined Lida
1041484
Dr. 
Hashimi 
performed 
an 
exploratory 
heart
2
catheterization; 
the 
catheterization 
revealed 
no 
heart 
damage,
no significant blockage of arteries, normal left ventricular
function, and a mild narrowing of the right coronary artery
that did not require treatment.
Dr. Hashimi recommended the blood-thinning medication
3
because a patient such as Lida, whose heart rhythm is in
atrial fibrillation, has an increased risk of developing an
embolus (i.e., a blood clot) in the heart.  If a clot
develops, it can be "thrown" when the patient's heart converts
3
in the emergency room of the Infirmary.  Lida explained that
she 
was 
experiencing 
what 
the 
record 
describes 
as
"intermittent epigastric" and chest pains as well as
indigestion.  Although a number of tests were performed on
Lida, Dr. Hashimi could not determine the cause of her atrial
fibrillation.  However, he did determine that she had not
suffered a heart attack.   Dr. Hashimi prescribed Cardizem to
2
lower Lida's blood pressure, and he admitted Lida to the
Infirmary for observation in the cardiac-care unit.
Dr. 
Hashimi 
recommended 
that 
Lida 
undergo 
a
"cardioversion" procedure, which would electronically convert
her heart rhythm from atrial fibrillation to a normal rhythm.
However, Dr. Hashimi told Lida that she would need to take
blood-thinning medication for approximately 30 days before
undergoing the procedure.   Dr. Hashimi told Lida and Robert
3
1041484
to a normal rhythm, creating a condition known as "peripheral
embolization."  (Robert's brief, p. 14 n.5 ("Peripheral
embolization occurs when a blood clot in the heart, created
because of the heart's decreased ability to move blood during
atrial fibrillation (i.e., stasis), breaks loose and travels
to other parts of the body where it lodges and blocks the
blood and oxygen supply to certain organs and extremities."
(summarizing expert medical testimony)).)
4
that he intended to keep her in the hospital for a couple of
days to monitor her condition and to start her on blood-
thinning medication.  
Dr. Hashimi examined Lida at about 8:30 a.m. on Saturday,
June 5, 1999; Lida informed Dr. Hashimi that she was "feeling
pretty good."  After Dr. Hashimi left, Robert remained in the
room with his mother until lunchtime.  From 7:00 a.m. until
approximately 1:00 p.m., Lida's condition was normal, and she
did not complain of pain. 
Dr. Hashimi went "off call" at approximately 1:00 p.m.,
and another cardiologist employed by CAM, Dr. J. Brian
DeVille, took over Dr. Hashimi's patients, including Lida.
Also at 1:00 p.m., registered nurse Michelle Swearingen began
her shift as a "triage nurse" for CAM, which she performed
from her house.  Nurse Swearingen's responsibilities included
handling 
patient 
and 
physician 
inquiries 
forwarded 
to 
her 
from
1041484
Robert, Teresa, and Robert and Teresa's son Todd each
4
testified that they saw Lida "bent over" in pain, and Robert
testified that she was "screaming in pain."  Although Robert
testified that he thought Nurse Greene was in the room when
Lida was screaming in pain, Nurse Greene testified as follows:
5
CAM's weekend answering service.
As Nurse Swearingen began her shift on Saturday at 1:00
p.m., registered nurse Amy Greene was approximately halfway
through her 12-hour shift in the Infirmary's cardiac-care
unit, where she was caring for Lida.  In accordance with Dr.
Hashimi's orders, 
Nurse 
Greene 
had weaned Lida off intravenous
Cardizem and had begun giving her Cardizem in pill form.
Nurse Greene also was administering intravenous heparin, a
blood-thinning medication, to Lida. 
According to Lida's medical records, at approximately
noon her heart rhythm spontaneously converted from atrial
fibrillation to a normal rhythm; her heart rate at that time
was 88, and her blood pressure was 132/71.  However, between
1:15 p.m. and 1:35 p.m., Lida's heart rhythm again went into
atrial fibrillation, and Nurse Greene's "focus note" in the
hospital records indicates that Lida complained at 1:30 p.m.
that she had begun experiencing abdominal pain that was the
"worst she'[d] ever had."   At about the same time, Lida's
4
1041484
"Q.  Now, where were you and [Lida] when you got
that information?
"A.  We were in her room.
"Q.  Where was she in her room?
"A. She was standing, kind of walking back and
forth around her bed.
"Q.  Amy, did you ever see [Lida] doubled over?
"A.  No, sir.
"Q.  Did anybody--[Lida]'s family ever tell you
that she was doubled over in pain?
"A. No, sir.
"Q. When you came in that day and you got that
information, was [Lida] screaming?
"A. No, sir.
"Q. Did you ever hear her screaming?
"A. No, sir.
"Q. Did anybody ever tell you she was screaming
in pain?
"A. No, sir."
6
heart rate increased to 160, and her blood pressure went up to
170/86.
 Robert returned to the hospital at about the time Lida
began to complain of abdominal pain, and he immediately asked
1041484
Nurse Greene called CAM because Dr. Hashimi and Dr.
5
DeVille were listed as Lida's admitting physicians.
In particular, Nurse Swearingen testified that Nurse
6
Greene said that
"she had a patient, Ms. Lida Tyler, who was on
telemetry and who had been admitted the day before
with rapid atrial fib.  She had converted to sinus
7
Nurse Greene for help and asked her to call for a doctor.
Consistent with orders Dr. Hashimi had given when Lida was
admitted 
to 
the Infirmary on 
Friday, 
Nurse 
Greene administered
Darvocet and Phenergan to Lida for her abdominal pain.  Nurse
Greene also examined Lida's abdomen and determined that it
appeared to be normal, despite her complaints of severe pain.
Robert and Lida, however, asked to see a physician.
At 1:40 p.m., Nurse Greene placed the first of three
telephone calls to CAM to report Lida's complaints.   The
5
answering service for CAM answered the call, and the service
then telephoned Nurse Swearingen, who, in turn, telephoned
Nurse Green at the Infirmary.  
Nurse Swearingen testified that she understood Nurse
Greene's "primary concern[s]" in their first conversation to
be Lida's "atrial fib with the increased heart rate and [her]
elevated blood pressure."   Nurse Swearingen testified that
6
1041484
rhythm that morning and that afternoon she had gone
back into atrial fib with elevated heart rate and
elevated blood pressure.
"[Nurse Greene] told me that she had ... taken
her off of the IV Cardizem she had been on since
Friday, earlier that morning. ... She told me that
she was on the pill form of Cardizem .... [and]
Coumadin. ... [And] [s]he was on IV Heparin.  She
told me she was having nausea and abdominal pain.
And she had given Phenergan and Darvocet and Milk of
Magnesia earlier that afternoon."
8
she did not understand from Nurse Greene that Lida's situation
was any type of an emergency.  At the conclusion of their
conversation, Nurse Swearingen told Nurse Green to restart
Lida's intravenous Cardizem and to give her an additional
five-milligram dose or "bolus" of Cardizem.
Nurse Swearingen then telephoned Dr. DeVille.  She
relayed to Dr. DeVille that Dr. Hashimi had admitted Lida on
Friday and that Lida continued to experience atrial
fibrillation even though Lida's heartbeat had spontaneously
converted from atrial fibrillation to a normal rhythm for a
period of time on Saturday morning.  Nurse Swearingen
testified that she also told Dr. Deville that Lida was taking
heparin, Coumadin, and Cardizem and that Lida was having
episodes of abdominal pain even though her abdominal
1041484
Robert testified that he told Nurse Greene:
7
"[I]f you didn't get a doctor in here, I'm going
to take her out of this room and carry her down to
the emergency room where I can at least see a
doctor.  I mean, she's in a hospital.  I remember
Nurse Amy going back out of the room and calling
again."
9
examination had revealed nothing out of the ordinary.  Dr.
DeVille approved the order given by Nurse Swearingen to Nurse
Greene to restart Lida's intravenous Cardizem and to
administer a five-milligram bolus of Cardizem.
At approximately 2:00 p.m., Lida continued to complain of
nausea and stomach pain.  Robert again relayed the complaints
to Nurse Greene, and he again asked her to request that a
physician examine Lida.   Nurse Greene placed a second call to
7
CAM; again, the answering service relayed a message to Nurse
Swearingen, and she telephoned Nurse Greene at the Infirmary.
In their second conversation, Nurse Greene told Nurse
Swearingen that Lida was still in atrial fibrillation, that
her blood pressure was at 190/90 to 200/100, and that her
heart rate was varying between 110 and the 160s.  Nurse Greene
also stated that Lida was still complaining of nausea and of
abdominal pain that was "worse than usual."  Nurse Greene also
1041484
10
stated that the family wanted to speak with a doctor; however,
Nurse Swearingen testified that Nurse Greene did not present
Lida's situation as an emergency.
Nurse Swearingen testified at trial that she then
telephoned Dr. DeVille and informed him that Lida's heart rate
and blood pressure remained elevated, that she was having
abdominal pain and nausea, that the abdominal pain was "worse
than usual," and "that the family had requested to see a
physician, talk to a physician."  The evidence is somewhat
conflicting regarding Dr. DeVille's response at that point:
Nurse Swearingen testified that Dr. DeVille did not tell her
to make any changes at that time, but Dr. DeVille testified
that in either the second or third telephone call, he told
Nurse Swearingen to order Nurse Greene to give Lida an
additional 15-milligram bolus of Cardizem and to increase the
infusion rate of the intravenous Cardizem.
At approximately 2:27 p.m., a third call was placed to
CAM.  Nurse Greene reported to Nurse Swearingen that Lida's
vital signs had not returned to normal and that her nausea and
stomach pain persisted.  Nurse Swearingen again contacted Dr.
DeVille.  She told him that Lida's heart rate and blood
1041484
11
pressure remained elevated, that she was still in atrial
fibrillation, and that she continued to experience abdominal
pain and nausea.
Dr. DeVille told Nurse Swearingen to order Nurse Greene
to apply nitroglycerin paste to Lida's chest, and Dr. DeVille
ordered another 15-milligram bolus of Cardizem for Lida.  Dr.
DeVille also requested Nurse Swearingen to consult Dr. S. Cyle
Ferguson, a gastroenterologist, about Lida's abdominal pain;
the consultation order, however, was not a "stat" or
emergency 
order. 
Nurse 
Swearingen 
relayed 
Dr. 
DeVille's 
orders
to Nurse Greene.
Nurse Greene put in a request for the consult with Dr.
Ferguson.  At approximately 4:00 p.m. Nurse Swearingen
telephoned the Infirmary and spoke with Nurse Patti Elrod to
determine the status of the gastrointestinal consult.  Nurse
Elrod confirmed that a consult had been ordered and that Dr.
DeVille's other orders had been carried out.  Nurse Elrod also
told 
Nurse 
Swearingen, 
erroneously, 
that 
the
gastroenterologist consult had been completed.
For the remainder of the afternoon, Lida rested, and her
blood pressure and heart rate dropped from their earlier
1041484
12
elevated levels.  However, she continued to experience
abdominal pain.  
At approximately 6:30 p.m., registered nurse Jason Lundy,
who was employed by the Infirmary, began to take over Lida's
care.  At about the same time, Dr. C. Ivey Williamson, a
gastroenterologist and Dr. Ferguson's partner, visited the
Infirmary to perform the consultation Dr. DeVille had
requested.  Dr. Williamson performed the consultation because
Dr. Ferguson was not on call.
Lida told Dr. Williamson that her abdominal pain earlier
in the day was "more severe than she usually had."  Dr.
Williamson recorded that her bowel sounds were active and that
her abdomen was slightly tender.   He concluded that her pain
as described by Lida was out of proportion to his physical
findings, and he thought that Lida probably was suffering from
peptic-ulcer disease or pancreatitis.  Dr. Williamson
recommended 
that 
Lida undergo an ultrasound 
of 
her gallbladder
the next morning.  
Nurse Lundy continued to monitor Lida, and he telephoned
CAM for authorization to run the tests Dr. Williamson had
ordered.  Dr. DeVille returned Nurse Lundy's call and
1041484
13
authorized the tests.
On the morning of Sunday, June 6, Nurse Greene began
another shift and assumed Lida's care.  Lida's condition had
worsened.  Nurse Greene observed that Lida was, according to
Nurse Greene's testimony, "moaning" and "only responsive to
pain."  Nurse Greene also noted that Lida's abdomen was
distended and hard.  Nurse Greene placed Lida in the
Infirmary's intensive-care unit.  After Dr. Hashimi examined
Lida, he telephoned Dr. Gerhard Boehm, a surgeon.  Dr. Boehm
concluded that Lida needed emergency surgery.
Dr. Boehm's surgery revealed that Lida's intestine was
necrotic and that she was suffering from an infection.  Dr.
Boehm determined that the necrosis was caused by a mesenteric
blood clot.  He concluded that her condition was fatal, and he
recommended that her family authorize the hospital to forgo
resuscitation efforts.  Lida died on Monday, June 7, 1999.  
On July 12, 2000, Robert, as administrator of Lida's
estate, filed a complaint in the Mobile Circuit Court against
Dr. Hashimi, Dr. DeVille, Nurse Swearingen, CAM, Dr.
Williamson, Dr. Ferguson, Internal Medicine Center, L.L.C.
1041484
Dr. Williamson and Dr. Ferguson were employed by IMC. 
8
The complaint initially named "Mobile Infirmary Medical
9
Center" as a defendant.  However, the parties stipulated
before trial that the "Mobile Infirmary Association" was the
proper corporate name for the entity Robert originally named
as the "Mobile Infirmary Medical Center."
Dr. Williamson died in March 2003, while the action was
10
pending.  The personal representative of his estate was
substituted as a defendant in his place.  See Rule 25, Ala. R.
Civ. P.
The trial court granted the Infirmary's motion to the
11
extent it sought a JML on the negligence claims stated in
subparagraphs 8.f, 8.g, and 8.h of the plaintiff's seventh
amended complaint.  Those claims alleged that the Infirmary
had negligently caused Lida's death by:
14
("IMC"),  and the Infirmary.   The complaint alleged claims of
8
9
wrongful death and medical malpractice.  
Before trial, summary judgments were entered in favor of
Dr. 
Ferguson 
and 
Nurse 
Swearingen. 
 Robert's 
action 
eventually
proceeded to trial against Dr. Hashimi, Dr. DeVille, CAM, Dr.
Williamson's estate,  IMC, and the Infirmary.  At the close
10
of Robert's case-in-chief, all the defendants filed motions
for a judgment as a matter of law ("JML").  The trial court
granted the motions of Dr. Hashimi, Dr. Williamson's estate,
and IMC but denied the motions filed by Dr. DeVille and CAM.
The trial court granted in part and denied in part the
Infirmary's motion for a JML.   At the close of the
11
1041484
"f.  Failing to timely administer Heparin to
[Lida] ...;
"g.  Negligently administering pain medication
to [Lida]  before knowing the cause of her acute
abdominal pain and nausea and before consulting with
a physician;
"h.  Negligently failing to act upon what
appeared to be  a significant decline in and/or
change in [Lida's] condition during the early
morning hours of June 6, 1999."
15
defendants' cases-in-chief, the remaining defendants filed
motions for a JML, which the trial court denied.  
The jury then returned a verdict against solely the
Infirmary for $5,500,000 in damages.  The trial court denied
all postjudgment motions filed by the Infirmary, and the
Infirmary timely filed a notice of appeal.
Discussion
I.
The parties agree that certain provisions of the Alabama
Medical Liability Act, § 6-5-480 et seq., Ala. Code 1975, as
supplemented by the Alabama Medical Liability Act of 1987, §
6-5-540 et seq., Ala. Code 1975 ("the Act"), apply to this
case.  Any liability on the part of the Infirmary is derived
from the actions of its nurses; therefore, under § 6-5-548(a)
1041484
16
of the Act, Robert had "the burden of proving by substantial
evidence that the health care provider [i.e., the Infirmary's
nurses] failed to exercise such reasonable care, skill, and
diligence 
as 
other 
similarly 
situated 
health 
care 
providers 
in
the same general line of practice ordinarily have and exercise
in a like case."  
The Infirmary argues first that the trial court should
have granted the Infirmary's motions for a JML or,
alternatively, its motion for a new trial, because, the
Infirmary contends, there was not sufficient evidence to
support Robert's claim that the 
Infirmary's 
nurses breached an
applicable standard of care.  The Infirmary also contends that
Robert failed to offer sufficient evidence of causation.
The standard of review applicable to a ruling on a motion
for a JML was stated in Mobile Infirmary Medical Center v.
Hodgen, 884 So. 2d 801, 808-09 (Ala. 2003):
"Our standard of review for a renewed motion for
a JML is well settled:
"'In reviewing the trial court's ruling on
a motion for a JML, an appellate court uses
the same standard the trial court used in
ruling on the motion initially.  Thus, "'we
review the evidence in a light most
favorable 
to 
the 
nonmovant, 
and 
we
determine whether the 
party 
with the 
burden
1041484
17
of proof has produced sufficient evidence
to 
require 
a 
jury 
determination.'"
Acceptance Ins. Co. v. Brown, 832 So. 2d 1,
12 (Ala. 2001), 
quoting American Nat'l Fire
Ins. Co. v. Hughes, 624 So. 2d 1362,
1366-67 (Ala. 1993); see, also, Jim Walter
Homes, Inc. v. Kendrick, 810 So. 2d 645,
649-50 (Ala. 2001).'
"Hicks v. Dunn, 819 So. 2d 22, 23-24 (Ala. 2001).
Thus, in reviewing the evidence in this case, we are
required to construe the facts and any reasonable
inferences that the jury could have drawn from them
most favorably to [the nonmovant]."
Moreover, this Court noted in Liberty Life Insurance Co. v.
Daugherty, 840 So. 2d 152, 156 (Ala. 2002):
"'"A judgment as a matter of law is proper only
where there is a complete absence of proof on a
material issue or where there are no controverted
questions of fact on which reasonable people could
differ and the moving party is entitled to a
judgment as a matter of law."'  Southern Energy
Homes, Inc. v. Washington, 774 So. 2d 505, 510-11
(Ala. 2000), quoting Locklear Dodge City, Inc. v.
Kimbrell, 703 So. 2d 303, 304 (Ala. 1997).  In
reviewing the denial of a motion for a judgment as
a matter of law, this Court is required to view the
evidence in a light most favorable to the nonmovant.
Kmart Corp. v. Kyles, 723 So. 2d 572, 573 (Ala.
1998).  Therefore, where the evidence in the record
is disputed, we present it in a light most favorable
to [the nonmovant]." 
Our standard for reviewing a trial court's ruling on a
motion for a new trial has been stated as follows:
"There is a strong presumption that a trial
court's ruling on a motion for a new trial is
1041484
18
correct.  Alabama Dep't of Transp. v. Land Energy,
Ltd., 886 So. 2d 787, 792 (Ala. 2004).  The trial
court's ruling on a motion for new trial '"should
not be disturbed on appeal unless the record plainly
and palpably shows that the trial court erred and
that some legal right has been abused."'  886 So. 2d
at 792 (quoting McBride v. Sheppard, 624 So. 2d
1069, 1070-71 (Ala. 1993)). However, we review a
ruling on a question of law de novo.  Ex parte
Forrester, 914 So. 2d 855, 858 (Ala. 2005)."
Parker Bldg. Servs. Co. v. Lightsey, 925 So. 2d 927, 930 (Ala.
2005).
A.
The Infirmary contends that Karen Cepero, a registered
nurse who testified during Robert's case-in-chief, was not
qualified as 
a 
"similarly situated health 
care provider" 
under
§ 6-5-548(b), Ala. Code 1975, to testify against the
Infirmary's nurses, particularly against Nurse Greene. 
At trial, Robert focused primarily on the actions of
Nurse Greene, who, at the time she provided care to Lida, was
a registered nurse providing hands-on patient care in the
Infirmary's 
cardiac-care 
unit. 
 
Therefore, 
Robert 
was 
required
to offer substantial evidence showing that Nurse Greene's
actions fell below the standard of care stated in § 6-5-
548(a).  
To meet that burden, Robert had to offer testimony from
1041484
19
"a 'similarly situated health care provider'" in conformity
with § 6-5-548(b), Ala. Code 1975, which provides:
"(b) Notwithstanding any provision of the
Alabama Rules of Evidence to the contrary, if the
health care provider whose breach of the standard of
care is claimed to have created the cause of action
is not certified by an appropriate American board as
being a specialist, is not trained and experienced
in a medical specialty, or does not hold himself or
herself out as a specialist, a 'similarly situated
health care provider' is one who meets all of the
following qualifications:
"(1) Is licensed by the appropriate
regulatory board or agency of this or some
other state.
"(2) Is trained and experienced in the
same discipline or school of practice.
"(3) 
Has 
practiced 
in 
the 
same
discipline or school of practice during 
the
year preceding the date that the alleged
breach of the standard of care occurred."
The Infirmary's principal objection to Nurse Cepero's
qualifications is whether she meets the requirement stated in
§ 6-5-548(b)(3).  Thus, the Infirmary argues that "there was
no affirmative showing by [Robert] that Nurse Cepero provided
'hands on care' to any patient in the telemetry units for
which she had responsibility in the year preceding 1999."
(Infirmary's brief, p. 23.) 
In response, Robert contends that the Infirmary failed to
1041484
Robert also contends that Nurse Cepero in fact testified
12
that she practiced hands-on patient care in the year before
June 1999, and he contends that Nurse Cepero "has far greater
qualifications than those required by [§ 6-5-548(b)]." 
The record indicates that the Infirmary did object to
13
testimony by Nurse Cepero that a consult order should have
been "stat."  However, there is no indication that the
Infirmary objected to Nurse Cepero's qualifications.
20
object to Nurse Cepero's qualifications at the time Robert
introduced Nurse Cepero's testimony at trial; therefore,
Robert argues, the Infirmary waived any objection to her
qualifications.   We agree.
12
The Infirmary filed a pretrial motion objecting to the
qualifications of Nurse Cepero, and, at the close of Robert's
case, filed a motion for a JML that, among other things,
objected to Nurse Cepero's qualifications.  However, the
Infirmary did not object to Nurse Cepero's qualifications at
the time Robert sought to introduce her testimony into
evidence at the trial.   Consequently, the Infirmary did not
13
raise a timely objection to the qualifications of Nurse Cepero
as a similarly situated health-care provider.  
"'An objection must be made and a ground stated
therefor or the objection and error are deemed to
have been waived.'  Costarides v. Miller, 374 So. 2d
1335, 1337 (Ala. 1979).  See also HealthTrust, Inc.
v. Cantrell, 689 So. 2d 822, 825-26 (Ala. 1997).
1041484
21
'Objections must be "raised at the point during
trial when the offering of improper evidence is
clear," see Charles W. Gamble, McElroy's Alabama
Evidence § 426.01(3) (5th ed. 1996).'  HealthTrust,
689 So.2d at 826.  Dr. Vaughan and the Group did not
challenge Dr. Rodan's qualifications as a similarly
situated health-care provider until the close of the
plaintiff's 
evidence.  Consequently, their challenge
was untimely and was waived. HealthTrust, supra, and
Paragon Eng'g, Inc. v. Rhodes, 451 So. 2d 274, 277
(Ala. 1984)."
Vaughan v. Oliver,  822 So. 2d 1163, 1169 (Ala. 2001).
B.
In response to the Infirmary's contention that there was
not sufficient evidence to support the conclusion that the
Infirmary's 
nurses 
negligently 
breached 
an 
applicable 
standard
of care, Robert argues, among other things, that there was
sufficient evidence from which the jury could conclude that
Nurse Greene negligently failed to adequately and accurately
communicate to CAM the nature and severity of Lida's abdominal
pain.  We agree.
At trial, Robert testified as follows:
"Well, when I got back [to the Infirmary on June
5], I'm guessing it was around 1:00 o'clock,
possibly 1:30, somewhere thereabouts, when I walked
in the door, [Lida] was screaming in pain.  When I
say screaming, she was, 'Oh, [Robert], help me.  Oh,
I'm hurting.'  She was sitting up in bed. And as
best I can remember, it was [Nurse Greene] in there
with her at the time.
1041484
Teresa testified:
14
"Q.  Do you remember any statements that she was
making to you, or to your husband, or to your son
while y'all were there in the room that afternoon
and she was in this pain?
"A.  Well, she just kept saying how much she was
hurting.  And one time, I was working--She liked to
work crossword puzzles, so I was just sitting there
working a crossword puzzle, and she looked at me and
asked me, she said, 'Teresa, do you think I'm going
to make it?'"
Todd testified:
"A.  When we got there, my grandma was screaming
in horrible pain when we arrived, at the end of her
bed crouched over holding her stomach.
"Q.  Was your father there in the room at the
time?
"A.  Yes, sir, he was in the room.
"Q.  Do you remember what he was doing?
22
"....
"[Lida] was sitting up in bed.  And I can't
remember for sure if her legs were off the bed or
over the foot of the bed or what.  She was sitting
up in bed screaming, '[Robert], help me. Oh, I'm
hurting.  Oh, oh, I'm hurting,' just like that, you
know, nothing near about any kind of ordinary pain
that you have in your abdomen."
Robert's testimony was corroborated by testimony from Teresa
and from Robert and Teresa's adult son, Todd.   
14
1041484
"A.  He was just tending to her and he was
trying to get some help to come into the room to get
something done.
"Q.  Okay.  Did you stay in that room most of
the afternoon that afternoon?
"A.  Yes.
"Q.  You say your grandmother was--she was
sitting up on the bed?
"A.  Right.
"Q.  And holding her stomach?
"A. (Nods head affirmatively).
"Q.  Do you remember anything she was saying or
anything she was doing at that point?
"A.  She was just saying, 'Bobby, I need some
help. It hurts me really bad, you know.'  I even
remember ... [s]he asked my mom if she thought she
was going to make it a little while later."
23
In addition, Nurse Greene had prepared "focus notes" that
documented her experience in caring for Lida; those notes were
admitted into evidence as a part of Lida's records from the
Infirmary.  Those notes and testimony regarding them at trial
indicate that Nurse Greene had written that at 1:30 p.m. on
June 5, Lida reported experiencing the worst abdominal pain
1041484
At trial, Nurse Greene testified that she could not
15
remember specifically telling Nurse Swearingen that Lida
stated she was experiencing the worst abdominal pain she had
ever had.  However, Nurse Greene admitted that Lida described
the pain as the worst she had ever had.  Nurse Greene
testified:
"Q.  Now, is this another focus note where
you're summarizing events that have taken place?
"A.  Yes, sir.
"Q.  Now, I want you to read that for us, if you
would.
"A. 'Patient complains of nausea and pain in
stomach, worst she has ever had.' ...
"Q.  Now, this, 'worst she has ever had,' is
that a quote right there and that a quote?
"A.  That is a quote.
"Q.  Where did you get that from?
"A.  Well, I had asked Mrs. Tyler to describe
the pain when she complained of the pain. I just
asked her to describe it to me. And I asked her
questions, you know, is it dull, is it aching, is it
a burning pain, where is it at, and she couldn't
describe it any other way to me.  She said, 'It's
just the worst that I ever had.'"
24
she had ever had.15
Nurse Swearingen testified that Nurse Greene told her
Lida was experiencing abdominal pain.  However, Nurse
Swearingen testified that Nurse Greene did not tell her that
1041484
25
Lida described the pain as the worst abdominal pain she had
ever experienced.  Instead, Nurse Swearingen testified that
Nurse Greene told her that Lida had a history of abdominal
pain and that Nurse Greene stated, during one of their
telephone conversations, that Lida described her pain as
"worse than usual."  Nurse Swearingen stated that in their
telephone conversations, Nurse Greene's focus was on Lida's
atrial fibrillation and her rapid ventricular response.  
Specifically, Nurse Swearingen testified as follows:
"Q.  Tell us about the [first] conversation you
had with Nurse Greene; what did she tell you?
"A.  Okay. She told me she had a patient, Mrs.
Lida Tyler, who was on telemetry and who had been
admitted the day before with rapid atrial fib. She
had converted to sinus rhythm that morning and that
afternoon she had gone back into atrial fib with
elevated heart rate and elevated blood pressure.
"She told me that she had weaned the--she had
taken her off of the IV Cardizem she had been on
since Friday, earlier that morning. We talked about
her medications. She told me that she was on the
pill form of Cardizem. ... She had weaned the IV
Cardizem earlier. And Heparin. She was on IV
Heparin. She told me she was having nausea and
abdominal pain. And she had given Phenergan and
Darvocet 
and 
Milk 
of 
Magnesia 
earlier 
that
afternoon.
"Q.  Now, from your discussion with Nurse
Greene, what did you understand the purpose of this
first call to be?
1041484
26
"A.  The atrial fib with the increased heart
rate and elevated blood pressure was her primary
concern.
"Q.  Was this being--was it being presented to
you as any type of emergency?
"A. No.
"....
"Q.  Now, in regard to Mrs. Tyler's pain, you
were told--what were you told about her abdominal
pain?
"A.  I asked [Nurse Greene] if Mrs. Tyler had
had a history of abdominal pain and she said she
didn't know.  And I asked her if there was any
family with her that could answer that or if Mrs.
Tyler could answer that and she put me on hold and
she went and talked to someone.  And I actually
could hear them in the background.  It was a male.
I couldn't hear the words he said. But when she came
back, she said that Mrs. Tyler did have a history of
abdominal pain.
"Q.  Okay. Did that occur in the first call or
the second call?
"A.  That was in the first phone call.
"Q.  Now, were you told whether or not she
had--in regard to the abdominal assessment, you were
told there were positive bowel sounds?
"A.  Right.  We talked about the abdominal
assessment and she told me that she had bowel sounds
in all four quadrants and that her abdomen was
nontender.  It was nondistended.
"....
1041484
27
"Q.  Now, what did you do at that point? After
you got that information, what did you do?
"A.  I called Dr. Deville ... [and] told [him]
that there was a patient, Lida Tyler, who was
admitted to Mobile Infirmary on Friday.  She had had
a normal heart cath.  And she had been admitted
primarily for a rapid atrial fib, which she had gone
into sinus rhythm Saturday morning.  She had been on
IV Cardizem; it was weaned.  She was back in atrial
fib with a rapid rate.  She had elevated blood
pressure.  Elevated heart rate.
"We went over her medications.  I told him she
was on Heparin and Coumadin and PO Cardizem. And we
talked about her exam, her abdominal exam, her
peripheral exam and that I had given [Nurse Greene]
instructions to give a Cardizem bolus and restart
the Cardizem and that she had had a history of
abdominal pain.
"Q.  Did you tell him about the abdominal
assessment that [Nurse] Greene had done?
"A. Yes.
"Q. That is her abdominal assessment showed
positive bowel sounds in all four quadrants, soft,
nontender, nondistended?
"A. Right.
"Q. And you told him that you had been informed
that she had a history of the same abdominal pain?
"A. I did.
"....
"Q.  What did [Nurse] Greene tell you on the
second call?
1041484
28
"A. [Nurse Greene] told me that [Lida's] blood
pressure was still elevated.  Her heart rate was
still elevated.  Still in atrial fib.  And she was
having nausea and abdominal pain.  We talked about
the nausea and abdominal pain.  She told me that it
was worse than usual, is how [Lida] stated it, not
how [Nurse Greene] stated it. [Lida] had expressed
that her abdominal pain was worse than usual.
"Q.  Were there any other descriptions that you
were given?
"A.  Yes.  She told me that [Lida's] family had
asked to speak to a physician.
"....
"Q.  Were you ever told by anyone from Mobile
Infirmary and these calls from [Nurse] Greene that
Mrs. Tyler was in the worst pain she had ever had?
"A.  I was not told that.
"Q.  Would that have been important for you to
know?
"A.  I would like to know everything the nurse
has to offer so I can tell the doctor. Any
information, yes, sir, would be helpful.
"Q. And if, in reality, this was not the same
type of indigestion she had had at home, but instead
this was the most severe abdominal pain that bent
her over at about 1:00, and that she was begging for
help and wanted the doctor, and that her son had
demanded the doctor, that's not the picture that was
painted to you, is it?
"A.  No, sir.
"....
1041484
29
"Q.  What, if anything, would you have done
differently, given those additional facts?
"A.  I wouldn't have done anything differently.
I would have taken the facts and given them to Dr.
Deville, just like I did.
"Q. So the only thing that would have been
different is you would have given him more
information, information you did not otherwise have;
is that correct?
"A. Different information.
"....
"Q.  Now, it's true that in at least two of
these phone conversations that [Nurse] Greene
sounded anxious, according to your testimony at your
deposition?
"....
"A.  When [Nurse Greene] called me, she sounded
anxious about the atrial fib and the elevated heart
rate and the elevated blood pressure. That is what
was communicated to me that her anxiety was about
the rhythm and the rate.
"....
"Q. You had no indication in any of these phone
conversations that Mrs. Tyler had been doubled over
in pain, abdominal pain, and that her family was
demanding a doctor?
"A.  No, sir, I had no indication of that."
Thus, Nurse Swearingen's testimony was sufficient evidence
from which the jury could conclude that Nurse Greene did not
1041484
30
communicate to Nurse Swearingen that Lida stated that she was
experiencing the worst pain she had ever had.
Robert presented testimony from Nurse Cepero, a similarly
situated health-care provider, that Nurse Greene breached the
applicable standard of care if Nurse Greene failed to
communicate 
to 
Nurse 
Swearingen 
that Lida was experiencing 
the
worst abdominal pain she had ever had.  Specifically, Nurse
Cepero testified in deposition:
"'Q.  If Nurse Greene in the phone conversation
she had with Nurse Swearingen on June 5, 1999, in
the afternoon, had not ... reported that Lida Tyler
had a sudden acute onset of the worst stomach pain
she ever had in her life, and that it occurred soon
after spontaneous cardioversion, and instead of
communicating 
that, 
Nurse 
Greene 
told 
Nurse
Swearingen that Mrs. Tyler's abdominal pain was
worse than the usual pain she historically had at
home, do you have an opinion whether that fell below
the standard of care for nurses, if it happened?
"'....
"'A.  I just want to make sure I understand your
question properly. ... Are you saying, sir, that if
[Nurse] 
Greene 
didn't 
communicate 
to 
Nurse
Swearingen that the patient had abdominal pain worse
than ever, would that fall below a standard of care,
if it happened?
"'Q. And in the context of Mrs. Tyler being an
atrial 
fibrillation 
patient 
who 
spontaneously
converted; right?
"'A.  It would have fallen below standard of
1041484
Portions of a video of Nurse Cepero's deposition were
16
played for the jury, but those portions were not transcribed
and made a part of the reporter's transcript of the trial
proceedings.  The Infirmary filed a motion to supplement the
record on appeal to include transcribed portions of Cepero's
videotaped deposition.  That motion was granted.
As noted, to establish that Nurse Cepero testified as to
the standard of care regarding Nurse Greene's duty to
communicate to Nurse Swearingen Lida's description of her
pain, Robert quotes from Nurse Cepero's deposition.  Although
the pages 
of 
Nurse 
Cepero's 
deposition testimony 
Robert quotes
from are not included in the pages submitted by the Infirmary,
we  assume the testimony cited by Robert was in fact put into
evidence at trial, because at pages 31-32 of its brief to this
Court the Infirmary quotes the same testimony from Nurse
Cepero that Robert quotes.  
31
care if she didn't communicate that information to
Nurse Swearingen.
"'Q.  In other words, we're talking about the
level of pain, the quality of pain?
"'....
"'A.  Yes.  That's part of our assessment.'"
(Robert's brief, pp. 49-50 (quoting plaintiff's trial exhibit
163, pp. 48-49).)16
The Infirmary argues that Nurse Cepero's testimony was
insufficient to establish that Nurse Greene was negligent.
The Infirmary contends that Nurse Cepero's testimony is
deficient because, the Infirmary says, it fails to give "[t]he
judge and jury ... [a] benchmark by which to assess [Nurse
1041484
32
Greene's] care."  (Infirmary's brief, pp. 33-34.)  The
Infirmary cites two cases: Henson v. Mobile Infirmary Ass'n,
646 So. 2d 559 (Ala. 1994); and Pruitt v. Zeiger, 590 So. 2d
236 (Ala. 1991). 
In Henson, this Court held that a doctor's testimony as
to "the 'safest' way for a health care provider to prepare a
patient for an MRI test" did not necessarily establish "what
is required by 'reasonable care, skill and diligence."  646
So. 2d at 563 (emphasis added).  This Court noted that the
doctor "repeatedly stated that his testimony reflected his
individual opinion, and 
he 
conceded 
that 
health care 
providers
could have opposing opinions as to 'the best course of action'
in a given situation and still 'be within the standard of the
care.'" 646 So. 2d at 563.  This Court concluded that "by
limiting his testimony to the statement of a 'personal
opinion,' [the doctor] failed to address a community standard
(of what is reasonable 'care, skill and diligence')."  646 So.
2d at 563.
Henson is distinguishable from this case.  Unlike the
doctor in Henson, Nurse Cepero expressed her familiarity with
the applicable standard of care.  (Robert's brief, p. 49
1041484
33
(citing 
plaintiff's 
trial 
exhibit 163, pp. 30-31).)  
Moreover,
Nurse Cepero testified that a failure by Nurse Greene to
"communicate to Nurse Swearingen that [Lida] had abdominal
pain worse than ever ... would have fallen below standard of
care."  Unlike the testimony at issue in Henson, it is not
apparent that Nurse Cepero's statement was based on only her
personal opinion.
In Pruitt, this Court held that the standard of care had
not been established by the plaintiff's expert.  Regarding the
defendant's care, the expert had testified that his "'main
complaint and objection was the breakdown or the absence of or
the deterrence of any communication between the various
caretakers.'"  590 So. 2d at 238.  This Court rejected that
statement as establishing the standard of care. 
"Although 
Dr. 
Taylor 
alluded 
to 
a 
'breakdown' 
in
communication throughout his testimony, he failed to
explain the manner in which communication was
deficient.  It was incumbent upon Dr. Taylor to
explain how 'physicians ... in the same general
neighborhood, and in the same general line of
practice,'  Ala. Code 1975, § 6-5-484(a), would
communicate under the circumstances presented in
this case.  A blanket statement that communication
was poor does not establish a standard of care.  'In
order to establish a physician's negligence, the
plaintiff must offer expert medical testimony as to
the proper practice, treatment, or procedure.'
Dobbs v. Smith, 514 So. 2d 871, 872 (Ala. 1987).
1041484
34
Dr. Taylor did not describe a procedure that rises
to the level of a standard of care.  He merely gave
his opinion as to what Dr. Zeiger should have done
under the circumstances presented in this case.
'The law does not permit a physician to be at the
mercy of testimony of his expert competitors,
whether they agree with him or not.'  Sims v.
Callahan, 269 Ala. 216, 225, 112 So. 2d 776, 783
(1959).
"Although Dr. Taylor was repeatedly asked to
describe the standard of care, he was unable to
define that standard or describe any procedure that
Dr. Zeiger was required to follow in order to comply
with the standard of care.  The following is
representative of the broad statements made by Dr.
Taylor in response to this line of questioning:
"'Q. Doctor, then, is it your opinion that
Dr. Zeiger deviated from the national
medical community standards in the
care and treatment of Mr. Pruitt in
that regard in this case?
"'A. Well, I don't want to point fingers.
But I do think that there was some
reduced care below the standards.'
"Testimony that the care rendered was 'below the
standards' without establishing those standards 
does
not satisfy the Pruitts' burden.  Before the expert
witness can establish a deviation from the standard
of care, the witness must establish the standard
from which the deviation occurred.
"In Hines v. Armbrester, 477 So. 2d 302 (Ala.
1985), this Court stated:
"'We are to view the testimony [of the
plaintiff's expert] as a whole, and, so
viewing it, determine if the testimony is
sufficient 
to 
create 
a 
reasonable 
inference
1041484
35
of the fact the plaintiff seeks to prove.
In other words, can we say, considering the
entire 
testimony 
of 
the 
plaintiff's 
expert,
that an inference that the defendant 
doctor
had acted contrary to recognized standards
of professional care was created?'
"Id. at 304-05. In viewing the testimony in this
case as directed in Hines, we conclude that the
Pruitts failed to meet their burden to produce
competent 
expert 
testimony 
of 
Dr. 
Zeiger's
malpractice."
590 So. 2d at 238-39.  
Pruitt, however, is also distinguishable from the instant
case.  First, Nurse Cepero did not make a generalized
criticism 
of 
Nurse 
Greene's 
communication 
to 
Nurse 
Swearingen.
Instead, Nurse Cepero testified that Nurse Greene's action in
failing to communicate a very specific item of information--
i.e., Lida's description of her pain as the worst abdominal
pain she had ever experienced--fell below the applicable
standard of care.  Second, unlike the scenario in Pruitt,
there is a specific way in which Nurse Greene could have
complied with the standard established by Nurse Cepero's
testimony.  That is, if Nurse Greene had communicated to Nurse
Swearingen 
that 
Lida 
reported 
experiencing 
the 
worst 
abdominal
pain she had ever had, then her communication would not have
1041484
Although not a part of the Robert's case-in-chief, Nurse
17
Katrina Brown, a witness called by the Infirmary, testified:
"Q.  You agree that Lida Tyler and her family
had the right to have the severity of her condition
accurately and effectively communicated to the
doctors at [CAM]?
"A.  Yes, sir.
"Q.  And you agree that the nurses at the Mobile
Infirmary were responsible for that communication?
"A. Yes, sir.
"....
"A.  I think as nurses we do not necessarily
determine when a patient needs a doctor unless we
get to an emergency situation such as a code
situation or so forth. Our job is to relay every bit
of information we have to the doctor when we need to
do that."
Similarly, Nurse Greene testified:
"Q.  In your training as a nurse and working at
the Infirmary, let me ask you if you agree with
these nursing principles, all right?  Do you agree
that a nurse ought to exercise reasonable care?
"A.  Yes, sir. 
"Q.  And you agree that a nurse ought to report
the patient's change of condition when it's
necessary?
"A.  Yes, sir.
36
violated the standard of care.17
1041484
"Q.  Should a nurse be accurate in what they
tell somebody, whether it's another nurse or another
doctor?
"A.  Yes, sir."
(Emphasis added.)
37
Consequently, Robert offered sufficient evidence of the
standard of care applicable to Nurse Greene.  Even so, the
Infirmary also contends that testimony at trial "shows Nurse
Greene did communicate that [Lida] 'had abdominal pain worse
than ever.'" (Infirmary's brief, p. 34.)  However, the trial
testimony cited by the Infirmary does not show that Nurse
Greene communicated that Lida had abdominal pain that was
"worse than ever."  Instead, the testimony relied on by the
Infirmary 
shows 
that Nurse Greene 
reported 
to 
Nurse 
Swearingen
that Lida said the pain was "worse than usual."  See, e.g.,
Infirmary's 
brief, 
p. 
34 
(quoting 
Nurse 
Swearingen's 
testimony
at trial that "'[Nurse Greene] told me that ... [Lida] was
having nausea and abdominal pain. ... She told me that it was
worse than usual .... [Lida] expressed that her abdominal pain
was worse than usual ....'" (emphasis added)); Infirmary's
brief, p. 36 (quoting Dr. DeVille's testimony that "'I was
told [by Nurse Swearingen] that the pain was worse than
1041484
Robert offers at least four additional examples of
18
conduct by the Infirmary's nurses that he contends provided
sufficient evidence of negligence.  However, because there is
sufficient evidence that Nurse 
Greene 
was negligent in failing
to accurately report Lida's pain to Nurse Swearingen, we
pretermit discussion of any additional evidence of negligence
by the Infirmary.  
38
usual'" (emphasis added)).  
Abdominal pain that is "worse than usual" may indeed be
abdominal pain that is the worst a person has ever
experienced.  However, there was evidence--most notably the
focus note prepared by Nurse Greene--that Lida described the
pain as the worst she had ever experienced.  There also was
evidence that, despite Lida's description of the pain as the
worst she had ever experienced, Nurse Greene reported the pain
as being only "worse than usual."  Consequently, the jury had
sufficient evidence from which it could conclude that Nurse
Greene breached the standard of care in reporting Lida's
pain.18
C.
The Infirmary does not dispute that there was sufficient
evidence to show that Lida suffered from bowel infarction that
caused her death.  Nor does the Infirmary dispute that there
was sufficient evidence to support Robert's theory that the
1041484
During his case-in-chief, Robert presented testimony
19
from Dr. Joel Feinstein, a board-certified physician in
internal medicine and gastroenterology.  Dr. Feinstein opined
that Lida "threw" an embolus on Saturday, which, he testified,
eventually 
lodged in her 
superior 
mesenteric artery.
According to Dr. Feinstein, the embolus then cut off or
significantly limited the blood supply in that artery,
eventually resulting in necrosis of the bowels.  
39
bowel infarction was caused by a peripheral embolization--
i.e., a thrown embolus--that eventually lodged in Lida's
superior mesenteric artery resulting in "acute mesenteric
ischemia."   However, the Infirmary contends that Robert
19
failed to offer sufficient evidence to show that Nurse
Greene's failure to accurately report Lida's pain probably
caused or contributed to Lida's death.  Specifically, the
Infirmary contends that "there was absolutely no evidence ...
that an earlier examination ... by any physician would have
resulted in a different diagnosis, different treatment plan,
or different outcome for [Lida]."  We disagree.
"'To prove liability in a medical malpractice
case, the plaintiff is required to show that the
health care provider failed to exercise such
reasonable care, skill, and diligence as other
similarly situated health care providers in the same
general line of practice ordinarily have and
exercise in a like case.'  Parker v. Collins, 605
So. 2d 824, 826 (Ala. 1992).  'There must be more
than the mere possibility that the negligence
complained of caused the injury; rather, there must
1041484
40
be evidence that the negligence complained of
probably caused the injury.'  Id.
"... Unless 'the cause and effect relationship
between the breach of the standard of care and the
subsequent complication or injury is so readily
understood that a layperson can reliably determine
the 
issue 
of 
causation,' 
causation 
in 
a
medical-malpractice case must 
be 
established 
through
expert testimony.  Cain v. Howorth, 877 So. 2d 566,
576 (Ala. 2003); see also Bradley v. Miller, 878 So.
2d 262 (Ala. 2003); Rivard v. University of Alabama
Health Servs. Found., P.C., 835 So. 2d 987 (Ala.
2002)."
DCH Healthcare Auth. v. Duckworth, 883 So. 2d 1214, 1217-18
(Ala. 2003).
In his brief to this Court, Robert provides the following
summary of the medical evidence introduced at trial regarding
the risk and symptoms of acute mesenteric ischemia in patients
with atrial fibrillation: 
"Atrial fibrillation has a number of potential
complications, 
including, most dangerously, the 
risk
of 'peripheral embolization' or throwing a blood
clot.5
"People in atrial fibrillation can, and often
do, cardiovert back to a normal or 'sinus' rhythm on
their own.  Other times doctors will cardiovert
patients 
pharmacologically 
or 
electrically.
However, cardioversion brings an increased risk of
peripheral embolization. ... The reason for the
increased 
risk 
is 
that 
a 
heart 
in 
atrial
fibrillation generally does not have the power to
dislodge a clot which may develop in its atrium.
However, once normal sinus rhythm is restored, the
1041484
Nurse Greene testified:
20
"Q.  You're aware that if there is a blood clot,
it can cut off the oxygen supply to the organs?
"A.  Yes, sir.
"Q.  You knew that in 1999, right?
"A.  Yes, sir.
"Q.  And if that happens, it's life threatening?
"A.  Yes, sir.
"Q.  And if that happens ultimately what's going
to need to happen is a surgeon is going to have to
take care of that?
"A.  Yes, sir."
41
efficiency of the heart is restored and clots which
have developed are expelled to other parts of the
body. ... For this reason, A-fib patients are
anticoagulated 
for 
thirty 
days 
prior 
to
cardioversion. ...
"Every one of Mrs. Tyler's treating health care
providers were aware of her risk of embolization,
including, especially, the Infirmary's nurse, Amy
Greene.
 ... It was ... acknowledged ... that a
[20]
blood clot could travel to the patient's mesenteric
vasculature causing 'acute mesenteric ischemia,'
which is fatal if not promptly diagnosed ... and
immediately treated. ... The classic symptom of
acute mesenteric ischemia is a sudden acute onset of
severe abdominal pain so dramatic and out of
proportion to other findings that the diagnosis
should not be missed.
1041484
42
"____________
" The 
most 
dangerous 
complication 
is 
a
5
peripheral embolization--i.e., throwing a blood
clot. ... Peripheral embolization occurs when a
blood clot in the heart, created because of the
heart's decreased ability to move blood during
atrial fibrillation (i.e., stasis), breaks loose and
travels to other parts of the body where it lodges
and blocks the blood and oxygen supply to certain
organs and extremities. ..."
(Robert's 
brief, 
pp. 
14-18 
(footnotes 
and 
citations 
omitted).)
Regarding the diagnosis and treatment of acute mesenteric
ischemia, Robert's brief offers this summary:
"[E]mbolization is easily diagnosable and 
treatable.
Generally, all that is required is an x-ray to rule
out other possible abdominal problems, an angiogram
to confirm the diagnosis, and a simple embolectomy
performed by a general or vascular surgeon to
evacuate the blood clot and restore blood flow. ...
Depending on the location and size of the clot,
vasodilating drugs may be used. ... The diagnosis
and treatment carries little risk of complication.
... 
When 
timely 
detected 
and 
treated, 
the
probability of survival is great.12
"____________
" Clinical trials and studies utilizing the
12
approach 
of 
early angiography established the
likelihood of survivability when diagnosed 
promptly.
The key to survival is to treat the condition before
signs of peritonitis and infarction begin to appear.
Medical literature read to the jurors confirmed
these points:
"--
'In our center, more than 50% of the patients
with AMI treated according to our approach
1041484
43
survived, and more than 75% have lost less than
a meter of intestine.  The importance of early
diagnosis is emphasized by the survival of 90%
of patients who had AMI but no signs of
peritonitis and who had angiography early in
their course. Ideally, all patients with AMI
should be studied when plain films of the
abdomen are normal, before signs of an acute
surgical abdomen and laboratory evidence of
infarction appear.' ...
"--
'[I]f 
the 
diagnosis 
is 
not 
made 
before
intestinal infarction, the mortality rate is
seventy percent to ninety percent.' ..."
(Robert's 
brief, 
pp. 
19-20 
(citations 
and 
footnotes 
omitted).)
Robert does not contend that Nurse Greene was responsible
for diagnosing acute mesenteric ischemia.  However, he does
argue that there was sufficient evidence to show that timely
diagnosis and successful treatment of Lida's acute mesenteric
ischemia 
was prevented by Nurse Greene's 
failure 
to 
adequately
communicate to Nurse Swearingen (and, in turn, to Dr. DeVille)
the severity of Lida's abdominal pain.  In other words, Robert
contends that if Nurse Greene had adequately communicated to
Dr. DeVille the severity of Lida's pain, Lida's acute
mesenteric ischemia probably would have been timely diagnosed
and successfully treated.  Specifically, Robert argues that
adequate communication from Nurse Greene to Nurse Swearingen
probably would have caused Dr. DeVille to order a stat or
1041484
In addressing the issue of causation, the Infirmary does
21
not address in its briefs to this Court the evidence on which
Robert relies to assert that, had Dr. DeVille been properly
informed, he would have initiated a surgical consult, which,
in turn, probably would have resulted in Lida's survival.
Instead, although it states generally that there was
"absolutely no evidence ... that an earlier examination ... by
any physician would have resulted in a different diagnosis,
different treatment plan, or different outcome for [Lida],"
the Infirmary addresses its specific arguments regarding
causation only to the question whether an earlier consult with
a gastroenterologist would have resulted in a different
outcome; as to that specific question, the Infirmary contends
there was not sufficient evidence of causation.  
Thus, the Infirmary does not specifically address
Robert's alternative theory of causation, which is that Nurse
Greene's failure to accurately communicate Lida's symptoms of
pain caused Dr. DeVille to fail to order a surgical consult,
which, in turn, prevented Lida from receiving a timely life-
saving surgical procedure.  
44
emergency consultation with a surgeon, which, in turn,
probably would have resulted in a different outcome, i.e.,
Lida probably would have survived.21
At trial, Robert presented testimony from Dr. David J.
Korn, 
a 
doctor 
board-certified 
in 
internal 
medicine,
cardiology, and critical care.  Dr. Korn's testified as to
what was required by the standard of care applicable to Dr.
DeVille.  Specifically, Dr. Korn testified as follows:
"Q.  Do you have an opinion, based upon your
training, education, and experience, as to whether
a cardiologist, any board-certified cardiologist,
1041484
45
... as of June 1999 had an obligation to have a high
index of suspicion of a vascular emergency where
there was a patient with an identified risk of
peripheral embolization that was in the hospital in
the telemetry unit; the patient had been in atrial
fibrillation; had not been fully anti-coagulated to
a therapeutic level; at that time, spontaneously
converted from atrial fibrillation to normal sinus
rhythm; shortly thereafter, converted from normal
sinus rhythm back to atrial fibrillation; and soon
thereafter, was followed by the worst gut pain she
had ever had in her life? I want you to assume those
facts.
"A.  Yes, sir.
"Q.  Would a reasonable cardiologist practicing
then and there, if ... that information was
communicated to that person, have an obligation to
have a high index of suspicion of peripheral
embolization?
"A.  The answer is yes.
"Q.  And why is that your opinion?
"....
"A.  Okay. The answer is that you have to have
a high index of suspicion for embolization when
someone 
is 
in 
atrial 
fibrillation. 
Atrial
fibrillation is an irregular heartbeat, and when
that occurs, there's a very high likelihood or
possibility that the patient may have a clot that's
thrown from the heart.
"When this patient went back and forth from
atrial fibrillation back to sinus rhythm and then
from sinus rhythm back to atrial fibrillation, she
was at increased risk at that point for throwing
those clots.  Those are the specific times when she
goes from atrial fib to sinus and from sinus to
1041484
46
atrial fib. Those are the key areas. So, when she
had the worst pain that she ever had, it was
incumbent upon the doctor to say, oh, my, what's
going on with this lady.  It was, obviously, a risk
of a clot going somewhere, and because she was
complaining of abdominal pain or gut pain, the
likely place that the clot was going was to the
abdominal area."
(Emphasis added.)
Dr. Korn also testified regarding what he referred to as
a "differential diagnosis."
"Q.  I want you to assume that a reasonable
cardiologist, 
board 
certified, 
practicing 
on
Saturday, June 5, 1999, with that presentation, if
he examined the patient and she was doubled over in
pain with that history that we've gone over, whether
it would be incumbent upon them, if they were
complying with the standard of care, to include
vascular blood clot in their differential?
"....
"A.  Yes, sir.
"Q.  And do you have an opinion whether the
failure to include that in the differential would be
a violation of the standard of care applicable to
cardiologists?
"....
"A.  Yes, it is a violation of the standard of
care and is applicable to all cardiologists, yes.
"....
"Q.  Are you familiar with the standard of care
as it pertains to how cardiologists should deal with
1041484
47
the risks of peripheral embolization if it's
included in the differential?
"A.  Yes, sir.
"Q. ... What is a differential? ...
"A.  Okay.  A differential diagnosis is
something that we learned when we were in medical
school, that we have to come up with a number of
different diagnoses as to the possibilities of
what's going on with a patient.  In other words, if
a patient has abdominal pain, it may come from a
number 
of 
different 
sources. 
It 
could 
be
gallbladder, could be stomach, could be intestine.
So, a differential diagnosis means listing the
possibilities of where the source of the pain comes
from.
"Q. ... In following the standard of care, is
there a priority of how those are ruled out?
"A. Yes, you ... try to go with the most
dangerous one first and then come down to the ones
that are not as dangerous.
"Q. 
And 
peripheral 
embolization 
is 
an 
emergency,
if it exists?
"A.  Peripheral embolization is an emergency. I
mean, you know, clots can fly off to the head. They
can go to the gut. They can go to the legs. Anywhere
they go is, obviously, an emergency.
"....
"Q.  What about if you include peripheral
embolization in your differential, what's the
approach by a cardiologist?
"A.  Basically, the approach by a cardiologist,
and even an internist, but by a cardiologist too is
1041484
48
the fact that patients have to be anti-coagulated
promptly.  And ... [w]hen she starts to have the bad
abdominal gut pain, at that point, it's very
important to actually come in, see the patient,
examine the patient, see what's going on with this
lady and make the appropriate decisions as to
whether there's an abdominal catastrophe or disaster
going 
on 
so 
that 
you 
may 
have 
to 
get 
a
gastroenterologist to see her, a surgeon to see her,
and get the ball rolling so we can take care of this
lady before she dies."
(Emphasis added.)
Thus, Dr. Korn, a similarly situated health-care provider
to 
Dr. 
DeVille, 
testified 
that 
a 
reasonable 
cardiologist--when
told of a patient who had undergone spontaneous conversion
from atrial fibrillation to normal rhythm and back again,
which was accompanied by the worst abdominal pain the patient
had ever experienced--would have promptly gone to examine the
patient.  Moreover, Dr. Korn testified as follows based on a
1993 article from the American Heart Association regarding
acute mesenteric ischemia and its diagnosis and treatment:
"Q.  There's a sentence that precedes that I
would like to cover with you. ... 'The most
catastrophic event is acute embolic occlusion of the
superior mesenteric artery.'
"A.  That's correct, that's what it says.
"Q.  1993?
"A.  Yes, sir.
1041484
49
"Q.  American Heart Association?
"A.  That's correct.
"....
"Q.  Do you agree with this, Doctor:  The
clinical 
presentation--And 
we're 
talking about acute
embolic occlusion of the superior mesenteric artery.
'The clinical presentation is so dramatic and
characteristic, 
acute, 
unrelenting 
abdominal
cramping, that the diagnosis should not be missed.'
Do you agree with that?
"A.  Yes, I do.
"Q.  'Soon after the occlusion, the patient will
have loud peristaltic rushes that coincide with the
development 
of 
the 
pain, 
but 
no 
abdominal
tenderness.'
"Q.  Do you agree with that?
"A. Yes, I do.
"....
"Q.  The same article, Doctor, from the American
Heart Association, 1993.  See if you agree with
this. ... 'There is no time for delay with acute
occlusion of the superior mesenteric artery.'  You
agree with that?
"A.  Yes, I do.
"Q. 'Death of the small bowel is accompanied by
a very high mortality rate. When the diagnosis is
not made before bowel infarction occurs, the
mortality rate is 70 to 90 percent.'  You agree with
that?
1041484
50
"A.  Yes, sir.
"Q.  I'm particularly interested in the next
sentence.  'Immediate referral to a general or
vascular surgeon without awaiting the results of
other than basic laboratory work is mandatory.'  Do
you disagree with that?
"A.  I do not disagree with that. I do agree
with that."
In this case, however, the cardiologist responsible for
Lida's care, Dr. DeVille, did not go to the hospital to
examine Lida.  At trial, Dr. DeVille explained that the facts
about Lida that were presented to him did not indicate that
there was an emergency or that he otherwise needed to examine
Lida.  In particular, he testified as follows regarding the
descriptions of Lida's complaints of abdominal pain:
"Q.  Were you told about abdominal pain and
nausea in those three telephone calls?
"A.  Yes, sir, I was.
"Q.  Do you have a recollection of whether or
not you were told about that in the first call or
the second call?
"A.  Well, what I remember was in, the first
call, I was told that she had some--I can't remember
if 
the 
phrase 
was 
abdominal 
or 
epigastric
discomfort, but that she had had that as an
outpatient and it was recurring.  The message was
that it didn't seem to be a new problem.
"Q.  Okay. ... Was there a description given to
1041484
51
you as to the severity of the pain? What type of
description were you given?
"A.  In the first call, it was just the presence
of the discomfort.  That's all I remember being told
was just that there was epigastric or abdominal, I
don't remember which, pain or discomfort in the
first call.  And where my memory really sort of
fails me is whether it was in the second or third
call that I was told that the pain was worse than
usual.
"....
"Q.  And you remember being told she had a
history of abdominal pain or how did you put it,
outside the hospital?
"A.  That before she had come into the hospital,
she had had recurrent episodes of abdominal pain.
"....
"Q.  Were you told by [Nurse] Swearingen at some
point about any abdominal assessment that was done
by [Nurse] Greene?
"A.  I was told that the nurse had assessed the
patient and there--although I don't remember the
exact specifics of it, the message was the abdominal
exam was unremarkable, that there was--that there
was nothing that suggested an acute or emergent
problem in the abdomen.
"....
"Q. ... What did you consider in regard to the
first call about the abdominal pain and nausea? What
consideration did you have at that point about that?
"A.  The first consideration was that she may be
having epigastric or lower chest or upper abdominal
1041484
52
discomfort due to the rapid heartbeat, which you
will sometimes see.  We call it an anginal
equivalent.  It's not necessarily--I didn't think
she was having a heart attack because she had had a
normal cath, but in patients who have a very rapid
rate, sometimes they'll get epigastric or chest or
throat discomfort.  So, my initial thought was that
if we got control of her heart rate and her blood
pressure, that her abdominal symptoms might improve.
 
"....
"A.  When I'm being told that she has a
recurrent abdominal problem that is now worse than
usual 
and 
this 
is 
a 
patient 
who 
just--The
information I got was she had just been started on
Heparin. The first thing I thought of was a bleeding
ulcer. 
She 
had 
peptic 
ulcer 
disease. 
Other
considerations would be gallbladder or any of the
other abdominal things, but the first thing that
came to my mind was a peptic ulcer."
(Emphasis added.)
 In addition, Dr. DeVille testified that he
was not told that Lida was "doubled over in pain" or that she
complained of the "worst pain she'd ever had in her life." 
Similarly, Nurse Swearingen testified that she was not told by
Nurse Greene that Lida had complained of the worst abdominal
pain she had ever experienced. 
Based on the testimony of Dr. Korn, including his
testimony regarding the 1993 article from the American Heart
Association, 
there 
was 
sufficient 
evidence 
from 
which 
the 
jury
could conclude that a patient suffering from acute mesenteric
1041484
53
ischemia is characterized by an "acute, unrelenting abdominal
cramping" that 
is 
"so 
dramatic" that 
a reasonable cardiologist
"should not ... miss" its diagnosis.  In this case, as noted,
there was evidence showing that Lida complained to Nurse
Greene of suffering from the worst abdominal pain she had ever
experienced.  However, there also was evidence from which the
jury could conclude that rather than communicating that
information to Nurse Swearingen (and, in turn, to Dr.
DeVille), Nurse Greene instead communicated that Lida's
abdominal pain was merely a "worse-than-usual" occurrence of
a recurrent problem.  
Thus, there was sufficient evidence for the jury to
conclude that Nurse Greene's negligent failure to accurately
communicate Lida's pain caused Dr. DeVille to fail to
diagnose--or to include in his "differential diagnosis"--
Lida's acute mesenteric ischemia.  In other words, there was
sufficient evidence for the jury to conclude that if Nurse
Greene had accurately communicated Lida's symptoms of pain to
a reasonable cardiologist, it is more probable than not that
the 
cardiologist 
would 
have 
included 
acute 
mesenteric 
ischemia
in 
his 
differential diagnosis. 
 Consequently, 
the Infirmary is
1041484
54
not accurate in its claim that there was "absolutely no
evidence ... that an earlier examination ... by any physician
would have resulted in a different diagnosis, different
treatment plan, or different outcome for [Lida]."
Moreover, based on Dr. Korn's testimony, a reasonable
cardiologist 
presented 
with 
that 
situation 
probably 
would 
have
initiated--as part of that diagnosis--a stat or emergency
order for a consultation with a surgeon.  At trial, Robert
presented the following testimony from Dr. Garry Ruben, a
board-certified general and peripheral vascular surgeon who
testified regarding proximate causation:
"Q.  Now , I want you to assume the following.
I want you to assume that a general surgeon who
practices and has privileges to do vascular surgery
or a vascular surgeon receives a telephone call
around 1:45 or 2:00 o'clock on a Saturday afternoon
and receives the following information: There is a
72-year-old patient who had atrial fibrillation, was
admitted to the telemetry unit.  She had not been
anticoagulated. The plan was to anticoagulate her
before cardioversion and to do so for 30 days before
cardioversion, but that she spontaneously, on her
own, converted from atrial fibrillation to normal
sinus rhythm at 11:57 a.m., and, thereafter, at
one--between 1:20 and 1:35 spontaneously converted
back and had an immediate sudden onset of the worst
abdominal pain she had ever had, and you are asked
to consult. ... Do you know what a reasonably
prudent surgeon or vascular surgeon would do or
should do under those circumstances?
1041484
55
"A.  I believe that I do, yes. ...
"Q.  Okay. And what would ... a reasonably
prudent specialist ... with the same specialty,
general surgery with vascular surgical privileges or
a vascular surgeon do in response to such a
communication?
"A.  Based upon the information you've given me,
a surgeon would order an urgent study, a stat study
to evaluate the mesenteric blood supply.  In the
alternative, if that was not possible to be
accomplished, then the blood supply would either
have to be evaluated by another stat study if one
was available, but, more likely, one would then take
the patient to the operating room to evaluate the
intestines and the gut and the blood supply
intraoperatively.
"Q.  What do you mean by stat?
"A.  Well, ... a surgeon would want the study
done within, I would say, two to three hours at the
outset.
"Q.  And what study? Are you referring to a
specific study?
"A.  Yes, sir, I'm talking about what we call a
mesenteric arteriogram or a mesenteric angiogram.
...
"Q.  If that was available, do you have any
experience as to how long that takes .... [i]f it's
ordered stat?
"A.  The study itself can be done in an hour.
Usually, you have, you know, an hour to get the
patient ready and down and prepare the unit, so
usually it can be done in two to three hours."
Thus, Dr. Ruben's testified that a reasonably prudent
1041484
Dr. Ruben also testified that in extreme emergencies the
22
time needed for an angiogram or arteriogram can be shortened,
because an experienced surgeon can "feel with [his] hands"
within the patient's abdominal cavity to determine where a
clot is located.
Dr. Ruben's testimony was supported by other evidence in
23
the record, including medical texts that were read into
evidence.
56
surgeon would have ordered a stat study--specifically, a
mesenteric arteriogram or a mesenteric angiogram--to be
completed in two or three hours.   Dr. Ruben testified that
22
an arteriogram or angiogram would have revealed the blood clot
in Lida's superior mesenteric artery, and, once the presence
of the clot was known, a general surgeon could have removed
the clot by performing an embolectomy.23
According to Dr. Ruben, had an embolectomy been performed
before Lida's bowel infarcted, Lida would have survived:
"Q.  Doctor, ... [d]o you have an opinion
whether, if a vascular surgeon on the evening of
June 5, 1999, or general surgeon, for that matter,
who could do [the embolectomy] procedure that you're
talking about had gotten to Mrs. Tyler and had done
the procedure before infarction occurred of the
bowel, do you have an opinion whether it's more
likely than not that she would have survived?
"A.  I do have an opinion.
"Q.  What is your opinion?
1041484
Dr. Ruben testified further regarding Lida's chances of
24
survival if a timely embolectomy had been performed:
"Most patients who have an embolic event don't
do so sitting on a cardiac monitor in a hospital
with nurses there to get the report immediately
about this event. Most of those patients do so at
home, in a nursing home, in an outside institution.
Many of them have advanced diseases of other types
that makes the mortality high even if they do have
prompt intervention.
"In addition, most of these patients are not
seen promptly.  Many of them have severe abdominal
pain and sit at home not telling anybody or telling
a family member who does not have any medical
training and doesn't make much of it for several
hours 
until 
they 
begin 
to 
see 
the 
patient
deteriorate. Then these patients call the doctor who
says go to the emergency room.  At the point we see
most of these patients, several hours have gone by
and we're at the point where there is nothing we can
do to change the clinical course.
"Mrs. Tyler fell into a specific category of, A,
a patient with very little co-morbidity. She had
atrial 
fibrillation, 
but, 
otherwise, 
she 
was
healthy. She was a healthy vigorous person. And, B,
she had this acute event in the hospital and was
able to communicate this to a trained professional
almost immediately. ... [I]f we were to look at this
kind of sub-set of patient and see what the
57
"....
"A. ... [M]y opinion is that she would have
survived. ... So, if we operate on her and save the
bowel before it infarcts, we save the bowel and,
certainly, enough bowel for her to survive.  And
since she is a relatively healthy 70-year-old woman,
her chances of surviving were overwhelming."24
1041484
morbidity would be, assuming good medical care, I
suspect we would see a greater than 80 or 90 percent
survival."
58
(Emphasis added.)
Thus, there was sufficient evidence to show that an
accurate communication from Nurse Greene to Nurse Swearingen
regarding Lida's pain probably would have ultimately resulted
in a surgeon performing an embolectomy, which Lida probably
would have survived.  The only remaining question regarding
causation is whether there was sufficient evidence that there
was enough time for those events to take place. 
In his brief to this Court, Robert summarizes the time
that was available for those events to occur:  
"There were at least six hours during which
diagnostic and restorative efforts could have been
initiated before Mrs. Tyler's bowels were damaged so
severely that she became 'unsalvageable.' ...
According to Dr. Kirby, Mrs. Tyler's bowels
infarcted late Saturday night or early Sunday
morning:
"'Q : Do you know or have an opinion
when her bowel infarcted?
"'A: I don't know with certainty. I
would estimate sometime between 10:00 p.m.
and 2:00 a.m.
"'....
1041484
59
"'Q: That Saturday?
"'A: June 5 to June 6, over that
period of time.'
"Dr. Ruben agreed with [the opinion of Dr. Donald
Kirby, 
a 
gastroenterologist 
whose 
deposition
testimony was introduced at trial,] of the range
between 10:00 p.m. on June 5th and 2:00 a.m. on June
6th ... stating that Mrs. Tyler's bowels infarcted
at approximately 11:00 p.m. 'give or take an hour or
so.' ... He noted that according to Nurse Jason
Lundy's June 5th 7:00 p.m. nursing assessment ...,
Mrs. 
Tyler's 
gastrointestinal 
assessment 
was
'[Within Normal Limits]' with no indication of any
'bowel sounds absent or hypoactive.' ... So, too,
Dr. Williamson's 6:00 to 6:30 p.m. gastroenterology
consult revealed normal active bowel sounds."
(Robert's brief, pp. 63-64.)  The Infirmary has not
demonstrated that this evidence was insufficient to support
Robert's assertion that there was enough time for a reasonable
cardiologist to order a stat surgical consult and for a
surgeon, 
once 
consulted, 
to 
examine, 
diagnose, 
and
successfully treat Lida's condition.  Accordingly, Robert
presented sufficient evidence from which the jury could
conclude 
that 
Nurse 
Greene's 
negligent 
communication 
prevented
Lida from receiving the medical care that probably would have
prevented her death from acute mesenteric ischemia. 
D.
The Infirmary also argues that the "good count/bad count"
1041484
The Infirmary's argument regarding the "good count/bad
25
count" rule appears at pages 56-57 of its initial brief to
this Court.  In its entirety, the Infirmary's argument is as
follows:
"Because there is insufficient evidence of
proximate cause as to any of the negligence claims
against the Infirmary, the judgment against the
Infirmary should be reversed and rendered in favor
of the Infirmary.  Nevertheless, even if [Robert]
failed to put on substantial evidence of negligence
or proximate cause as to only one of his negligence
claims, the judgment must be reversed and remanded
for a new trial pursuant to the good-count,
bad-count rule, which this Court has summarized [in]
.... [Ex parte Grand Manor, 778 So. 2d 173, 177
(Ala. 2000)]."
(Infirmary's brief, pp. 56-57.)
60
rule requires reversal and a new trial in this case.   We
25
disagree.
Ex parte Grand Manor, Inc., 778 So. 2d 173, 177 (Ala.
2000), includes the following discussion of the "good
count/bad count" rule:
"In a case where several claims are submitted to the
jury, over JML motions by the defendant, and the
jury renders a general verdict as to those claims,
on appeal this Court must determine whether the
plaintiff presented substantial evidence in support
of each of the claims.  See Palm Harbor Homes, Inc.
v. Crawford, 689 So. 2d 3, 8 (Ala. 1997).  This
Court will not presume that the general verdict was
returned on a 'good count' (i.e., on a count or
claim supported by substantial evidence); rather,
'[i]f a verdict should have been directed as to one
1041484
61
or more of the claims, then the judgment based on
those claims must be reversed.'  Id.  However, where
the defendant does not challenge the 'bad counts'
(i.e., those not supported by substantial evidence)
with specificity in his motions for JML, this Court
will presume that the verdict was returned on the
'good count.'  See Goodyear Tire & Rubber Co. v.
Washington, 719 So. 2d 774, 778 (Ala. 1998);
Aspinwall v. Gowens, 405 So. 2d 134, 138 (Ala.
1981).2
"____________
" In Aspinwall, this Court held:
2
"'[I]f a complaint has more than one count
and the defendant believes that the
evidence is not sufficient to support one
or more of those counts, he must challenge
this by motion for directed verdict,
specifying the 
count 
which is not 
supported
by evidence and detailing with specificity
the grounds 
upon which the particular count
is not supported by the evidence.  If this
is not done and all counts go to the jury
and a general verdict is returned, the
court will presume that the verdict was
returned on a valid count.'
"405 So. 2d at 138 (opinion on application for
rehearing). This Court has also held:
"'It 
follows 
from 
[the 
holding 
in
Aspinwall] that, if the defendant files a
motion for [a JML] as to a count which is
not supported by the evidence and the court
denies such a motion, a general jury
verdict will not be presumed to have been
returned on a count which is supported by
the evidence.... We cannot presume that 
the
general jury verdict relates to one of the
counts which the evidence did support,
1041484
62
where it is equally possible that it is
based on the count which is unsupported by
the evidence.' 
"John Deere Indus. Equip. Co. v. Keller, 431 So. 2d
1155, 1157 (Ala. 1983); accord National Sec. Fire &
Cas. Co. v. Vintson, 454 So. 2d 942, 946 (Ala.
1984); South Cent. Bell Tel. Co. v. Branum, 568 So.
2d 795, 798-99 (Ala. 1990)."
It is necessary to determine what "counts" or "claims"
were submitted to the jury in this case.  Robert and the
Infirmary do not agree as to what constitutes a "count" or
"claim."  In essence, Robert argues that the allegations in
paragraph 8.a-8.e 
of 
his 
complaint constitute 
only one 
"count"
or "claim."  The Infirmary, however, argues in its reply brief
that each "theory" of negligence constitutes a separate
"count" or "claim."  It states:
"This was a 'multiple theory case' against the
Infirmary. This Court cannot determine, for example,
whether the jury found for [Robert] based upon the
alleged failure to change the 'see today ' order, or
based upon Nurse Greene not stating the exact words
'worse pain ever.'"  
(Infirmary's reply brief, p. 27.)
We need not decide whether this case is a "multiple
theory case," however.  Even if it were, the Infirmary has not
shown that more "theories" were submitted to the jury than
those allegations stated in the plaintiff's seventh amended
1041484
63
complaint, which also formed the basis of the trial court's
instruction to the jury.
In its instruction to the jury, the trial court stated:
"[Robert] sues Mobile Infirmary alleging breaches of
the standard of care; more specifically, the failure
to properly assess the condition of Lida Mae Tyler,
failing to properly report the condition of Lida Mae
Tyler, failure to obtain appropriate medical care
and treatment for the condition of Lida Mae Tyler,
failure to timely notify physicians of the condition
of Lida Mae Tyler, and failing to timely act and
obtain treatment for Lida Mae Tyler."
That was the only instruction regarding Robert's allegations
that the Infirmary had breached a standard of care; it was
based on the language of the plaintiff's seventh amended
complaint, which states:
"8.  The death of LIDA MAE TYLER was proximately
caused by the negligence of the [Infirmary] by and
through its agents, servants or employees and
including various nursing personnel acting within
the line and scope of their employment as employees
of the [Infirmary] in one or more of the following
respects:
"a.  Failing to properly assess the condition of
the said LIDA MAE TYLER on June 5, 1999 ...;
"b.  Failing to properly report the condition of
the said LIDA MAE TYLER on June 5, 1999 ...;
"c.  Failing to obtain appropriate medical care
and treatment for the condition of the said LIDA MAE
TYLER on June 5, 1999 ...;
1041484
64
"d.  Failing to timely notify physicians of the
condition of the said LIDA MAE TYLER on June 5, 1999
...;
"e.  Failing to timely act and obtain treatment
for the said LIDA MAE TYLER'S condition on June 5,
1999 ...."
(Capitalization in original; emphasis added.)  
Even if each of those subparagraphs is viewed as a
separate "theory," however, each was supported by substantial
evidence, namely, the evidence showing that Nurse Greene
failed to adequately assess and report Lida's pain, as well as
the evidence of what that failure caused.  Subparagraphs 8.a
and 8.b allege 
specifically that 
the 
Infirmary's 
nurses failed
to properly assess and report Lida's condition.  The causation
evidence from that failure is substantial evidence supporting
the allegations in subparagraphs 8.c and 8.e, and the evidence
suggesting that Nurse Greene did not inform Nurse Swearingen
or Dr. DeVille of Lida's condition, i.e., that Lida was
experiencing the worst abdominal pain she had ever had, is
substantial 
evidence 
supporting 
the 
allegation 
in 
subparagraph
8.d.  Consequently, the Infirmary has not shown that a "bad"
negligence "count" or "claim" was submitted to the jury.
1041484
Section 6-5-547 provided:
26
"In any action commenced pursuant to Section
6-5-391 or Section 6-5-410, against a health care
provider whether in contract or in tort based on a
breach of the standard of care the amount of any
judgment entered in favor of the plaintiff shall not
exceed the sum of $1,000,000.  Any verdict returned
in any such action which exceeds $1,000,000 shall be
reduced to $1,000,000 by the trial court or such
lesser sum as the trial court deems appropriate in
accordance with prevailing standards for reducing
excessive verdicts. ..." 
65
II.
The Infirmary argues that this Court should revive § 6-5-
547, Ala. Code 1975,  which limited a judgment against a
26
health-care provider to $1,000,000.  Section 6-5-547 was
declared unconstitutional in Smith v. Schulte, 671 So. 2d
1334, 1343-44 (Ala. 1995).  In support of its argument for the
revival of the statute, the Infirmary cites this Court's
decision in Ex parte Apicella, 809 So. 2d 865, 874 (Ala.
2001).
In Mobile Infirmary Medical Center v. Hodgen, supra, this
Court rejected a similar argument to revive the damages
limitation imposed by § 6-5-544, Ala. Code 1975, a companion
statute to § 6-5-547.  This Court explained in Hodgen:
"Mobile Infirmary next invites this Court to
1041484
66
revive § 6-5-544(b), Ala. Code 1975, which, at one
time, placed a $400,000 cap on the noneconomic
damages 
that 
could 
be 
awarded 
in 
a
medical-malpractice case.  In Moore v. Mobile
Infirmary Association, 592 So. 2d 156 (Ala. 1991),
we 
declared 
§ 
6-5-544(b), 
Ala. 
Code 
1975,
unconstitutional, holding that the cap violated the
right to a trial by jury and the equal-protection
guarantees under the Alabama Constitution.  Mobile
Infirmary argues that because this Court has since
acknowledged that a cap on punitive damages does not
violate the right to a trial by jury under the
Alabama Constitution, see Ex parte Apicella, 809 So.
2d 865 (Ala. 2001), and because this Court has
acknowledged that the Alabama Constitution contains
no equal-protection clause, see Ex parte Melof, 735
So. 2d 1172 (Ala. 1999), this Court should overrule
Moore, supra, reinstate the $400,000 cap and apply
the cap to Hodgen's punitive-damages award in this
case.  We decline Mobile Infirmary's invitation to
revive § 6-5-544(b), Ala. Code 1975, because, since
we decided Moore, the Legislature has explicitly
addressed this issue.
"The 
Legislature, 
when 
it 
enacts 
legislation, 
is
presumed to have knowledge of existing law and of
the judicial construction of existing statutes. See
Ex parte Fontaine Trailer Co., 854 So. 2d 71 (Ala.
2003).  Thus, with the knowledge that § 6-5-544(b),
Ala. Code 1975, had been declared unconstitutional
in 1991 and that § 6-11-21, Ala. Code 1975, which
provided a general cap on punitive-damages awards,
had been declared unconstitutional in 1993, see
Henderson v. Alabama Power Co., 627 So. 2d 878 (Ala.
1993), the Legislature in 1999 rewrote § 6-11-21,
Ala. Code 1975, to provide caps on punitive-damages
awards to apply 'in all civil actions,' except in
class actions, wrongful-death actions, and actions
alleging the intentional infliction of physical
injury. Section 6-11-21(a), (b), (d), (h), and (j),
Ala. Code 1975. Section 6-11-21, Ala. Code 1975, as
so amended, has been recognized as a complete
1041484
67
replacement of the old statutory restrictions on
punitive damages.  See Morris v. Laster, 821 So. 2d
923, 927 (Ala. 2001).
"The 
fundamental 
principle 
of 
statutory
construction is that words in a statute must be
given their plain meaning.  See Simcala, Inc. v.
American Coal Trade, Inc., 821 So. 2d 197, 202 (Ala.
2001)(citing Ex parte Smallwood, 811 So. 2d 537, 539
(Ala. 2001); Ex parte Krothapalli, 762 So. 2d 836,
838 (Ala. 2000); and IMED Corp. v. Systems Eng'g
Assocs. Corp., 602 So. 2d 344, 346 (Ala. 1992));
Archer Daniels Midland Co. v. Seven Up Bottling Co.
of Jasper, Inc., 746 So. 2d 966, 969 (Ala.
1999)(citing John Deere Co. v. Gamble, 523 So. 2d 95
(Ala. 1988)).  Section 6-11-21(d), Ala. Code 1975,
provides:
"'(d) Except as provided in subsection
(j), in all civil actions for physical
injury wherein entitlement to punitive
damages shall have been established under
applicable laws, no award of punitive
damages shall exceed three times the
compensatory damages of the party claiming
punitive damages or one million five
hundred thousand dollars ($1,500,000),
whichever is greater.'
"(Emphasis added.)  As noted above, the only
exclusions from this cap on punitive-damages awards
for claims alleging physical injury are class
actions, 
wrongful-death 
actions, 
and 
actions
alleging the intentional infliction of physical
injury.  The wording of this statute, i.e., that it
applies to 'all civil actions,' clearly encompasses
actions alleging physical injury caused by medical
malpractice.  Although the Legislature excluded from
this statute certain types of claims, the statute
makes no mention of excluding actions brought
pursuant to the [Act].  Because the Legislature,
with knowledge of this Court's holding as to §
1041484
Unlike Hodgen, which involved only claims arising out of
27
nonfatal injuries a patient suffered as a result of medical
malpractice, this case involves a wrongful-death claim.
Therefore, § 6-11-21(j), Ala. Code 1975, rather than § 6-11-
21(d), would apply to this case.  Section 6-11-21(j) states
that "[t]his section shall not apply to actions for wrongful
death or for intentional infliction of physical injury."  Even
so, Hodgen noted that "[s]ection 6-11-21, Ala. Code 1975, as
so amended, has been recognized as a complete replacement of
the old statutory restrictions on punitive damages."  884 So.
2d at 814 (citing Morris v. Laster, 821 So. 2d 923, 927 (Ala.
2001) (emphasis added)). 
68
6-5-544(b), Ala. Code 1975, enacted a new statutory
cap on punitive damages that clearly encompasses
claims brought pursuant to the [Act], we decline
Mobile Infirmary's invitation to revisit the Moore
decision, despite the erosion of its holdings, and
to reinstate § 6-5-544(b), Ala. Code 1975."
884 So. 2d at 813-14.
Although relied on extensively by Robert in his brief to
this Court, see Robert's brief, pp. 66-69, the Infirmary has
not addressed this Court's decision in Hodgen.  Thus, the
Infirmary has not responded to Robert's argument that the
reasoning in Hodgen applies to preclude the Infirmary's
attempt to revive § 6-5-547 in this case.  Consequently, we
decline the Infirmary's invitation to revive the damages
limitation of § 6-5-547.27
III.
The Infirmary contends that under the guideposts set
1041484
69
forth in BMW of North America, Inc. v. Gore, 517 U.S. 559
(1996), and the factors set out in Hammond v. City of Gadsden,
493 So. 2d 1374 (Ala. 1986), and Green Oil Co. v. Hornsby, 539
So. 2d 218 (Ala. 1989), it is entitled to a remittitur of the
$5,500,000 punitive-damages award.  In a postjudgment order,
the trial court applied the Gore guideposts and the Hammond
and Green Oil factors and concluded that no remittitur was
necessary.  
"We review the trial court's award of punitive damages de
novo, with no presumption of correctness."  Mack Trucks, Inc.
v. Witherspoon, 867 So. 2d 307, 309 (Ala. 2003) (citing
Acceptance Ins. Co. v. Brown, 832 So. 2d 1, 24 (Ala. 2001)).
Our de novo review of the punitive-damages award in this case,
which involved our application of the Gore guideposts and the
Hammond and Green Oil factors, leads us to conclude that the
trial court should have reduced the award and that the
punitive-damages award should have amounted to no more than
$3,000,000.
Thus, we affirm the judgment of the trial court on the
condition that, within 14 days of the date of this opinion,
Robert file with this Court an acceptance of a remittitur of
1041484
70
the punitive-damages award in the amount of $2,500,000, which
would result in a judgment for him in the amount of $3,000,000
in punitive damages.  Otherwise, the judgment of the trial
court will be reversed and the case remanded for a new trial.
AFFIRMED CONDITIONALLY.
See, Stuart, Bolin, and Parker, JJ., concur.  
Cobb, C.J., and Lyons, Woodall, and Murdock, JJ., concur
in part and dissent in part.
1041484
71
COBB, Chief Justice (concurring in part and dissenting in
part).
I concur in Parts I and II of the main opinion; however,
as to Part III, I must dissent.
I agree with Justice Lyons that the remittitur ordered by
this court is excessive; therefore, I respectfully dissent
from the part of the opinion so ordering.
1041484
72
LYONS, Justice (concurring in part and dissenting in part).
I concur in all aspects of the main opinion except Part
III, as to which I respectfully dissent.
Our Court has consistently construed the wrongful-death
remedy in § 6-5-410, Ala. Code 1975, as permitting the
recovery of punitive damages only.  See Lance, Inc. v.
Ramanauskas, 731 So. 2d 1204, 1221 (Ala. 1999) (noting that
"this Court has, under the crushing weight of 150 years of
stare decisis, consistently held that our wrongful-death
statute allows for the recovery of punitive damages only").
The United States Supreme Court has endorsed the anomaly of
permitting the recovery of punitive damages for negligence
under Alabama's unique wrongful-death statute: 
"The legislation now challenged has been on the
statute books of Alabama in essentially its present
form since 1872.  The liability imposed is for
tortious acts resulting in death, but the damages,
which may be punitive even though the act complained
of involved no element of recklessness, malice, or
willfulness, may be assessed against the employer
who, as here, is personally without fault.  ...  
"....
"... [T]he aim of the present statute is to
strike at the evil of the negligent destruction of
human life ....  We cannot say that it is beyond the
power of a Legislature, in effecting such a change
in common law rules, to attempt to preserve human
1041484
73
life by making homicide expensive.  It may impose an
extraordinary liability such as the present, not
only upon those at fault but upon those who,
although 
not 
directly 
culpable, 
are 
able
nevertheless, in the management of their affairs, to
guard 
substantially 
against 
the 
evil 
to 
be
prevented."
Louis Pizitz Dry Goods Co. v. Yeldell, 274 U.S. 112, 114-16
(1927).
In the aftermath of BMW of North America, Inc. v. Gore,
517 U.S. 559 (1996), and its progeny, we are required to
conduct a due-process analysis in the context of punitive-
damages awards that are challenged as excessive.  But, unlike
other cases in which there is a predicate of compensatory
damages against which a multiplier may be applied to determine
whether the punitive-damages award is excessive, here we have
no such predicate.  For want of a better process, the due-
process analysis compelled by BMW v. Gore forces me to engage
in the callous business of establishing a base price for the
value of a human life measured in today's dollars and then
extrapolating therefrom an additional sum, also measured in
today's dollars, to determine what punitive damages above the
base price are appropriate to effectuate the legislative
policy of preventing homicide by making it expensive.
1041484
74
Under the circumstances of this case, the jury determined
that $5.5 million was appropriate.  The Court today affirms
conditionally the judgment entered on that verdict upon
reduction of the verdict to $3 million--a reduction of almost
50%.  I consider such a reduction excessive; therefore, I
respectfully dissent as to Part III.
There ought, however, to be a better process.  This Court
in Savannah & Memphis R.R. v. Shearer, 58 Ala. 672, 678
(1877), construed a statute approved on February 5, 1872,
permitting in a wrongful-death action the recovery of "such
sum as the jury deem just" to  be limited to the recovery of
punitive damages.  In 1892 in Richmond & Danville R.R. v.
Freeman, 97 Ala. 289, 295, 11 So. 800, 802 (1892), this Court
saw no substantive difference resulting from an amendment
changing the phraseology to "such damages as the jury may
assess."  Justice McClellan then reaffirmed the construction
of the predecessor to the statute applied in Savannah &
Memphis Railroad.  He did so without compliments for its
rationale, stating: 
"If [the question whether the wrongful-death statute
authorized the recovery of only punitive damages]
were [an open one], he [referring to Justice
McClellan, as author of the opinion for the Court]
1041484
75
should be much inclined to the view so ably urged by
counsel, that the statute was primarily intended to
afford compensation to the next of kin of a person
coming to his death through the wrong of another,
and to allow the imposition of punitive damages only
in 
those 
cases 
where 
they 
would 
have 
been
recoverable had the injury fallen short of death."
97 Ala. at 296, 11 So. at 802.  Cabined by stare decisis, the
Court in Richmond & Danville Railroad, like this Court in
numerous subsequent cases over the years, adhered to the
construction of the statute as limited to punitive damages.
See, e.g., Lance, Inc. v. Ramanauskas. 
The second of the four guideposts announced in BMW v.
Gore against which a punitive-damages award is measured to
determine 
compliance 
with 
due 
process 
is 
the 
disparity 
between
the actual or potential harm suffered by the plaintiff and the
punitive-damages award.  Subsequent to BMW v. Gore, I
concurred in rejecting a constitutional challenge to the
wrongful-death statute in Tillis Trucking Co. v. Moses, 748
So. 2d 874, 890 (Ala. 1999), in which the Court stated:
"The only basis on which these recent cases
[upholding 
the 
wrongful-death 
act] 
might 
be
questioned is the decision of the Supreme Court of
the United States in BMW [of North America, Inc.] v.
Gore, [517 U.S. 559 (1996)]. However, this Court in
Cherokee Elec. Coop. v. Cochran, 706 So. 2d 1188
(Ala. 1997), was able to conduct a meaningful review
of a wrongful-death punitive-damages award, and we
1041484
76
have done so here.
"In Cherokee Electric, supra, the Court applied
the three BMW v. Gore 'guideposts,' as well as the
Hammond [v. City of Gadsden, 493 So. 2d 1374 (Ala.
1986)] and Green Oil [Co. v. Hornsby, 539 So. 2d 218
(Ala. 1989)] principles of review, and affirmed a
$3,000,000 wrongful-death judgment on a verdict in
an electrocution case.  As to the ratio of punitive
damages to compensatory damages, the Court stated:
'Alabama law allows no compensatory damages in a
wrongful death case. This factor, therefore, does
not 
apply 
here.' 
 
706 
So. 
2d 
at 
1194.
Alternatively, one could say that it does not apply
as a mathematical ratio, but, if one considers the
purpose behind this factor, it applies in the sense
of proportionality between the punitive-damages
award and the harm that was caused or was likely to
be caused by the defendants' conduct.  Certainly,
the likelihood of death to a driver of a passenger
automobile is great in the case of collision with a
tractor-trailer truck fully loaded with logs and
weighing approximately 90,000 pounds.  Certainly,
death is a great harm.  Whether we say that the
ratio factor does not apply, as we said in Cherokee
Electric, or that it applies in principle without
mathematical application, the 
first 
'guidepost' 
from
BMW v. Gore does not require this Court to overturn
more than a century of precedent based on law
awarding only punitive damages in wrongful-death
actions."
(Emphasis added.)
 In State Farm Mutual Automobile Insurance Co. v.
Campbell, 538 U.S. 408, 425 (2003), the United States Supreme
Court discussed the second guidepost in BMW v. Gore as
follows:
1041484
77
"We cited that 4-to-1 ratio [approved in Pacific
Mutual Life Ins. Co. v. Haslip, 499 U.S. 1 (1991)]
again in Gore.  517 U.S., at 581.  The Court further
referenced a long legislative history, dating back
over 700 years and going forward to today, providing
for sanctions of double, treble, or quadruple
damages to deter and punish.  Id., at 581, and n.33.
While these ratios are not binding, they are
instructive.  They demonstrate what should be
obvious:  Single-digit multipliers are more likely
to comport with due process, while still achieving
the State's goals of deterrence and retribution,
than awards with ratios in range of 500 to 1, id.,
at 582, or, in this case, of 145 to 1."
I am becoming increasingly uncomfortable with the
constitutionality 
of 
a 
process 
that 
holds, 
alternatively, 
that
"the ratio factor does not apply" or that it "applies in
principle 
without 
mathematical 
application." 
 
Tillis 
Trucking,
748 So. 2d at 890.  I am willing to reconsider my vote in
Tillis Trucking in a future case in which we are reminded of
the diminished effect of stare decisis when faced with a
question of constitutionality and asked to overrule Tillis
Trucking.  If a majority of the Court were so inclined, then
we would have to make the difficult choice between striking
the wrongful-death statute down in its entirety or saving it
with a construction of the statute consistent with standards
of due process prevailing in the 21st century. 
 In the meantime, I choose not to ignore the
1041484
78
applicability of a ratio, so I must struggle today with the
second alternative in Tillis Trucking of treating death as "a
great harm" and then attempting to apply a ratio "in principle
without mathematical application."  748 So. 2d at 890.
1041484
79
WOODALL, Justice (concurring in part and dissenting in part).
I dissent from the main opinion as to the extent of the
remittitur of punitive damages.  Otherwise, I concur.
1041484
80
MURDOCK, Justice (concurring in part and dissenting in part).
I concur in Parts I and II of the main opinion; I
respectfully dissent as to Part III.