Title: Williams v. Barry

State: alabama

Issuer: Alabama Supreme Court

Document:

Rel: June 26, 2020
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
 OCTOBER TERM, 2019-2020
_________________________
1180352
_________________________
Angela Williams, as mother and next friend of Li'Jonas Earl 
Williams, a deceased minor
v.
Dr. Wesley H. Barry, Jr., and Advanced Surgical Associates,
P.C.
Appeal from Montgomery Circuit Court
(CV-16-901044)
WISE, Justice.
The plaintiff below, Angela Williams ("Williams"), as
mother and next friend of Li'Jonas Earl Williams, a deceased
minor, appeals from a judgment as a matter of law entered in
1180352
favor of the remaining defendants below, Dr. Wesley H. Barry,
Jr., and Advanced Surgical Associates, P.C. (hereinafter
sometimes collectively referred to as "the defendants").  We
reverse and remand.
Facts and Procedural History
Li'Jonas Williams was a 17-year-old with sickle-cell
disease.  On June 29, 2014, Li'Jonas went to the emergency
room at Southern Regional Medical Center in Georgia ("the
Georgia hospital") complaining of back and chest pain.  A CT
scan performed at the Georgia hospital showed that Li'Jonas
had cholelithiasis, which is stones in the gallbladder.
On July 7, 2014, Li'Jonas and Williams saw Li'Jonas's
pediatrician in Montgomery, Dr. Julius Sadarian.  Dr.
Sadarian's notes indicated that Li'Jonas "presents with
preventive exam and referral for gallstones removal."  Dr.
Sadarian referred Li'Jonas to Dr. Barry for gallbladder
removal. 
On July 17, 2014, Li'Jonas and Williams saw Dr. Barry, a
board-certified surgeon, at his practice, Advanced Surgical
Associates, P.C.  Dr. Barry stated that patients complete a
patient-history form and that his records include a summary of
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that history.  Dr. Barry noted that Li'Jonas was "[a] 17-year
old with documented gallstones"  based on a review of the CT
scan.  Dr. Barry also noted that Li'Jonas had sickle-cell
disease.  Dr. Barry's notes indicated that Li'Jonas had had
about a one-month history of intermittent pain in the upper
abdomen and then radiating to the back and that Li'Jonas's
symptoms were associated with nausea and fatty-food intake.
Dr. Barry testified that the fact that Li'Jonas's
symptoms 
were 
associated with 
fatty-food intake 
was 
consistent
with gallbladder disease.  Dr. Barry testified that he did not
order an ultrasound because he already had the CT scan showing
the presence of gallstones.  Dr. Barry diagnosed Li'Jonas with
chronic cholecystitis and cholelithiasis and recommended that
he undergo a cholecystectomy, which is the removal of the
gallbladder. 
Dr. Barry performed the cholecystectomy on Li'Jonas at
Jackson Hospital on the morning of August 4, 2014.  Dr. Barry
testified that Li'Jonas tolerated the procedure well; that
Li'Jonas did not experience any complications during the
surgery; and that Li'Jonas had only about 10ccs of blood loss
during the surgery.  Testimony was presented that 10ccs is the
3
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equivalent of about 2 teaspoons.  Dr. Barry testified that, to
remove the gallbladder, the cystic artery and the cystic duct
must be cut.  He further testified that, during such a
surgery, he typically places four surgical clips on the cystic
artery and four surgical clips on the cystic duct.  Dr. Barry
was asked whether, on occasion, he may have used more than
four clips.  Dr. Barry responded that he was sure that he
might have and that, if he did not like how one clip fit, he
might put another on.  Dr. Barry further testified that, once
he has put the four clips on the artery and the four clips on
the duct, he then cuts the artery and the duct between the
four clips on each structure.  Dr. Barry testified that, once
he cuts the artery and the duct, he removes the gallbladder;
that some of the clips come out with the gallbladder; that the
remaining clips stay inside the body; and that those clips are
intended to stay in the body forever.  He further testified
that the purpose of the clips is to close and secure the
artery and the duct so that, once the gallbladder is removed,
those structures are closed off and there is no bleeding from
the artery and nothing coming from the duct.  He further
testified that, if you were to cut the cystic artery without
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securing it with clips, it would continue to bleed
tremendously; that it would be immediately obvious; and that
that did not happen with Li'Jonas.
Li'Jonas did not experience any problems when he was in
the post-anesthesia-care unit or when he was in the outpatient
recovery room.  He was subsequently discharged from Jackson
Hospital at 11:22 a.m.
On the evening of August 4, 2014, Li'Jonas was found
unresponsive at his home.  Emergency personnel arrived at the
scene and started CPR.  Li'Jonas was transported to the
Baptist Medical Center South emergency room by ambulance. 
Li'Jonas arrived at the emergency room at 7:06 p.m.  According
to hospital records, Li'Jonas was brought to the hospital by
emergency-medical services ("EMS"); he was unresponsive; and
the amount of downtime was unknown.  The records also
indicated that EMS personnel stated that Li'Jonas had had his
gallbladder removed that day; that he went home; that his
family went to a football game; and that, when they came back
home, Li'Jonas was unresponsive.  Emergency-room personnel
continued CPR and performed various treatments in an attempt
to revive Li'Jonas.  The notes of Dr. Amitricia Lumpkin, one
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of the doctors who treated Li'Jonas in the emergency room,
indicated that Dr. John Moorehouse, another physician who
treated Li'Jonas, had performed a FAST1 ultrasound and that
the FAST ultrasound showed no cardiac activity and that there
was no free intraperitoneal fluid.  Testimony was presented
that the finding of no free intraperitoneal fluid meant there
was no fluid or blood in Li'Jonas's abdomen.  Ultimately, the
efforts to revive Li'Jonas were unsuccessful, and he was
pronounced dead at 7:38 p.m.  
On August 4, 2016, Williams sued Dr. Barry, Advanced
Surgical Associates, Jackson Hospital, and Renea Majors, a
postoperative nurse at Jackson Hospital, and she subsequently
amended her complaint several times.2  In her fourth amended
complaint, Williams asserted a wrongful-death claim based on
allegations of medical malpractice pursuant to the Alabama
Medical Liability Act, § 6-5-480 et seq. and § 6-5-540 et
1"FAST" stands for Focus Assessment with Sonogram for
Trauma.
2The trial court entered a summary judgment in favor of
Jackson Hospital and Majors "with regard to all acts or
omissions other than Nurse Majors' handling of Li'Jonas
Williams' discharge from the hospital on August 4, 2014."  The
remaining claims against Jackson Hospital and Majors were
subsequently dismissed.
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seq., Ala. Code 1975, and a claim of negligence/wantonness. 
On December 18, 2017, Dr. Barry and Advanced Surgical
Associates filed their answer to the fourth amended complaint,
which they later amended.
The trial in this case started on August 27, 2018.  On
September 10, 2018, the defendants filed a written motion for
a judgment as a matter of law at the close of Williams's
evidence.  Williams filed a written response and a
supplemental response to that motion.  On September 11, 2018,
the trial court entered an order granting the defendants'
motion for a judgment as a matter of law. 
On October 10, 2018, Williams filed a motion to alter,
amend, or vacate the judgment. On November 8, 2018, the
defendants filed their opposition to Williams's postjudgment
motion.  Williams's postjudgment motion was subsequently
denied by operation of law.  This appeal followed.
Standard of Review
"'"When reviewing a ruling on a motion
for a [judgment as a matter of law], this
Court uses the same standard the trial
court used initially in granting or denying
the motion.  Palm Harbor Homes, Inc. v.
Crawford, 689 So. 2d 3 (Ala. 1997).
Regarding questions of fact, the ultimate
issue 
is 
whether 
the 
nonmovant 
has
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presented sufficient evidence to allow the
case or issue to be submitted to the jury
for a factual resolution.  Carter v.
Henderson, 598 So. 2d 1350 (Ala. 1992)....
A reviewing court must determine whether
the party who bears the burden of proof has
produced substantial evidence creating a
factual 
dispute 
requiring 
resolution 
by 
the
jury.  Carter, 598 So. 2d at 1353.  In
reviewing a ruling on a motion for a
[judgment as a matter of law], this Court
views the evidence in the light most
favorable to the nonmovant and entertains
such reasonable inferences as the jury
would have been free to draw.  Id.  If the
question is one of law, this Court indulges
no presumption of correctness as to the
trial court's ruling. Ricwil, Inc. v. S.L.
Pappas & Co., 599 So. 2d 1126 (Ala.
1992)."' 
"[Alabama Dep't of Transp. v. Land Energy, Ltd.,]
886 So. 2d [787,] 791–92 [(Ala. 2004)] (quoting Ex
parte Alfa Mut. Fire Ins. Co., 742 So. 2d 1237, 1240
(Ala. 1999))."
Housing Auth. of Birmingham Dist. v. Logan Props., Inc., 127
So. 3d 1169, 1173 (Ala. 2012).
"'"We 
apply 
the 
same
standard of review to a ruling on
a motion for a [judgment as a
matter of law] as the trial court
used in initially deciding the
motion. 
This 
standard 
is
'indistinguishable 
from 
the
standard by which we review a
summary judgment.' Hathcock v.
Wood, 815 So. 2d 502, 506 (Ala.
2001).  We must decide whether
there was substantial evidence,
8
1180352
when viewed in the light most
favorable to the plaintiff, to
warrant a jury determination. 
City of Birmingham v. Sutherland,
834 So. 2d 755 (Ala. 2002).  In
Fleetwood 
Enters., 
Inc. 
v.
Hutcheson, 791 So. 2d 920, 923
(Ala. 2000), this Court stated
that '"[s]ubstantial evidence is
evidence 
of 
such 
weight 
and
quality that fair-minded persons
in the exercise of impartial
judgment can reasonably infer the
existence of the fact sought to
be proved."'  791 So. 2d at 923
(quoting West v. Founders Life
Assurance Co. of Florida, 547 So.
2d 870, 871 (Ala. 1989))."
"'Alabama Power Co. v. Aldridge, 854 So. 2d
554, 560 (Ala. 2002).'
"Black v. Comer, 38 So. 3d 16, 22 (Ala. 2009)."
Hill v. Fairfield Nursing & Rehab. Ctr., LLC, 134 So. 3d 396,
401 (Ala. 2013).
Discussion
Williams argues that the trial court erroneously granted
the defendants' motion for a judgment as a matter of law. 
Specifically, she asserts that she "presented substantial
evidence of breaches of the standard of care by Dr. Barry that
proximately caused Li'Jonas's death."  Williams's brief at p.
17. 
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"This Court has stated:
"'"To prevail on 
a 
medical-malpractice
claim, a plaintiff must prove '"1) the
appropriate standard of care, 2) the
doctor's deviation from that standard, and
3) a proximate causal connection between
the doctor's act or omission constituting
the breach and the injury sustained by the
plaintiff."'  Pruitt [v. Zeiger], 590 So.
2d [236,] 238 [(Ala. 1991)] (quoting
Bradford v. McGee, 534 So. 2d 1076, 1079
(Ala. 1988))."  Giles v. Brookwood Health
Servs., Inc., 5 So. 3d 533, 549 (Ala.
2008).
"'"A 
plaintiff 
in 
a
medical-malpractice action must
... 
present 
expert 
testimony
establishing a causal connection
between the defendant's act or
omission constituting the alleged
breach and the injury suffered by
the plaintiff. Pruitt v. Zeiger,
590 So. 2d 236, 238 (Ala. 1991). 
See also Bradley v. Miller, 878
So. 2d 262, 266 (Ala. 2003);
University 
of 
Alabama 
Health
Servs. Found., P.C. v. Bush, 638
So. 2d 794, 802 (Ala. 1994); and
Bradford v. McGee, 534 So. 2d
1076, 1079 (Ala. 1988).  To prove
c a u s a t i o n  
i n  
a
medical-malpractice 
case, 
the
plaintiff must demonstrate '"that
the alleged negligence probably
caused, rather than only possibly
caused, the plaintiff's injury."' 
Bradley, 878 So. 2d at 266
(quoting University of Alabama
Health Servs., 638 So. 2d at
802)."
10
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"'Sorrell v. King, 946 So. 2d 854, 862
(Ala. 2006).'
"Breland v. Rich, 69 So. 3d 803, 814–15 (Ala.
2011)."
Smith v. Fisher, 143 So. 3d 110, 123 (Ala. 2013).
"'The plaintiff in a medical-malpractice action
is 
required 
to 
present 
substantial 
evidence
indicating both that the defendant health-care
provider "failed to comply with the standard of care
and that such failure probably caused the injury or
death in question."'  Mobile OB–GYN, P.C. v.
Baggett, 25 So. 3d 1129, 1133 (Ala. 2009) (quoting
§ 6–5–549, Ala. Code 1975)." 
Hill, 134 So. 3d at 401.
A. Breach of the Standard of Care
Dr. Hien Tan Nguyen, a board-certified surgeon, testified
as an expert for Williams.  During his testimony, Dr. Nguyen
stated that, based on Dr. Barry's notes, it was his
understanding that Dr. Barry made three diagnoses when he
initially 
saw 
Li'Jonas 
-- 
sickle-cell 
disease, 
cholelithiasis,
and chronic cholecystitis, which means that there has been
long-term inflammation of the gallbladder.  He testified that
Dr. Barry's notes basically state that Li'Jonas might have a
condition associated with the dysfunction of his gallbladder. 
He further testified that, in this situation, Li'Jonas was
stating he was having nausea after fatty-food intake, which
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implies that there was something wrong with his gallbladder. 
However, he testified that, prior to this, there were no other
medical records that suggested that Li'Jonas had pain or
nausea of any kind after eating fatty foods.
Dr. Nguyen testified that Dr. Barry should have had an
ultrasound performed on Li'Jonas before he committed him to
surgery.  He also testified that the ultrasound was required
before making a diagnosis of cholecystitis.  He further
testified that, based on Li'Jonas's bilirubin levels, an
ultrasound should have been performed to determine whether
Li'Jonas also had a stone in his biliary tree, which would
have required a separate procedure from the cholecystectomy. 
Dr. Nguyen testified that the CT scan that had been conducted
at the Georgia hospital was a CT angiogram; that the purpose
of that CT scan was to look for blood-vessel issues; that it
was not performed to look at the gallbladder; and that the
scan just incidentally found gallstones in the gallbladder. 
He further testified that that CT scan was completely
inadequate for making a diagnosis of chronic cystitis; that it
was inadequate for determining whether there was a stone in
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the biliary tree; and that the CT scan was not designed to
look for those things.   Subsequently, the following occurred:
"[PLAINTIFF'S COUNSEL:]  Dr. Nguyen, do you
agree with me that Dr. Barry breached the standard
of care by not conducting this ultrasound on
Li'Jonas' gallbladder prior to performing the
surgery?
"[DR. NGUYEN:]  With all due respect, Dr. Barry,
I absolutely do think that you breached the standard
of care by not getting this ultrasound in this young
kid.
"....
"[PLAINTIFF'S COUNSEL:]  
Do 
you 
believe that Dr.
Barry breached the standard of care by recommending
this cholecystectomy?
"[DR. NGUYEN:]  I believe that there was an
insufficient evidence to make a diagnosis that the
gallbladder was inflamed.
"As a matter of fact, in retrospect, looking at
the pathology report, we know that the gallbladder
was normal and did not need to be removed. We also
know from Dr. Barry's own words that when he
performed the operation, the gallbladder looked
normal.  He described it as a Robin's egg, a blue
Robin's egg. That is a normal gallbladder and did
not need to be removed.
"There 
was 
insufficient 
evidence 
at 
the
beginning to make the diagnosis of gallbladder
disease. 
 
During 
the 
operation, 
there 
was
insufficient visual evidence that the gallbladder
was diseased.  And after the surgery, the pathology
report, which is something that we are mandated to
do -- we can't remove an organ from a patient and
throw it away.  We have to send it to pathology. 
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The pathologist came back with a thorough report
stating, in essence, that the gallbladder was
absolutely normal. And that basically corroborates
my opinion that this patient did not need his
gallbladder removed surgically.
"[PLAINTIFF'S COUNSEL:]  
And 
is 
it 
your opinion,
Dr. Nguyen, based on your training, skill, and
knowledge and experience as a general surgeon that
Dr. Barry breached the standard of care when he
performed this surgery on August 4, 2014?
"[DR. NGUYEN:]  It is."
Dr. Nguyen also testified that Dr. Barry's diagnosis of
cholelithiasis just meant that there were stones within the
gallbladder.  He went on to testify that the simple fact that
there are stones in the gallbladder does not mean that the
gallbladder is not working correctly.  He further testified
that, of the people who have stones in the gallbladder, maybe
20 percent become symptomatic; that 80 percent of people who
have gallstones do not need an operation because the stones
are not bothering them; that the only time the gallbladder
needs to be removed is if the stones are causing some of type
of dysfunction; that there was not evidence indicating that
the stones in Li'Jonas's gallbladder were causing any kind of
dysfunction in this case; and that, therefore, the diagnosis
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of having stones in the gallbladder was not enough to commit
Li'Jonas to surgery.
The 
defendants 
presented 
conflicting 
evidence 
to
establish 
that 
the gallbladder 
surgery 
was 
medically
necessary; that the standard of care did not require that Dr.
Barry order an ultrasound before recommending and performing
surgery on Li'Jonas; and that Dr. Barry did not breach the
standard of the care by recommending and performing the
cholecystectomy on Li'Jonas.  However, when viewing the
evidence in a light most favorable to Williams, Dr. Nguyen's
testimony presented substantial evidence to create a factual
dispute requiring resolution by the jury as to whether Dr.
Barry breached the applicable standard of care by 
recommending
and performing an unnecessary surgery on Li'Jonas.  
B. Proximate Cause
Next, we must determine whether Williams presented
substantial evidence that the purportedly unnecessary surgery
was the proximate cause of Li'Jonas's death.   
"The standard for proving causation in a
medical-malpractice action is not proof that the
complained-of act or omission was the certain cause
of the plaintiff's injury.  Instead, as this Court
has frequently reiterated, the standard is one of
the 'probable' cause:  '"'"There must be more than
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the mere possibility that the negligence complained
of caused the injury; rather, there must be evidence
that the negligence complained of probably caused
the injury."'"'  Lyons v. Vaughan Reg'l Med. Ctr.,
LLC, 23 So. 3d 23, 27–28 (Ala. 2009) (quoting
Sorrell v. King, 946 So. 2d 854, 862 (Ala. 2006),
quoting in turn DCH Healthcare Auth. v. Duckworth,
883 So. 2d 1214, 1217 (Ala. 2003), quoting in turn
Parker v. Collins, 605 So. 2d 824, 826 (Ala. 1992)
(emphasis omitted))."
Hill, 134 So. 3d at 406.  
"'In Cain v. Howorth, 877 So. 2d 566 (Ala.
2003), this Court stated:
"'"'"To present a jury question,
the 
p l a i n t i f f  
[in 
a
medical-malpractice action] must
adduce some evidence indicating
that the alleged negligence (the
breach 
of 
the 
appropriate
standard of care) probably caused
the injury.  A mere possibility
is insufficient.  The evidence
produced by the plaintiff must
have 'selective application' to
one theory of causation."'"
"'877 So. 2d at 576 (quoting Rivard v.
University 
of 
Alabama 
Health 
Servs. 
Found.,
P.C., 835 So. 2d 987, 988 (Ala. 2002)).'" 
Lyons v. Vaughan Reg'l Med. Ctr., LLC, 23 So. 3d 23, 28 (Ala.
2009) (quoting Sorrell v. King, 946 So. 2d 854, 862 (Ala.
2006)).  In Golden v. Stein, 670 So. 2d 904 (Ala. 1995), this
Court noted that, when 
a plaintiff alleges medical malpractice
based on an 
unnecessary medical procedure, expert testimony is
16
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not necessary to prove certain types of damages.  However,
"any claims for damages based on complications from the
unnecessary procedure would be subject to the general rule
that expert testimony is normally required to establish
proximate cause in the medical malpractice context."  670 So.
2d at 908.  
In 
this 
case, 
Williams 
introduced 
into 
evidence
Li'Jonas's death certificate, which listed the cause of death
as cardiopulmonary arrest. "Post Gall bladder surgery" was
listed under the section of the death certificate titled
"Other 
Significant 
Conditions 
Contributing 
to 
Death." 
However, no autopsy was performed at that time.   
The evidence established that Li'Jonas's body was exhumed
over two and one-half years after he died; that Dr. James
Shaker performed an autopsy on Li'Jonas's body on March 20,
2017; that Dr. Shaker prepared an autopsy report; and that Dr.
Amy Hawes and Dr. Jonathan Eisenstat observed the autopsy. 
Evidence was also presented indicating that the embalming of
Li'Jonas's body was not very good and that the body was
severely decomposed at the time of the autopsy.
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Dr. Shaker did not testify at trial, but his autopsy
report was admitted into evidence.  In the "Final Anatomic
Diagnoses" section of his report, Dr. Shaker listed the
following under the subsection titled "Hepatobiliary System":
"A.
Intraperitoneal hematoma, approximately 110
grams of clotted blood mixed with liquid blood
"B.
Cystic duct with surgical metallic clip
"C.
Cystic 
artery 
without 
visible 
surgical
clipping."
He further listed the cause of death as "Postoperative
Complication 
of 
Cholecystectomy." 
 
In 
the 
"Internal
Examination" section of the report, under the Hepatobiliary
System subsection, Dr. Shaker stated, in pertinent part:
"The gallbladder has been surgically removed with
one surgical clip noticed over the cystic duct.  The
cystic artery has no surgical clipping."
During the trial, Dr. Nguyen testified that he believed
that the surgery performed by Dr. Barry caused Li'Jonas's
death.  Subsequently, the following occurred:
"[PLAINTIFF'S COUNSEL:]  And what do you base
that -- what medical findings do you base that on?
"[DR. NGUYEN:]  Well, first of all, it's a
17-year-old kid who died within 12 hours after an
operation.  There's not a lot of things that can
kill a person that fast.  One of which is bleeding. 
If the person bleeds, they can die within 12 hours.
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In this situation I base my opinion on the operative
notes on what was used to clip the cystic artery on
the medical records showing that the patient
basically was in cardiopulmonary arrest after he was
discharged from the hospital the same day and an
autopsy report which documented there was -- that
there was no clip on the cystic artery which is one
of the blood vessels that has to be divided for the
gallbladder to be removed.
"[PLAINTIFF'S COUNSEL:]  And did that surgery
report also document that there was a certain amount
of blood in the area of the operation?
"[DR. NGUYEN:]  The autopsy report was striking
to me in that it was done two years after Li'Jonas
died.  This body was exhumed and evaluated by
forensic pathologists.
"Within the documentation, there was also
mention of 110 grams of blood or blood-related
products found within the pelvis two years after the
patient died.
"[PLAINTIFF'S COUNSEL:]  
And 
is 
that striking 
to
you as a physician?
"[DR. NGUYEN:]  Absolutely, it is.  Because, as
you know, blood products, these red blood cells, are
rather fragile. You know, if it's just a small
amount of blood, it probably would have broken down
by the time that the forensic pathologist exhumed
the body."
Dr. Eisenstat testified as an expert for the defense. 
Dr. Eisenstat testified that he was the chief medical examiner
for the Georgia Bureau of Investigation and that, on occasion,
he would consult on private litigation matters such as this
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case.  In this case, Dr. Eisenstat attended Dr. Shaker's
autopsy of Li'Jonas's body as an observer.  He further
testified that the first thing he noted during the autopsy was
the fact that the body was severely decomposed.
Dr. Eisenstat testified that, at the time of the autopsy,
he knew there was a question regarding the cholecystectomy Dr.
Barry had performed on Li'Jonas before his death; that he and
Dr. Shaker focused pretty intensely on the location where the
gallbladder was removed; and that that was the area underneath
the liver.  He testified that he observed while Dr. Shaker
exposed and viewed that area of the body and that he took
multiple photographs as well.  Dr. Eisenstat testified that he
saw that Dr. Shaker had reported that he "found the cystic
duct with surgical metal clip and the cystic artery without
visible surgical clipping."  However, he testified that he did
not agree with those findings from Dr. Shaker.  When asked why
he did not agree, he replied:
"Well, it's very apparent for me at the time of
autopsy and then obviously reviewing the photographs
as I reviewed the case that there were multiple
clips on different structures in what I'll call the
gallbladder fossa or the area where the gallbladder
used to be."
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On a subsequent page of the autopsy report, Dr. Shaker
reported that the gallbladder had been surgically removed with
one surgical clip noticed over the cystic duct and that the
cystic artery had no surgical clipping.  Dr. Eisenstat
testified that he absolutely disagreed with that finding.  
Dr. Eisenstat was asked about Dr. Shaker's opinion as to
Li'Jonas's cause of death.  Dr. Eisenstat testified that,
essentially, Dr. Shaker's opinion was that there was no clip
on the cystic artery, which led to bleeding that in turn led
to or contributed to Li'Jonas's death.  He stated that it was
his understanding that Dr. Shaker's general conclusion was
that Li'Jonas bled to death because the cystic artery was not
clipped.  However, Dr. Eisenstat testified that there was not
any evidence that Li'Jonas bled to death.
When going through the photographs, Dr. Eisenstat
testified that he could see multiple surgical clips at the
location where the gallbladder had been removed and that he
could see surgical clips on two different structures.  In
discussing one of the photographs he took during the autopsy,
Dr. Eisenstat stated:
"So we have two structures where the anatomy of
that area and what is supposed to be clipped is the
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cystic duct and the cystic artery, and we have two
tubular structures that are at different angles that
are both clipped multiple times."
While Dr. Eisenstat was looking at a photograph Dr. Hawes
took during the autopsy, the following occurred:
"[DEFENSE COUNSEL:]  So is it your opinion that
we've got five or six surgical clips documented at
the location they should be following the removal of
the gallbladder?
"[DR. EISENSTAT:]  Yes, sir.
"[DEFENSE COUNSEL:]  And do I follow that based
on your opinion of what we're looking at, based on
the angle and the direction and the plane on which
these clips are viewed here that -- am I following
you that these clips in your opinion show that a
tubular structure is clipped and these clips show
that a separate tubular structure is clipped?
"[DR. EISENSTAT:]  Yes, sir.
"[DEFENSE COUNSEL:]  And, Doctor, what is your
understanding as to how many structures are clipped
and secured during the removal of a gallbladder?
"[DR. EISENSTAT:]  So the two major structures
are the cystic duct and the cystic artery. Now, you
know, you may have little what we call -- what the
surgeons call bleeders which doesn't mean a massive
bleed.  They're just -- you need to clip off these
little vessels.
"But the major structures are the cystic artery
which is a branch of a bigger artery going up to the
gallbladder and then the cystic duct which is a
branch of a bigger duct that goes to the liver
that's going up to the gallbladder.
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"So those are -- need to be clipped prior the
removal of the gallbladder?
"[DEFENSE COUNSEL:]  And is it your opinion that
there are two tubular structures clipped and secured
in these photographs?
"[DR. EISENSTAT:]  Yes, in the area of the
gallbladder fossa.
"[DEFENSE COUNSEL:]  
Doctor, in 
terms of 
general
anatomy, can you discern from this photo where the
artery would likely be in comparison with the duct?
"[DR. EISENSTAT:]  Well, you know, from -- from
anatomy itself, the artery actually comes up a
little over the duct itself. So, you know, if you
were to look at these two structures, the one that's
coming out at us just from an anatomical point of
view would be the artery and the one coming down
would be the duct.
"But I have to say, you know, he was decomposed,
so there was alteration of the normal tissue.  And
I'll say, you know, I -- I can't be specific, but
that would be the normal anatomy there.
"[DEFENSE COUNSEL:]  Dr. Eisenstat, given the
condition of the body, did you observe any specific
dissection identification and dissection by Dr.
Shaker of the artery and the duct during the
autopsy?
"[DR. EISENSTAT:]  I did not, no."
(Emphasis added.)
Dr. Eisenstat testified that, based on what he had
observed during the autopsy and what he had observed in the
autopsy photographs, it was his opinion that there was no
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evidence indicating that Li'Jonas was bleeding from the 
cystic
artery as a result of the surgery.  He further testified that
he had reviewed the medical records from Dr. Barry and Jackson
Hospital regarding the surgery; that he did not see any
indication that there were any issues with bleeding during the
surgical procedure; and that he did not see anything in the
records that would be indicative of an intra-abdominal bleed. 
He further testified that he had reviewed the emergency-room
records from Baptist South.  With regard to those records, he
stated:
"[DEFENSE COUNSEL:]  Did you see any indication
in the emergency room records that would support a
theory that Li'Jonas Williams had bled to death
prior to his arrival at the emergency room?
"[DR. EISENSTAT:]  So, I mean, he essentially
came in essentially dead on arrival. So there were
a number of -- there was nothing in there that would
have said that he -- he bled to death.  But already
being dead on arrival, that's a little hard.
"But there wasn't -- they did do a test that
confirmed what I saw at autopsy that there wasn't
any intra-abdominal hemorrhage.
"[DEFENSE COUNSEL:]  And what test is that?
"[DR. EISENSTAT:]  That's the FAST test,
F-A-S-T."
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He further testified that he was referring to the FAST
ultrasound.
Dr. Eisenstat testified that he was also familiar with
Dr. Shaker's conclusion that he found approximately 110 grams
of clotted blood mixed with liquid blood.  Defense counsel
asked Dr. Eisenstat if he had considered that conclusion and
if he had an opinion as to whether that was an indication of
internal bleeding.  Dr. Eisenstat replied that he absolutely
did consider that and that there were a few problems there. 
He testified that he believed that the 110 grams was a mixture
of a little bit of blood, decomposed liver, and possibly some
embalming fluid.  Dr. Eisenstat testified that the amount of
material that was present and the localization of whatever the
decomposed material was was nowhere near what he would expect
for 
hemorrhagic 
complications 
from 
a 
procedure 
that
contributed to or caused someone's death.  
When asked if he agreed or disagreed with Dr. Shaker's
conclusion in the autopsy report that the cause of death was
postoperative complications of cholecystectomy, Dr. Eisenstat
replied:
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"Well, I mean, it's a very general statement.  As I
-- as we've talked about, there's no mechanical
post-operative complication of the cholecystectomy.
"....
"...  You know, unfortunately, Li'Jonas did not
have an autopsy right when he died.  So doing an
autopsy on an embalmed, whether it be good embalming
or a not good embalming, decomposed individual makes
it much more difficult to say what the actual cause
of death was.  But as far as post-operative
complication 
of 
cholecystectomy, 
there 
was
absolutely 
no 
mechanical 
post-operative 
complication
from the procedure."
He further testified that it was his opinion that Li'Jonas
"did not die as a result of the cystic artery not being
clipped because the cystic artery was clipped."
Defense counsel asked whether Dr. Eisenstat had any
opinions as to what might have caused Li'Jonas's death.  Dr.
Eisenstat testified that he had a differential diagnosis,
which was a list of possibilities.  He further testified that
he did not believe that anyone, including Dr. Shaker, could
make a definitive determination to a degree of medical
probability as to what was the cause of death for Li'Jonas. 
However, he stated that he thought he could say to a
reasonable degree of medical certainty that mechanical
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complications from the surgery and bleeding were not what
caused his death.  
During 
the 
plaintiff's counsel's cross-examination of 
Dr.
Eisenstat, the following occurred:
"[PLAINTIFF'S COUNSEL:]  And I want to get this
straight.  It's your testimony today to the ladies
and gentlemen of the jury that you can look in that
photograph and it's your position that those clips
are on the cystic artery and cystic duct?
"[DR. EISENSTAT:]  Yes.  Because they're both
tubular structures.  And also there's no evidence of
any bile leak or -- which would be a green
discoloration.  There's no evidence of, in my
opinion, a hemorrhagic complication.  So in that
area which is where you have the cystic duct and
cystic artery, it's basically what's there may be a
little soft connective tissue.
"We 
have 
multiple 
clips 
on 
two 
tubular
structures which is the area of the cystic duct and
cystic artery.  So more likely than not, it is the
cystic duct and cystic artery."
Subsequently, the following occurred:
"[PLAINTIFF'S COUNSEL:]  
And 
so 
can 
you 
identify
for me where the cystic duct is?
"[DR. EISENSTAT:]  Well, where all of those
clips are going up is clipping off one tubular
structure, and then up to the left coming out of us
-- out of the picture towards us is another tubular
structure. So like I said when I was asked on
direct, I started to say from an anatomic standpoint
which would be which, but then I followed up by
saying, well, he's decomposed, so it's a little more
difficult to say which one is which.
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"[PLAINTIFF'S COUNSEL:]  That it's decomposed
and it's hard to show these people or even yourself
as a forensic pathologist where the cystic duct and
artery is?
"[DR. EISENSTAT:]  What I can say is I can't
tell you which one is which, but they're both
tubular structures, and those are the two tubular
structures that lie underneath the liver in that
location.
"[PLAINTIFF'S COUNSEL:]  Is it your testimony
that that's one of those tubular structures that's
on that scissored clip?
"[DR. EISENSTAT:]  
I 
think the 
tubular structure
runs where all the clips are.  So, yes, underneath
that, there is a tubular structure, but it's also
the clip at the bottom and the clip just above it. 
"So it's not just one clip on one tubular
structure.  There's a number of clips on that
tubular structure."
______________________
"[PLAINTIFF'S COUNSEL:]  Do you agree with me
that, more likely than not, this surgery contributed
in causing Li'Jonas Williams' death?
"[DR. EISENSTAT:]  No, I can't say that.
"[PLAINTIFF'S COUNSEL:]  Okay.  But you can't
rule that out, can you, as possible?
"[DR. EISENSTAT:]  I will agree with you. I
can't fully rule that out.  I can rule out the
mechanical aspect, but I can't rule out that it had
any contributing factor."
(Emphasis added.)  Subsequently, the following occurred:
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1180352
"[PLAINTIFF'S COUNSEL:]  Can you identify where
the cystic artery is?
"[DR. EISENSTAT:]  Well, like I said, it's
difficult because of the decomposition, but through
the line of questioning of the -- the structure
that's up and towards the top and the left with the
two clips on it, that's probably the cystic artery. 
But what I'll say is that can I be a hundred percent
specific?  No, I can't.
"[PLAINTIFF'S COUNSEL:]  Okay. So you can't sit
here today, you didn't see it at the autopsy, and
you can't see it here today after blowing these
pictures up, and you can't identify to the jury
where there is a clip on the cystic artery?
"[DR. EISENSTAT:]  No.  What I can say is that
there's two tubular structures in that area, each of
which have multiple clips on them, and that's the
area where the cystic duct and the cystic artery
are.
"[PLAINTIFF'S COUNSEL:]  That tubular, what you
suggest is the cystic artery, is not visible?
"[DR. EISENSTAT:]  I'm sorry.  Say again.
"[PLAINTIFF'S COUNSEL:]  Is the cystic artery
visible?
"[DR. EISENSTAT:]  Well, it's decomposed and
squished for lack of a better term.
"[PLAINTIFF'S COUNSEL:]  All right. And Dr.
Shaker said he dissected that artery; correct?
"[DR. EISENSTAT:]  He said that in his
deposition, yes.
"[PLAINTIFF'S COUNSEL:]  But is there -- of all
of these photos, is there anything better than this
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photograph that's up there to show how there is a
clip on the cystic artery?
"[DR. EISENSTAT:]  No. This is by far the best
photograph.
"[PLAINTIFF'S COUNSEL:]  And you can't tell the
ladies and gentlemen of the jury which -- if there
is a clip on the cystic artery, you can't point it
out, can you?
"[DR. EISENSTAT:]  Well, again, I'm going to go
back to the same thing.  There are two tubular
structures in that area.  Anatomically, it would
make sense that the top left is the cystic artery,
but due to decomposition, I can't say specifically
if that is the artery or not.
"[PLAINTIFF'S COUNSEL:]  And is that a single
clip on the cystic duct?  Is that what you suggest
is the cystic duct?  Did I not hear you say just in
redirect right here that on the anatomy, this --
these lower ones would be the cystic duct?
"[DR. EISENSTAT:]  Correct.
"[PLAINTIFF'S COUNSEL:]  Okay. So Dr. Shaker
says that there was one clip on the cystic duct;
correct?
"[DR. EISENSTAT:]  I know what he says there. 
He says that there's only one clip in the entirety
of the gallbladder fossa.  It's very obvious that
there are multiple clips there.
"So I don't want to get into an argument with
Dr. Shaker.  I full on disagree with him.  It's very
obvious that there are multiple clips in different
planes on two different structures that are located
in the area where the cystic duct and the cystic
artery would be.  There's no significant associated
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hemorrhage.  You can't just take one thing by itself
and you put the case together.
"And I -- so I disagree with Dr. Shaker.  He did
say there's one clip, which I'll let the picture
speak for itself, and that it was only on one
structure.  I don't know what else I can say about
that.
"[PLAINTIFF'S COUNSEL:]  I'll pull it up and
read it to you. But it says under hepatobiliary
system, B, cystic duct with surgical, metallic clip;
correct?
"[DR. EISENSTAT:]  Yes, he said that.
"[PLAINTIFF'S 
COUNSEL:] 
 
That's 
a 
singular 
clip.
"Can you identify where the cystic duct is
clamped by more than one clip in this picture?
"[DR. EISENSTAT:]  Well, in my opinion and,
again, through anatomy, the duct is probably that
here right there where you have the one, two, three
clips going upwards, at least three clips going
upwards.
"[PLAINTIFF'S COUNSEL:]  But can you see the
cystic duct in those?
"[DR. EISENSTAT:]  Sir, it's decomposed, so
things are going to collapse.  So can I say I see
the cystic duct?  No. Can I say I see the cystic
artery? No.  
"But when you look at where the clips are and
you look that they're scrunched, decomposed tubular
structures, they are the cystic duct and cystic
artery because there's nothing else that's there."
(Emphasis added.)
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The defense also called Dr. Richard Stahl as an expert. 
Dr. Stahl testified that he was a surgeon and an associate
professor of surgery in the gastrointestinal-surgery division
at the University of Alabama at Birmingham and that he was
board certified in general surgery.  Dr. Stahl testified that
he had had occasions to become involved in determinating cause
of death in cases and in preparing death certificates.  
Dr. Stahl testified that he had reviewed Dr. Shaker's
deposition. 
 
He 
further 
testified 
that 
it 
was 
his
understanding that Dr. Shaker, upon conducting an autopsy two
and one-half years after death, had concluded that Li'Jonas
bled to death and that he reached that conclusion because the
cystic artery remained unclipped and unsecured after the
gallbladder-removal surgery.  Dr. Stahl testified that he had
reviewed the autopsy report and photographs and that, based
upon his review, he disagreed with Dr. Shaker's conclusion
that Li'Jonas bled to death from an unclipped artery.  Dr.
Stahl testified that Dr. Shaker indicated in his deposition
that there was a single clip.  However, Dr. Stahl testified
that he saw at least five, and possibly six, surgical clips in
an autopsy photograph; that those clips appeared to be on two
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1180352
separate structures; and that those clips appeared to be
appropriately placed.  He further testified that there was not
a great deal of blood in the abdomen.  Dr. Stahl testified
that, based on the autopsy photographs, he believed that the
findings of a cystic duct with a surgical clip and a cystic
artery without visible surgical clipping were wrong.  When
testifying, he stated that the photographs showed two
structures that were clipped and identified what he believed
to be the cystic artery and the cystic duct in one of the
autopsy photographs.  He further testified that, when a
cholecystectomy is performed, two structures are clipped by
the surgeon -- the cystic artery and the cystic duct -- and
that he believed there were two structures clipped in the
autopsy photograph. 
Dr. Stahl acknowledged that, during his deposition, he
said that the clips were applied to structures but that the
structures 
themselves were 
largely 
decomposed; 
that 
there 
were
two structures; and that he was not sure which one was the
cystic duct and cystic artery.  When asked if he was now able
to review and determine the cystic duct and the cystic artery,
Dr. Stahl replied:
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"With not a hundred percent certainty, but, yes, I
think we have a pretty good idea.  I have a pretty
good idea of which is which."
He further explained that the deposition was a telephone
deposition and that he was looking at Xerox copies of the
photographs and not high-resolution images.  Dr. Stahl
testified that, when looking at the photographs on the
computer with higher resolution, he had a pretty good
estimation as to which structure was which.  He further
testified that he could see the cystic duct and the cystic
artery in the photographs. 
Dr. Stahl testified that he had also seen Dr. Shaker's
findings 
and 
conclusions 
stating 
that 
there 
was 
an
intraperitoneal hematoma that consisted of approximately 110
grams of clotted blood mixed with liquid blood.  However,
after having seen the photographs, the autopsy report, and Dr.
Shaker's deposition testimony, it was his opinion that that
finding would not support a conclusion that Li'Jonas bled to
death.
Dr. 
Stahl also testified regarding differential diagnoses
as to the cause of death in this case.  He subsequently
testified that, based on what happened at the time of death
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and the passage of time until the autopsy, he thought it would
be impossible to tell with certainty the cause of death for
Li'Jonas.  However, he testified that he believed, "to a
degree of medical certainty," that Li'Jonas did not die
because he bled to death from an unclipped artery.  He further
testified that he did not think that there was any evidence of
that.  Dr. Stahl also testified that, based upon his
education, training, and experience and his review of all the
information and records, it was his opinion that Dr. Barry's
surgery did not cause any injury or trauma to Li'Jonas; that
Dr. Barry performed the surgery in an appropriate manner in
accordance with the standard of care; and that the surgery did
not cause Li'Jonas to suffer internal bleeding that resulted
in his death.  Dr. Stahl further testified that it was his
opinion that Li'Jonas did not die from a postoperative
complication of a cholecystectomy and that that was to a
reasonable degree of medical certainty.  He further testified
that, although Li'Jonas died after undergoing surgery, he did
not die as a direct result of that surgery.  Finally, Dr.
Stahl testified that, although he stated in his deposition
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that he was not certain as to what caused Li'Jonas's death, he
could pretty easily say that it was not caused by hemorrhage. 
The theory of Williams's claim against Dr. Barry was that
he had breached the standard of care by recommending and
performing an unnecessary surgery and that the unnecessary
surgery was the proximate cause of Li'Jonas's death.  Dr.
Nguyen testified that it was his opinion that Dr. Barry had
breached the standard of care by recommending and performing
the surgery without first conducting an ultrasound and that
the surgery was the proximate cause of Li'Jonas's death.  Dr.
Nguyen testified that he based his opinion as to the cause of
death on the findings in Dr. Shaker's autopsy report.  It is
true that the defendants presented sharply conflicting
evidence as to the issue of causation.  Although Dr. Shaker's
autopsy report referenced only one surgical clip, the
undisputed evidence presented at trial established that
multiple surgical clips were found in the location where
Li'Jonas's gallbladder had been removed.  Dr. Eisenstat and
Dr. Stahl testified that the autopsy photographs showed that
two distinct structures had been clipped.  The defense also
presented evidence indicating that only two structures -- the
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cystic duct and the cystic artery -- are typically clipped
during a cholecystectomy.  
However, Dr. Eisenstat testified that he could not, with
100% certainty, identify the cystic artery because of the
decomposition of the body.  Additionally, although Dr.
Eisenstat testified that the cystic artery and the cystic duct
are the two structures that are typically clipped during a
cholecystectomy, he also stated:
"Now, you know, you may have little what we call --
what the surgeons call bleeders which doesn't mean
a massive bleed.  They're just -- you need to clip
off these little vessels."
Additionally, 
although 
Dr. 
Eisenstat 
testified 
that 
mechanical
complications from the surgery and bleeding were not what
caused Li'Jonas's death, he could not completely rule out the
possibility that the surgery was a contributing factor in
Li'Jonas's death.    
Based on the foregoing, when the evidence is viewed in a
light most favorable to the plaintiff, Williams presented
substantial evidence to create a factual dispute requiring
resolution by the jury as to the issue whether the surgery
performed by Dr. Barry was the proximate cause of Li'Jonas's
death.  
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For these reasons, the trial court erred when it granted
the defendants' motion for a judgment as a matter of law.
Conclusion
For the above-stated reasons, we reverse the trial
court's judgment and remand this case for proceedings
consistent with this opinion.3
REVERSED AND REMANDED.
Parker, C.J., and Bolin, Shaw, Bryan, Mendheim, Stewart,
and Mitchell, JJ., concur.
Sellers, J., dissents.
3Based on the foregoing, we pretermit discussion of the
remaining arguments raised by Williams.
38