COURT OF APPEALS EIGHTH DISTRICT OF TEXAS EL PASO, TEXAS

SCOTT A. PROTZMAN, M.D., EL PASO ORTHOPAEDIC SURGERY GROUP, P.A., AND FRED UTTER, CRNA , Appellant s ,

v. MARIA T. GURROLA, INDIVIDUALLY AND ON BEHALF OF ALL WRONGFUL DEATH BENEFICIARIES, AND AS REPRESENTATIVE OF THE ESTATE OF OSCAR GURROLA, DECEASED , Appellee. § § § § § § § § No. 08

- 1 5

- 00 281

- CV

Appeal from the
448 th District Court of El Paso County, Texas (TC# 2014

- DCV

- 3560 )

O P I N I O N This is a health care liability case subject to the Texas Medical Liability Act

. T EX .C IV .P RAC .&R EM .C ODE C H
. 74 (W est 2011). On November 9, 2012, Mr. Oscar Gurrola underwent a non - surgical manipulation of his shoulder which was performed under anesthesia at El Paso Specialty Hospital , was discharged, suffered cardiac arrest, and died. His wife, Maria Gurrola, sued E l Paso Specialty Hospital, Dr. Scott A. Protzman, El Paso Orthopaedic Surgery Group (EPOSG) , and N urse A nesthetist Fred Utter, CRNA. 1 Maria timely served Dr. Michael

1 El Paso Specialty Hospital challenges the trial court’s ruling on the expert report as to the hospital in a separate2

Koumjian’s expert reports on the defendants. The trial court heard the defendants’ objec tions to the expert reports and denied their motion to dismiss Maria’s suit. T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.351( b) (West Supp. 2015). In this interlocutory appeal, Appellants ask us to determine whether the trial court abused its discretion when it overr uled their objections and denied their motion to dismiss.
T EX
. C IV .P RAC .&R EM .C ODE A NN
. § 51.014(a)( 9 ) (West Supp. 2015). Appellants assert the expert reports were inadequate because : (1) Dr. Michael Koumjian failed to establish his qualifications to opine on the standard of care, breach of that standard , and causation in support of Maria’s health care liability claims relating to the death of her husband, Oscar ; and (2) the expert reports fail to satisfy the TMLA requirements regardi ng causation based on the conduct of Dr. Scott A. Protzman and Nurse Utter, and as to the standard of care and breach of that standard in relation to the conduct of Nurse Utter

. T EX .C IV .P RAC .&R EM .C ODE A NN
. § 51.014( a)(10)

. We conclude the trial court did not abuse its discretion in denying the defendants’ objections and motion to dismiss Dr. Koumjian’s expert report regarding Dr. Protzman’s conduct , and affirm the trial court’s ruling

. However, Dr. Koumjian’s expert report re garding Nurse Utter is inadequate to constitute an objective good faith effort to comply with TMLA’s statutory requirements. T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.351( l ) (West Supp. 2015)

. We affirm in part , reverse in part, and remand the case for further pro ceedings. T EX .R.A PP .P. 43.2( a), (d)

. BACKGROUND The basis of Maria’s claim and the focus of Dr. Koumjian’s report involves Oscar’s post

- procedure tachycardia as well as the acts or omissions of the Hospital’s employees or agents

appe al. See El Paso Specialty Hospital, LTD v. Maria Gurrola, Individually and on Behalf of all Wrongful Death Beneficiaries and as Representative of the Estate of Oscar Gurrola, Deceased, No. 08

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- 00282

- CV.3

in relation thereto, speci fically with regard to the failure to monitor, diagnose, care for and treat the condition. Maria alleges that while Oscar was under the care of the defendants, he developed symptoms of congestive heart failure but was discharged home where he suffered a c ardiac arrest, was cared for by emergency personnel , and transported to another medical facility where he was pronounced dead. An autopsy revealed that Oscar died from severe coronary atherosclerosis. DISCUSSION Standard of Review We review the trial court’s ruling to determine whether it abused its discretion in ruling on the adequacy of the expert report

. Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 877 (Tex. 2001) ; Tenet Hospitals Ltd. v. Boada , 304 S.W.3d 528, 533 (Tex.App

. -- El Paso 2009, pet. denied)

. Under an abuse of discretion standard, the appellate court defers to the trial court’ s factual determinations if they are supported by evidence, but reviews the trial court ’ s legal determinations de novo. See Stockton v. Of fenbach, 336 S.W.3d 610, 615 (Tex. 2011) (citing In re Labatt Food Serv., L.P., 279 S.W.3d 640, 643 (Tex. 2009) ). A trial court abuses its discretion if it rules without reference to guiding rules or principles. Samlowski v. Wooten, 332 S.W.3d 404, 410 (Te x. 2011)

. I. Expert Qualifications Appellants present their complaints in four issues. In Issues One and Two respectively , Appellants challenge Dr. Koumjian’s qualifications to render expert opinions on the standards of

care and breach of applicable standards , and his qualifications to opine regarding the causal nexus between the alleged negligence and Oscar ’s death. We first address Issue Two.
To opine on whether a physician departed from accepted standards of medical care for physici ans, an expert must be a physician who:4

(1) is practicing medicine at the time such testimony is given or was practicing medicine at the time the claim arose; (2) has knowledge of accepted standards of medical care for the diagnosis, care, or treatment of the ill ness, injury, or condition involved in the claim; and (3) is qualified on the basis of training or experience to offer an expert opinion regarding those accepted standards of medical care

. T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74. 401(a)(West 2011) ; T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74. 351(r)(5)(A)

. To opine on whether a health care provider other than a physician departed from accepted standards of health care, an expert must be a person who:

(1) is practicing health care in a field of practice that involves the same type of care or treatment as that delivered by the defendant health care provider, if the defendant health care provider is an individual, at the time the testimony is given or was practicing that type of health care at the time the claim arose; (2) has knowledge of accepted standards of care for health care providers for the diagnosis, care, or treatment of the illness, injury, or condition involved in the claim; and (3) is qualified on the basis of training or experience to offer an expert opinion regarding those ac cepted standards of health care.
T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74. 402(b) ; T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74. 351(r)(5)(A)

. To opine on causation in any healthcare liability claim , an expert must be a physician who is otherwise qualified to render opinions on such causal relationship

un der the Texas Rules of Evidence. T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.351(r)(5)(C)

. An expert report or its required accompanying curriculum vitae must show that the expert is qualified to opine on the subject matter at issue. T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74. 351(a) ; In re McAllen Med. Center , Inc. , 275 S.W.3d 458, 463 (Tex. 2008) . The medical expert need not practice in the same specialty as the defendant in order to qualify as an expert

. Roberts v. Williamson , 111 S.W.3d 113, 122 (Tex. 2003) . However , not every licensed physician is a lways5

qualified to testify on every medical question. Broders v. Heise , 924 S.W.2d 148, 152 (Tex. 1996)

. To determine whether an expert report is sufficient to demonstrate the qualifications of the expert to opine , the trial court should focus on the medical expert’s “knowledge, skill, experience,

t raining, or education” concerning the specific issue before the court which would qualify the expert to give an opinion on that particular subject. B roders , 924 S.W.2d at 153

- 54 (apply ing Texas Rule of Evidence 702 ) ; see also Tenet Hospitals, Ltd. v. Garcia , 462 S.W.3d 299, 306 (Tex.App.

-- El Paso 2015, no pet.) ( application of rules of evidence in assessing expert’s qualifications to opine on causation as set forth in Section 74.351(r)(5)(C) pertains only to expert’s qualifications and does not extend to expert’s opinion )

. T he focus of the trial court should not be on the specialty of the medical expert. Roberts , 111 S.W.3d at 122

. A medical expert from one specialty may be qualified to testify if he has practical knowledge of what is traditionally done by medical experts of a different specialty under circumstances similar to those at issue in the case

. Pediatrix Med. Services Inc. v. De La O , 368 S.W.3d 34, 40 (Tex.App.

-- El Paso 2012, no pet.)

. If the subject matter is common to and equally recognized and developed in all fields of practice, any practitioner familiar with the subject may testify as to the standard of care. Id

. at 40. The trial court must ascertain that the expert does indeed possess the expertise on the subject for which he is giving an expert opinion. Palafox v. Silvey , 247 S.W.3d 310, 316 (Tex.App.

-- El Paso 2007, no pet.)

. The proffered medical expert’s qualif ications must be evident from the four corners of his expert report and curriculum vitae

. See Palacios , 46 S.W.3d at 878

. W e cannot infer causation either by filling in missing gaps or by guessing what an expert likely meant or intended. Tenet Hosps. Lt d. v. Bernal , 482 S.W.3d 165, 171 (Tex.App.

-- El Paso 2015, no pet.) ; Tenet Hosps, Ltd.6

v. Garcia, 462 S.W.3d 299, 310 (Tex.App.

-- El Paso 2015, no pet.) (citing Bowie Mem'l Hosp. v. Wright, 79 S.W.3d 48, 5 2 (Tex. 2002) )

. The basis of Maria’s claim and the focus of Dr. Koumjian’s report involves Oscar’s post

- procedure tachycardia as well as the acts or omissions of Dr. Protzman and Nurse Utter in relation thereto, specifically with regard to the failure to diagnose, care for and treat the condition. Maria a lleges that while Oscar was under the care of the defendants, he developed symptoms of congestive heart failure but was discharged home where he suffered a cardiac arrest, was transported to another medical facility, and was pronounced dead. An autopsy re vealed that Oscar had died from se vere coronary atherosclerosis.

1 . Qualifications to Opine on Standard s of Care and Breach In Issue Two, Appellants complain Dr. Koumjian is not qualified to render expert opinions regarding the standard of care or the brea ch of that standard by Dr. Protzman or Nurse Utter

. As
to Protzman, Appellants contend that Dr. Koumjian has failed to demonstrate “how or why” he is familiar with the standard of care , and assert that his failure to specify standards for post

- procedure

c are r enders his report too ambiguous, vague , and overbroad to render him qualified to opine as to the standards applicable to Dr. Protzman or Nurse Utter

. They also complain that Dr. Koumjian fails to explain how or why Dr. Protzman should have been aware of the severe nature of Oscar’s cardiovascular disease or should have acted differently

. Appellants argue that Dr. Kou m jian has not shown that he is qualified to opine on the standard of care and breach of the standard that is applicable to Nurse Utter because he fails to show that he is practicing health care in a field of practice that involves the same type of care or treatment as that delivered by Nurse Utter, providing anesthesia, or was practicing that type of7

heal th care at the time Maria’s claim arose , or has knowledge of the accepted standards of care for health care providers for the diagnosis, care, or treatment of the illness, injury, or condition involved in the claim

. We disagree with these assertions. In h er petition, Maria asserts that: (1) Appellants knew or should have known that Oscar was at risk for “developing a cardiac arrest because of

severe coronary disease ;” (2) while Oscar was at the hospital , the standard of care included proper assessment and treatment to prevent a patient like Oscar from “developing a cardiac arrest because
of severs coronary artery disease ;” (3) Appellants violated the standard of care by failing to provide proper assessment and treatment to prevent Oscar’s cardiac arrest an d death; and (4) at all relevant times, the Hospital and EPOSG acted by and through its employees and agents and are vicariously liable for their negligent acts and omissions. 2 There is no question that Maria’s complaint addresses Oscar’s status as an at

- risk cardiac patient, and challenges the Hospital’s compliance with the proper standard of care to be provided him as an at

- risk cardiac patient. Therefore, pursuant to Sectio n 74.351(r)(5)(B) , Dr. Koumjian must establish that he is qualified under the requirements of Section s 74.401 and 74.402 to testify as an expert witness on the issue of whether the physician and defendant health care provider departed from those applicable accepted standards of care. T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.351(r)(5)(B) ; T EX .C IV .P RAC .&
R EM .C ODE A NN
. § § 74.401 , 74.402

.

2 We analyze the sufficiency of the expert report only with respect to the actions of EPOSG’s employees and agents in Maria’s vicarious liability claim. See Certified EMS, Inc. v. Potts , 392 S.W.3d 625, 626 (Tex. 2013) (defendant did not challenge adequacy of expert report as to its vicarious liability); TTHR Ltd. Partnership v. Moreno , 401 S.W.3d 41, 45 (Tex. 2013) (expert report is analyzed as to physician’s actions, and plaintiff’s claims that hospital was vicariously liable for the physician’s actions may proceed if expert report regarding physician’s actions adequately address the standard of care, breach, and causation as to physician); see also Tenet Hosp. Ltd. v. Bernal , 482 S.W.3d 165, 174 (Tex.App.

-- El Paso 2015, no pet.) (expert must consider both th e pleadings and the medical record in formulating opinion, but is not required to address hospital’s vicarious liability for physician’s acts or omissions in order for expert’s report to be adequate)(citing Loaisiga v. Cerda, 379 S.W.3d 248, 261 (Tex. 2012 ) ).8 Applicable Law In a suit involving a health care liability claim against a physician for injury to or death of a patient, a person may qualify as an expert witness on the issue of whether the physician departed from accepted standards of medical care only if the person is a physician who: (1) is practicing medicine at the time such testimony is given or was practicing medicine at the time the claim arose; (2) has knowledge of accepted standards of medical care for the diagnosis, care, or treatment of the illness, injury, or condition involved in the claim; and (3) is qualified on the basis of training or experience to offer an expert opinion regarding those accepted standards of medical care.
T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.401(a)

. For the purpose of this section, “practicing medicine” or “medical practice” includes, but is not limited to, training residents or students at an

accre dited school of medicine or osteopathy or serving as a consulting physician to other physicians who provide direct patient care, upon the request of such other physicians.
T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.401 (b)

. In determining whether a witness is qualified on the basis of training or experience, the court shall consider whether, at the time the claim arose or at the time the testimony is given, the witness: (1) is board certified or has other substantial training or experience in an area of medica l practice relevant to the claim; and (2) is actively practicing medicine in rendering medical care services relevant to the claim.
T EX .C IV .P RAC .&R EM .C ODE A NN . § 74.401(c)(1), (2)

. The court shall apply the criteria specified in Subsections (a), (b), and (c) in determining whether an expert is qualified to offer expert testimony on the issue of whether the physician departed from accepted standards of medical care, but may depart from those criteria if, under the circumstances, the court determines that t here is a good reason to admit the expert ’ s testimony. T EX .C IV .P RAC .&R EM .C ODE A NN . § 74.401 (d)

.9

In a suit involving a health care liability claim against a health care provider, a person may qualify as an expert witness on the issue of whether the health care provider departed from accepted standards of care only if the person: (1) is practicing health care in a field of practice that involves the same type of care or treatment as that delivered by the defendant health care provider, if the defendant healt h care provider is an individual, at the time the testimony is given or was practicing that type of health care at the time the claim arose; (2) has knowledge of accepted standards of care for health care providers for the diagnosis, care, or treatment of the illness, injury, or condition involved in the claim ; and (3) is qualified on the basis of training or experience to offer an expert opinion regarding those accepted standards of health care. [Emphasis added].
T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.402(b)

. “ P racticing health care” includes: (1) training health care providers in the same field as the defendant health care provider at an accredited educational institution; or (2) serving as a consulting health care provider and being licensed, certified, o r registered in the same field as the defendant health care provider.
T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.402(a)

. In determining whether a witness is qualified on the basis of training or experience, the court shall consider whether, at the time the claim arose or at the time the testimony is given, the witness: (1) is certified by a licensing agency of one or more s tates of the United States or a national professional certifying agency, or has other substantial training or experience, in the area of health care relevant to the claim; and (2) is actively practicing health care in rendering health

care services relevan t to the claim. T EX .C IV .P RAC .&R EM .C ODE A NN . § 74.402(c) . I n determining whether an expert is qualified to offer expert testimony on the issue of whether the defendant health care provider departed from accepted standards of medical care, t he court shall10

apply the criteria specified in Subsections (a), (b), and (c) but may depart from those criteria if, under the circumstances, the court determines that there is a good reason to admit the expert ’ s testimony. T EX .C IV .P RAC .&R EM .C ODE A NN . § 74.401(d)

. If it departs from the specified criteria, the court shall state on the record its reason for admitting the testimony. Id. Analysis Maria filed Dr. Kou m

jian’s expert reports regarding Dr. Protzman and Nurse Utter on March 23, 2015, and April 6, 2015, respectiv ely. In each, Dr. Koumjian’s curriculum vitae indicates that he has been licensed to practice medicine since 1978, is currently the Chief of Surgery at Sharp Grossmont Hospital, has appointments as attending staff, consulting staff, provisional staff, or transitional staff in cardiothoracic surgery at seven hospital facilities, is board certified in Thoracic Surgery, and also conducts a private practice in cardiovascular and thoracic surgery. Thus, he was licensed and practicing medicine as a cardiovascular and thoracic surgeon and as Chief of Surgery at the time of his expert report and at the time Maria’s claim arose . He has previously served as Chief of the Cardio

- Thoracic Section of Scripps Mercy Hospital, and has served as a Distric t Counselor for the American College of Cardiologists. Dr. Koumjian has completed residencies in general surgery and cardiothoracic surgery, as well as fellowships involving cardiac surgery, cardiac transpl antation, and cardiac “valve.” He has lectured o n the intra

- operative use of inotropic agents during and immediately post

- cardiopulmonary bypass , and has served as an assistant clinical professor of surgery for the University of California at San Diego’s Department of Cardiac Surgery. In his expert repo rt s , Dr. Koumjian states that his medical practice involves the diagnosis and treat ment of coronary artery disease under the same or similar circumstances here , and that he11

is familiar with the standard of care concerning the evaluation of both the risk an d prevention of de ath caused by severe coronary a therosclerosis under the same or simil ar circumstances in this

case. He is familiar with the evaluation, consultation, diagnosis, and treatment of patients who are at risk for death caused by atherosclerosi s , and notes that the standard of care for identifying the risks and symptoms of severe coronary artery disease and obtaining cardiology consultation under the same or similar circumstances in this case applies to all physicians, including orthopaedic surg eons , and to nurse anesthetists

. Dr. Koumjian works closely with nurses who evaluate patients who are at risk and have symptoms associated with severe coronary artery disease under the same or si milar circumstances in this instance, and is familiar with t he nursing standard of care for reporting to physicians the symptoms associated with coronary artery disease , the diagnosi s, care, or treatment of which is involved in Maria’s claim

. In his expert report, Dr. Koumjian notes that a cardiologist had determined ten days before Oscar’s shoulder

- manipulation procedure that although surgery was not contraindicated, Oscar would need to be closely monitored due to his history of coronary artery disease

. Oscar was at risk of death due to severe coronary artery disease , and Dr. Koumjian states that Appellants knew or should have known this as Oscar had a diagnosis of atherosclerotic disease, coronary artery stents, uncontrolled diabetes, and hypertension , which are factors for tachycardia

. Without prompt diagnosis and treatment, tachycardia can lead to cardiac arrest

. Dr. Koumjian claims Appellants failed to properly diagnose and treat the signs and symptoms which Oscar presented post

- procedure . These symptoms included elevated blood pres sure, elevated heart rate, pain , and dizziness

. He asserts that the applicable standard of care required the performance of a “STAT cardiac workup

. ” This workup would have shown Oscar ’s tachycardia and would have require d12

immediate treatment such as defibrillation, intubation, and mechanical ventilation . These
treatments, more likely than not , would have prevented Oscar ’s cardiac arrest and death

. According to Dr. Koumjian, in addition to the standard of care applicable to both physicians and healthc are providers, the standard of care further required that Dr. Protzman as a physician both closely monitor Oscar because of his high risk for cardiac arrest due to coronary artery disease, and provide orders to staff to carefully monitor Oscar for any sign s or symptoms related to heart failure, such as a significant change in blood pressure, tachycardi a, or dizziness, and to notify him immediately if they occurred. Instead, Dr. Protzman failed to closely monitor
Oscar , and failed to provide orders to staff to carefully monitor Oscar for signs or symptoms of heart failure such as changes in blood pressure, tachycardia, or dizziness. This breach of the standard resulted in a failure to diagnose and treat Oscar ’s ventricular tachycardia before he was discharg ed from El Paso Specialty Hospital

. Oscar experienced a significant change of blood pressure, tachycardia, and dizziness while at the hospital but was sent home where he died that same day. According to Dr. Koumjian, had the standard of care been followe d, the h ospital’s nursing staff would have notified Dr. Protzman or a physician , Oscar more likely than not would have been diagnosed with tachycardia and treated, and with such diagnosis and treatment, Oscar ’s ventricular tachycardia would have resolved and his cardiac arrest and death would have been prevented. We do not find Dr. Koumjian’s recitations regarding his experience, training, knowledge, or familiarity with the diagnosis, care, or treatment of the condition, injury, or harm in this case to be vague, overbroad, or permitting of impermissible inferences as Appellants suggest.
Dr. Koumjian’s qualifications to opine on the standards of care and breach of those standards13

regarding Maria’s claims in this case are evident from the four corners of his expert report and curriculum vitae

. See Palacios , 46 S.W.3d at 878

. Consequently, we conclude the trial court did not abuse its discretion in concluding that Dr. Koumjian is qualified to opine on the standard of care and breach thereof as it applies to Dr. Protzman as a physician and to Nurse Utter as a health care provider. Issue Two is overruled. 2. Qualif i cations to Opine on Causation In Issue One, Appellant s argue Dr. Koumjian has failed to explain his qualifications and has therefore not demonstrat ed that he is qualified to render an expert opinion on causation . They label as insufficient Dr. Koumjian’s assertion that his practice of medicine “involves the diagnosis and treatment of coronary artery disease, under the same or similar circumstances as in this case

. ” They specifically complain that Dr. Koumjian provides no insight regarding how his practice involves matters confronted by either Dr. Protzman or Nurse Utter, fails to address whether he treats patients like Oscar or is fa miliar with the issues presented in Maria ’s claim, and fails to assert that he is familiar with the consequences of the purported breaches of the standards of care. Although acknowledging that Dr. Koumjian may be qualified to opine on causation, Appellant s assert his expert reports contain insufficient information, such as an explanation of his familiarity with the non - surgical interventions that he claims were required and could have prevented Oscar ’s death. To opine on causation in any healthcare liabili ty claim, an expert must be a physician who is otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence. T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.351(r)(5)(C) ; T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.401(a) . Rule of Evidence 702 provides that a witness who is qualified as an expert by14

knowledge, skill, experience, training, or education may testify in the form of an opinion if the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to
und erstand the evidence or determine a fact issue. See T EX .R.E VID
. 702

. Section 74.351(r)(5)(C) incorporates the rules of evidence in the context of the expert ’ s qualifications, not the substance of the opinion itself. Garcia , 462 S.W.3d at 306 . Consequen tly, Rule 702 ’s requirement that the witness must be qualified by “knowledge, skill, experience, training, or education” applies here

. Id. That an expert is qualified to opine on the subject matter at issue may be shown in the expert’s report or its required accompanying curriculum vitae

. T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74. 351(a) ; In re McAllen Med. Center , 275 S.W.3d at 463 . We have examined Dr. Koumjian’s report and curriculum vitae , and find that he has adequately shown that he is qualified b y knowledge, skill, experience, training, or education to opine on causation on the matter at issue

. To the extent we have addressed D r. Koumjian’s qualifications by knowledge, skill, experience, training, or education as presented within the four corners of his expert report s , we need not repeat them here. However, in addition to stating that his “practice of medicine involves
the di agnosis and treatment of coronary artery disease, under the same or similar circumstances as in this case,” Dr. Koumjian also notes his familiarity with the standard of care for the prevention of death under the same or similar circumstances as those of Os car . Dr. Koumjian’s qualifications to opine on the standards of care, breach of those standards, and causation arising from such breach with regard to the claims in this case are evident within the four corners of his expert report and curriculum vitae

. See Palacios , 46 S.W.3d at 878

. Consequently, b ecause Dr. Koumjian’s expert report shows that he is a physician having15

knowledge and experience concerning the subject of his opinion, we conclude the trial court did not abuse its discretion in determining that Dr. Koumjian was qualified to offer an opinion on the cause of Oscar ’s cardiac arrest and death. Issue One is overruled. II. Sufficiency of Expert Reports In Issues Three and Four respectively, Appellants complain the trial court abused its discretio n in overruling their objections to the adequacy of Dr. Koumjian’s expert reports and in failing to dismiss Maria’s suit. Issue Three complains that Dr. Koumjian’s expert report fails to
prov ide a non

- conclusory, factually

- supported explanation of the cau sal link between
Dr. Protzman and Nurse Utter’s alleged negligence and Oscar ’s death. Issue Four asserts that
Dr. Koumjian’s expert report fails to establish the standard of care applicable to Nurse Utter, and Nurse Utter’s breach of that standard of care

. Applicable Law A plaintiff asserting a health care liability claim must serve each defendant with an expert report that includes “a fair summary of the expert ’ s opinions .

. . regarding applicable standards of care, the manner in which the care rendered by the physician or health care provider failed to meet the standards, and the causal relationship between that failure and the injury, harm, or damage claimed.” T EX .C IV .P RAC
. &R EM .C ODE A NN
. § 74.351(r)(6) ; Van Ness v. ETMC First Physicians , 461 S.W.3d 140, 141 (Tex. 2015) ; Bustillos v. Rowley , 225 S.W.3d 122, 130 (Tex.App.

-- El Paso 2005, pet. denied) (expert report need not include full statement of applicable standard of care a nd how it was breached; fair summary must set out what care was expected, but not given)(citing Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 880 (Tex. 2001) )

. A challenge to the sufficiency of a report must be sustained if the report does not represent an objective good16

f aith effort to comply with the statutory requirements. T EX .C IV .P RAC .&R EM .C ODE A NN
. § 74.351( l ) ; Van Ness , 461 S.W.3d at 141

. A report is a good faith effort if it pr ovides adequate information to inform th e defendant of the specific conduct the plaintiff has called into question, provides a basis for the trial court to conclu de that the claims have merit, and does not contain a material deficiency. Van Ness , 461 S.W.3d at 141

- 42

. The evidence in the expert report need not be the same evidence as if the merits of the claim are being litigated. Palacios, 46 S.W.3d at 879 ; Tenet Hosps. Ltd. v. Barajas , 451 S.W.3d 535, 540 (Tex.App.

-- El Paso 2014, no pet.) . Rather, the expert’s repor t can be informal and the information contained therein “does not have to meet the same requirements as the evidence offered in a summary

-

judgment proceeding or at trial.” Palacios, 46 S.W.3d at 879 ; Barajas , 451 S.W.3d at 540

. However, an expert must ex plain, based on facts set out in the report, how and why the breach caused the injury. Van Ness , 461 S.W.3d at 142 , citing Jelinek v. Casas, 328 S.W.3d 526, 539

- 40 (Tex. 2010) . A bare expert opinion that the breach caused the injury will not suffice. Va n Ness , 461 S.W.3d at 142

. Analysis
Dr. Koumjian set out the following facts in his report as those on which he based his opinions. Oscar ’s cardiologist, Dr. Gregorio J. Castillo, examined him on October 29, 2012.
Dr. Castillo noted that Oscar was scheduled for surgery the following week , that his blood sugars were elevated after increasing the dose of medication, that his blood pressure was 110/70 , and his pulse was 63. Although Oscar had no symptoms of dizziness or syncope, Dr. Castillo obse rved that Oscar had uncontrolled diabetes and atherosclerotic cardiovascular disease. He noted that
Oscar did not have a medical contraindication for surgery under general anes thesia for treatment of17

his right shoulder adhesive capsulitis, but indicated t hat Oscar would require close monitoring because of his history of coronary ar tery disease. On November 9, 2012, Oscar went to El Paso Specialty Hospital for a right shoulder ther apeutic manipulation under general anesthesia and an injection of anesthetic, steroid, and arthrogram

. Dr. Scott Protzman, an orthopaedic surgeon, and N urse A nesthetist Fred Utter performed the orthopaedic procedure. Oscar ’s pre

- anesthesia blood pressure was 128/90, and his heart rate was 84. The anesthesia was started at 9:05 a .m., and the procedure was commenced at 9:21 a.m. The procedure ended at 9:30 a.m., and Oscar was in the recovery room at 9:42 a.m. At that time, his heart rate was 82, and his respirations were 18. A nesthesia was ended eight minutes later at 9:50 a.m. In the recovery room, Oscar c omplained of increasing pain. He subsequently underwent a block for post

- operative pain, with anesthesia commending at 11:20 a.m. and ending at 11:45 a.m. Dr. Koumjian’s expert report does not identify the person who administ ered this anesthesia to
Oscar

. In the recovery room, Oscar ’s blood pressure was 163/91, and his heart rate had increased
to 91. Oscar told the recovery room nurse that he was feeling dizzy and very sleepy . The nurse informed Oscar that his symptoms were normal, and noted to Oscar and Maria that although
Oscar ’s blood pressure was high, that was normal as well. The unidentified recovery room nurse did not notify a physician about Oscar ’s reported symptoms , and at approximately 12:50 p.m., “ the

nurse ” ins tructed Oscar and Maria to return home. As instructed, Oscar and Maria returned home

. Maria assisted Oscar out of their car and into their home, and at approximately 2 p.m., Maria left to run errands. When Maria returned home, she found Oscar unresponsive and called 9

- 1

- 1. Emergency medical services arrived at18

4:30 p.m., initiated cardio

- pulmonary resuscitation on Oscar , and transported him to a hospital, arriving there at 4:47 p.m. Cardio

- pulmonary resuscitation was discontinued at 4:59 p.m ., and
Oscar was pronounced dead. An autopsy report shows Oscar died from severe coronary atherosclerosis , and the certificate of death identifies Oscar ’s immediate cause of death was s evere coronary artery disease. B. Expert Reports on Causation In Issue Three, Appellants complain that Dr. Koumjian fails to provide a factual underpinning for his causation conclusions, and fails to explain how or why Oscar ’s ventricular tachycardia led to his fatal cardiac arrest, fails to discuss any connection be tween the ventricular tachycardia and the severe coronary atherosclerosis found after autopsy, or how immediate treatment consisting of defibrillation, intubation, and mechanical ventilation would have prevented the fatal cardiac arrest “hours later.”
In h is five

- page expert reports, Dr. Koumjian notes that Oscar ’s post

- procedure heart rate, elevated blood pressure, and dizziness are signs and symptoms of ventricular tachycardia. He states that untreated ventricular tachycard ia can lead to cardiac arrest. There is no evidence noted in the expert report that the recovery room nurse or any nurse ever notified Dr. Protzman or any physician about Oscar’s tachycardia signs and symptoms. Rather, the recovery nurse informed Oscar and Maria that Oscar ’s symptoms were normal and instructed them to return home.
Dr . Koumjian explain s that Dr. Protzman breach ed the standard of care by failing to closely monitor Oscar , by failing to provide orders that staff carefully monitor Oscar for any signs and symptoms of heart f ailure such as a significant change in blood pressure, tachycardia, or dizziness, and to notify him or a doctor of such signs and symptoms

. This breach of the standard19

of care resulted in the failure to diagnose and treat Oscar ’s ventricular tachycardia b efore he was discharged and sent home. Oscar experienced a significant change of blood pressure, tachycardia, and dizziness post

- procedure while at the hospital. Had the standard of care been followed, the hospital’s nursing staff would have notified Dr. Protzman or a physician , and Oscar more likely than not would have been diagnosed with ventricular tachycardia and immediately treated with defibrillation, intubation, and mechanical ventilation

. More likely than not , this diagnosis and treatment would h ave prevented Oscar ’s cardiac arrest and death

. In his report regarding Nurse Utter, Dr. Koumjian explains that Nurse Utter breached the standard of care by failing to carefully monitor Oscar for any signs and symptoms of heart failure such as a significant change in blood pressure, tachycardia, and dizziness. H e opines that h ad Nurse Utter followed the standard of care, he would have assessed Oscar , found that Oscar had a significant change of blood pressure, tachycardia, and dizziness, and would have reported these findings to a physician. According to Dr. Koumjian, Nurse Utter’s breach of the standard of care
resulted in a failure to diagnose and treat Oscar ’s ventricular tachycardia befor e he was discharged and sent home. I f Nurse Utter had followed t he standard of care, more likely than not, Oscar would have been treated for tachycardia by defibrillation, intubation, and mechanical ventilation

. This diagnosis and treatment, based on a r easonable medical probability, more likely than not would have resolved Oscar ’s ventricular tachycardia and prevented his cardiac arrest and death. Dr. Koumjian’s expert reports demonstrate that Dr. Protzman’s and Nurse Utter’s alleged negligence are causa lly related to Oscar ’s death

. He reports that the signs and symptoms of
Oscar ’s ventricular tachycardia were evident, detectable , and treatable , and that adherence to the standard of care by providing proper monitoring and administration of treatment more likely than20

not would have resolved the tachycardia and prevented Oscar ’s cardiac arrest and death

. It was incumbent upon the trial court to review the reports, sort out their contents, resolve incons istencies, and decide w hether the expert reports demonstrated a good faith effort to show that Maria ’s claims have merit

. See Van Ness , 461 S.W.3d at 144

. Based on our review, the reports provide a fair summary of Dr. Koumjian’s opinions as to the causal relationship between Dr. Protzman’s and Nurse Utter’s alleged breaches and the harm claimed , inform the defendants of the conduct being called into question, and provide a basis for the trial court to conclude that Maria ’s claims have merit

. Consequently, we conclude the trial court did not abuse its discretion by determining that the expert reports are not conclusory and constitute a good

- faith effort to comply with the TMLA’s requirements as to causation

. Issue Three is overruled.

1 . Exp ert Report on Nurse Utter’s Standard of Care and Breach.
In Issue Four, Appellants complain the trial court abused its discretion by overruling their objections to the expert report regarding Nurse Utter on the basis that Dr. Koumjian’s report fails
to est ablish the standard of care applicable to Nurse Utter and his alleged breach of that standard.
A ccording to Dr. Koumjian’s expert report , the standard of care for a nurse anesthetist , like that of Dr. Protzman, required that Nurse Utter monitor Oscar for signs a nd symptoms associated with heart fail u re and ventricular tachycardia, “ such as a significant change in blood pressure, tachycardia, and dizziness, ” and report them to a physician, and alleges that Nurse Utter breached the standard of care by failin g to do so

. Appellants counter that Dr. Koumjian’s report as to Nur se Utter is deficient in part because it fails to place Nurse Utter in the recovery room with Oscar or explain the role of a nurse

ane s thetist in providing post

- pr ocedure care. They contend the report is also deficient because it21

fails to identify or discuss Utter’s role in relation to that of the hospital’s nursing staff present in the recovery room with Oscar , or the hospital nursing staff to whom Dr. Protzman should have issued ord ers to closely monitor Oscar

. 3 Appellants note that Nurse Utter cannot be assumed to have provided post

- operative care to Oscar , and indicate that Dr. Koumjian’s report only links Nurse
Utter to Oscar during the administration of anesthesia between 9:05 and 9:50 a.m. , during which the report fails to claim that Oscar presented any observable symptoms of severe coronary artery disease such as elevated blood pressure, heart rate, and dizziness. Those sy mptoms, Appellant s ’ argue, presented only after a second administration of anesthesia by an unnamed provider. For these reasons, Appellants argue Dr. Koumjian’s expert report regarding Nurse Utter is speculative and without foundation as no facts recited in the report connect Nurse Utter’s care to Oscar ’s post

- procedure care. We agree with these assertions

. The facts recited in Dr. Koumjian’s expert report regarding Nurse Utter do not adequately explain how or why Nurse Utter’ s specific conduct constitute s a br each of the standard of care for a nurse anesthetist

. In his report, Dr. Koumjian specifically identifies Nurse Utter as the person who provided general anesthesia to Oscar between 9:05 and 9:50 a.m. O scar ’s pre

- anesthesia heart rate was 84 , and when he was taken to the recovery room at 9:42 a.m., eight minutes before anesthesia concluded at 9:50 a.m. , his heart rate
was 82. However, t he report does not identify Nurse Utter as the person who subsequently administer ed the anesthesia to Oscar for a pain

- control block, nor as a member of the nursing staff of the hospital or its recovery room. The facts which Dr. Koumjian recites regarding Oscar ’s post

- procedure complaints , signs, and symptoms , neither directly n or indirectly implicate any act

3 Maria does not claim that Nurse Utter is an employee of the hospital.22

or omi ssion by Nurse Utter which indicates that he breached the standard of care for a nurse anesthetist in this situation

. The trial court’s factual determination of Nurse Utter’s alleged breach is not supported by the facts recited in Dr. Koum jian’s expert report

. See Stockton, 336 S.W.3d at 615

. Because
Dr. Koumjian’s expert report does not provide adequate information to inform Nurse Utter of the specific conduct Maria has called into question, it fails to provide a basis for the trial court to conclude that Maria ’s claims against Nurse Utter have merit, and does not constitute an objective good faith effort to comply with the statutory requirements of an expert report

. See Van Ness , 461 S.W.3d at 141

- 42

. We conclude the trial court abused its discre tio n when it overruled Appellants’ objection s to Dr. Koumjian’s expert report regarding Nurse Utter’s alleged breach of the standard
of care . Issue Four is sustained. The Supreme Court has determined that when an appellate court reverses a trial cou rt’ s denial of a motion to dismiss a health care liability claim due to omission of any of the statutory expert report requirements, the appellate court may remand the case to the trial court to consider granting a thirty

- day extension to cure the deficiencies in the report. Leland v. Brandal, 257 S.W.3d 204, 207

– 08 (Tex. 2008) ; see also Lewis v. Funderburk, 253 S.W.3d 204, 208 (Tex. 2008) (stating that a deficient report may be cured by amending the report or by serving a new report from a separate expert that cures the deficiencies in the previously filed report) ; Regent Health Care Center of El Paso, L.P. v. Wallace, 271 S.W.3d 434, 441 (Tex.App.

-- El Paso 2008, no pet. )

. The trial court is in the best position to decide whether a cure for an inadequate expert report is feasible. See Samlowski v. Wooten, 332 S.W.3d 404, 411

– 12 (Tex. 2011)

. Base d on these decisions, it is appropriate to remand the case to the trial court for consideration of whether23

the deficiencies in the expert reports can be cured, and therefore, whether to grant an extension of time. CONCLUSION
T he t rial court ’ s order is affirmed in part, and reversed and remanded in part to the trial court for further proceedings

.

August 24, 2016 YVONNE T. RODRIGUEZ, Justice Before McClure, C.J., Rodriguez, and Hughes, JJ.