Title: Julie R. Lyons and Godfrey Lyons v. Vaughan Regional Medical Center, L.L.C.

State: alabama

Issuer: Alabama Supreme Court

Document:

Rel 04/24/2009
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, 2008-2009
_________________________
1071502
_________________________
Julie R. Lyons and Godfrey Lyons
v.
Vaughan Regional Medical Center, LLC
Appeal from Dallas Circuit Court
(CV-2005-327)
COBB, Chief Justice.
Julie R. Lyons and Godfrey Lyons, plaintiffs in a
medical-malpractice action in the Dallas Circuit Court, appeal
from a summary judgment entered in favor of Vaughan Regional
Medical Center, LLC ("Vaughan"), a limited liability company
1071502
2
that operates the Vaughan Regional Medical Center, a medical
facility.  We affirm.
Factual Background and Procedural History
On November 21, 2003, at approximately 4:30 p.m., Julie
was 
admitted 
to 
the 
Vaughan 
Regional 
Medical 
Center
complaining of severe lower-back pain that radiated down her
right leg; the diagnosis upon admission was an acute onset of
right lumbar radiculopathy.  A Heparin IV lock ("Hep-lock")
device was inserted into Julie's right hand by a nurse, and
Dilaudid for pain and Phenergan for nausea were administered
to Julie through the Hep-lock device.  According to Julie, she
felt a burning sensation in her hand as the medication was
administered.  Approximately four hours after the medication
had been administered, Julie awoke with pain in her right hand
and noticed redness and swelling in the hand.  Julie contends
that she mentioned to a nurse the next time the medication was
administered that the Hep-lock device was causing her
discomfort but that the nurse did not respond to her
complaints.  During the night Julie again complained to a
nurse about swelling and pain in her hand and asked the nurse
to bring her an ice pack to place on her hand, which the nurse
1071502
The record does not contain any of Julie's medical
1
records.
3
did.  The swelling and pain subsided.  However, during the
early morning hours of November 22, the pain and swelling
increased to a point that, according to Julie, "it was enough
to distract me from the pain in my back."  Julie pushed the
call button between two and four times without getting a
response from a nurse.  Finally, Julie was able to communicate
by intercom with a nurse at the nurses' station; she stated
that if a nurse did not come to remove the Hep-lock device she
would remove it herself.  Julie recalled her hand at this
point as being swollen from the tips of her fingers to
approximately her mid- forearm.  The Hep-lock device was
removed from Julie's right hand.  Julie alleges the Hep-lock
device "infiltrated," i.e., went completely through the vein
and into the soft tissues of her hand, and the medications
were thus administered into the tissues of her right hand
instead of into the vein.
From the deposition testimony contained in the record,1
it appears that the medical center's records indicate that at
5:15 a.m. on November 22, 2003, the nurse attending to Julie
noticed redness at the site where the Hep-lock device had been
1071502
During his deposition in this action, Dr. Iqbal Singh,
2
Julie's pain-management doctor and the physician who admitted
her to the medical center, recalled seeing during a prior
deposition in another action in which Julie was seeking Social
Security disability benefits a document in the medical
center's records possibly mentioning that the Hep-lock device
that had been used on Julie was not functioning. That
document, however, was not contained in the medical center's
records provided to Dr. Singh during his deposition in this
matter.
4
inserted. The medical center's records further indicate that
at 8:10 a.m. on the same date Julie complained of pain and
swelling in her right hand, that the nurse noted redness in
the hand, and that the Hep-lock device was discontinued.  The
record shows that the records from the medical center do not
indicate that Julie was diagnosed with an IV infiltration
while she was a patient at the medical center.   However,
2
according to Dr. Iqbal Singh, Julie's pain-management doctor,
the medical center's records indicate that later in the day of
November 22, 2003, Julie's right hand was being elevated on a
pillow and warm compresses were being applied.  Dr. Singh
stated that this would indicate that there was a problem with
the IV-access site and that Julie had developed an infection
or had inflammation at the IV-access site.  
Julie was discharged from the medical center on November
25, 2003, and was immediately transferred to HealthSouth
1071502
5
Medical Center in Birmingham for back surgery.  According to
Julie's husband, Dr. Singh told him on the day preceding
Julie's discharge from the medical center that he wanted to
see Julie concerning her hand as soon as she returned from
Birmingham.  According to Dr. Singh, Julie's medical records,
however, do not indicate that Dr. Singh diagnosed Julie with
an IV infiltration during her hospitalization at the medical
center.  The first indication in Dr. Singh's records of an
infiltration was during Julie's post-surgical follow-up visit
to Dr. Singh on December 9, 2003, the notes for which,
according to Dr. Singh, stated: "Patient's right hand
edematous, purple, and cool to touch.  Patient states she had
recent IV infiltrate in the right hand and it's still tender."
Dr. Singh diagnosed Julie as having reflex sympathetic
dystrophy ("RSD").  According to Dr. Singh:
"Reflex Sympathetic Dystrophy is a condition that is
seen after trauma of any kind.  And it results in
certain degree of changes in the extremity depending
on the stage of the problem.  Initially the pain in
that limb becomes out of proportion with the degree
of 
the 
injury 
and 
patient 
develops 
stimuli,
mechanical or otherwise.  Patient later on develops
changes in the skin which can be discoloration, the
extremity becomes cold and very painful.  As time
progresses on, patient develops some trophic changes
in the nail and the hair growth and skin quality
1071502
6
changes. 
 
And 
gradually 
patient 
can 
develop
contractures or permanent changes in the extremity."
Dr. Singh further stated that RSD can be caused by minor
trauma such as an abrasion, a cut, or even a pinprick.  The
trauma may be so minor that the patient does not recall the
trauma.  In regard to what caused Julie to develop RSD, Dr.
Singh, who also is the Lyonses' expert witness in this action,
testified as follows:
"[LYONSES' COUNSEL]: Do you know of any other
trauma that Ms. Lyons experienced here at the
hospital during that November 2003 hospitalization
which is capable of causing RSD other than the
infiltration?
"....
"[DR. SINGH]: I'm not aware of any other trauma.
"[LYONSES' COUNSEL]: In your opinion, what is
more likely to cause based upon your own education,
background, training, and experiences as well as
your own treatment of Ms. Lyons, what is the most
likely cause of RSD?
"....
"[DR. SINGH]: Most likely related to the IV.
"[LYONSES' COUNSEL]: And when you say most
likely related to the IV, what do you mean?
"....
"[DR. SINGH]: Just the process of starting an IV
or a problem resulting from IV infiltration, both
1071502
7
traumas can possibly initiate the Reflex Sympathetic
Dystrophy."
On September 13, 2005, the Lyonses initiated this action
against Vaughan in the Dallas Circuit Court.  Julie  alleged
negligence under the Alabama Medical Liability Act, § 6-5-480
et seq., Ala. Code 1975, and Godfrey alleged  loss of
consortium.  On February 8, 2008, Vaughan filed a motion for
a summary judgment as to the Lyonses' claims.  After the
Lyonses responded and a hearing was held, the trial court
entered a summary judgment in favor of Vaughan on June 23,
2008, without stating the grounds for the summary judgment.
The Lyonses appeal.
Standard of Review
"'"In reviewing the disposition of a
motion for summary judgment, we utilize the
same standard as that of the trial court in
determining whether the evidence before the
court made out a genuine issue of material
fact" and whether the movant was entitled
to a judgment as a matter of law.  Bussey
v. John Deere Co., 531 So. 2d 860, 862
(Ala. 1988); Rule 56(c), Ala. R. Civ. P.
When the movant makes a prima facie showing
that there is no genuine issue of material
fact, the burden then shifts to the
nonmovant to present substantial evidence
creating such an issue.  Bass v. SouthTrust
Bank of Baldwin County, 538 So. 2d 794,
797-98 
(Ala. 
1989). 
 
Evidence 
is
"substantial" if it is of "such weight and
1071502
8
quality that fair-minded persons in the
exercise 
of 
impartial 
judgment 
can
reasonably infer the existence of the fact
sought to be proved."  West v. Founders
Life Assurance Co. of Florida, 547 So. 2d
870, 871 (Ala. 1989).'
"Ex parte General Motors Corp., 769 So. 2d 903, 906
(Ala. 1999).
"'When the basis of a summary-judgment
motion is a failure of the nonmovant's
evidence, the movant's burden, however, is
limited to informing the court of the basis
of its motion--that is, the moving party
must indicate where the nonmoving party's
case suffers an evidentiary failure.  See
General Motors, 769 So. 2d at 909 (adopting
Justice Houston's special concurrence in
Berner v. Caldwell, 543 So. 2d 686, 691
(Ala. 1989), in which he discussed the
burden shift attendant to summary-judgment
motions); and Celotex Corp. v. Catrett, 477
U.S. 317, 323, 106 S. Ct. 2548, 91 L. Ed.
2d 265 (1986) (stating that "a party
seeking summary judgment always bears the
initial responsibility of informing the
[trial] 
court 
of 
the 
basis 
of 
its
motion").'
"Rector v. Better Houses, Inc., 820 So. 2d 75, 80
(Ala. 2001).
"'When the trial court does not give
specific reasons for entering a summary
judgment, we will affirm the judgment if
there is any ground upon which the judgment
could have been based.  Yarbrough v. C & S
Family Credit, Inc., 595 So. 2d 880, 881
(Ala. 1992).'
1071502
9
"McCloud v. City of Irondale, 622 So. 2d 1272, 1273
(Ala. 1993)."
Brown v. St. Vincent's Hosp., 899 So. 2d 227, 233-34 (Ala.
2004).
Analysis
In their complaint, the Lyonses allege that the staff of
the medical center breached the standard of care by
negligently assessing, observing, and evaluating the Hep-lock
device inserted in Julie's right hand and the injection of
medication through the Hep-lock device and by negligently
failing to remove the Hep-lock device in a timely manner when
Julie complained of pain, redness, and swelling in her hand.
They also allege in their complaint that because of these
purported inactions by the staff of the medical center, Julie
subsequently developed RSD.  On appeal, the Lyonses state that
"the only question before this Court is whether [Julie] met
her burden by substantial evidence to refute Vaughan's
contention that [Julie's] RSD was not related to any breach of
the standard of care of Vaughan's nurses."  (Lyonses' brief,
p. 25.)
In Sorrell v. King, 946 So. 2d 854 (Ala. 2006), this
Court observed:
1071502
10
"A plaintiff in a medical-malpractice action
must also 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 causation in 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).  See also DCH
Healthcare Auth. v. Duckworth, 883 So. 2d 1214, 1217
(Ala. 2003) ('"There must be more than 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."' (quoting Parker v. Collins, 605 So. 2d
824, 826 (Ala. 1992))); and Pendarvis v. Pennington,
521 So. 2d 969, 970 (Ala. 1988) ('"The rule in
medical malpractice cases is that to find liability,
there must be more than a mere possibility or one
possibility 
among 
others 
that 
the 
negligence
complained of caused the injury; there must be
evidence that the negligence probably caused the
injury."' (quoting Williams v. Bhoopathi, 474 So. 2d
690, 691 (Ala. 1985), and citing Baker v. Chastain,
389 So. 2d 932 (Ala. 1980))).  In Cain v. Howorth,
877 So. 2d 566 (Ala. 2003), this Court stated:
"'"'To 
present 
a 
jury 
question, 
the
plaintiff 
[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
1071502
11
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)).  However, the plaintiff in a
medical-malpractice case is not required to present
expert testimony to establish the element of
proximate causation in cases where 'the issue of
proximate cause is not ... "beyond the ken of the
average layman."'  Golden v. Stein, 670 So. 2d 904,
908 (Ala. 1995).  Therefore, '[u]nless "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.' 
 
DCH
Healthcare Auth., 883 So. 2d at 1217-18 (quoting
Cain, 877 So. 2d at 576)."
946 So. 2d at 862-63.
The Lyonses rely on the testimony of Dr. Singh to show a
causal connection between the IV infiltration and the RSD from
which Julie suffers.  If this Court were to presume that Julie
suffered an IV infiltration while she was a patient at the
medical center and that the IV infiltration was the result of
negligence on the part of Vaughan, Dr. Singh's testimony is
insufficient to create a genuine issue of material fact as to
whether 
Julie's 
RSD 
was 
probably 
caused 
by 
the 
IV
infiltration.  As previously noted, Dr. Singh testified as
follows:
1071502
12
"[LYONSES' COUNSEL]: In your opinion, what is
more likely to cause based upon your own education,
background, training, and experiences as well as
your own treatment of Ms. Lyons, what is the most
likely cause of RSD?
"....
"[DR. SINGH]: Most likely related to the IV.
"[LYONSES' COUNSEL]: And when you say most
likely related to the IV, what do you mean?
"....
"[DR. SINGH]: Just the process of starting an IV
or a problem resulting from IV infiltration, both
traumas can possibly initiate the Reflex Sympathetic
Dystrophy."
(Emphasis added.)  To have a valid claim under the Alabama
Medical Liability Act, the Lyonses must provide evidence
indicating that the negligence alleged is the proximate and
probable cause of Julie's injury; a mere possibility or one
possibility among others is insufficient to meet the burden of
proof.  See Sorrell v. King, supra.  Dr. Singh identified
various types of minor trauma that could be possible causes of
RSD.  Although he identified the Hep-lock device as "the most
likely" cause of Julie's RSD, he identified both the insertion
of the Hep-lock device and an infiltration of the Hep-lock
device as possible causes of the RSD.  Such evidence is
1071502
13
insufficient to show a causal connection between the purported
IV infiltration and the RSD.  Thus, the summary judgment in
favor of Vaughan is due to be affirmed.
The Lyonses alternatively argued before the trial court
that expert testimony was unnecessary because, they say, a
layperson could readily understand that IV infiltration
probably caused Julie's RSD.  However, she does not make that
argument on appeal.  "'An argument not made on appeal is
abandoned or waived.'" Muhammad v. Ford, 986 So. 2d 1158, 1165
(Ala. 2007) (quoting Avis Rent A Car Sys., Inc. v. Heilman,
876 So. 2d 1111, 1124 n. 8 (Ala. 2003)).
As to Godfrey's loss-of-consortium claim, "[a] loss-of-
consortium claim is derivative of the claims of the injured
spouse."  Flying J Fish Farm v. Peoples Bank of Greensboro,
[Ms. 1061833, October 24, 2008] ___ So. 3d ___, ___ (Ala.
2008).  Because Julie's claim fails, so must Godfrey's loss-
of-consortium claim fail.  Id.
Conclusion
Because the Lyonses have not established a proximate
causal connection between the purported IV infiltration Julie
sustained as a patient at the medical center and the RSD, we
1071502
14
affirm the summary judgment entered in favor of Vaughan as to
Julie's claim under the Alabama Medical Liability Act.
Because Godfrey's loss-of-consortium claim is derivative of
Julie's claim, we also affirm the summary judgment in favor of
Vaughan as to Godfrey's loss-of-consortium claim.
AFFIRMED.
Woodall, Smith, Parker, and Shaw, JJ., concur.