THI RD DI VI SI ON

DOYLE, P. J.

, DI LLA R D, P. J.

, and BROWN, J.

N O T IC E : M otions for r e c ons i de r a tion m us t be

ph y sic a l ly r e ce iv ed i n our c le r k ’s offic e w ithin te n

da y s of the da te of de c is ion to be de e m ed tim e ly file d.

https ://w w w

. ga a ppe a ls .us /r ule s

D E A D LIN E S A R E N O LO N G E R TO LLE D IN T

H I S

C O U R T. A LL FILIN G S M U ST B E S U B M I TTE D WITH IN

TH E TIM E S S E T B Y

O U R C O U R T R U LE S

.

October 27, 2021



# I n th e Co u r t o f

A p p eals o f

G eo r g ia

A2 1 A1 02 3

. CHYBICKI et al

. v

. COFFEE REGIONAL M E DICAL

CENTER, INC. et al

.

B R O W N , J u d g e.

Do n al d Bri an Ch y

b i ck i

, i n hi s cap aci t i es as t h e s u rv i v in g sp o u s e o f San d ra

Ch y b i ck i

, as wel l as t h e ex ecu t o r o f h er es t at e, al o n g wi t h M s. Ch y bi ck i ’ s t wo ad u l t

ch i l d ren (co l l ect i v el y “ p l ai ntif f s” )

, a ppe a l f r om tw o sum

m a r y j udgm e nt or de r s e n t ered

b y t h e t ri al co u rt in th i s m ed i cal m al p ract ice/ w ro n g fu l deat h cas e b ro u g h t ag ai n s t

n u m erous pe r sons a nd e ntitie s

, i n cl u d i n g t h e ap p el lees i n t hi s ap p eal

, Co ffee Reg i o n al

M ed i cal Cen t er, In c. (“ t he h o s p i t a l ” ) an d M y ra Bel k

, R. N

. (co l l ect i v el y “ h o s p i t al

d efe n d a n t s ” )

. Pl ai n t i ffs co n t en d t h at t h e t ri al co u rt erred i n (1 ) co n cl u di n g t h at a

t reat i n g p h y s i ci an , Dr. W i l l i am Pau l Iv es , was an i n d ep en den t co n t ract or fo r wh o m

t h e ho s p i t al co u l d n o t b e h el d l i a b l e an d g ran t i n g p art i al s u m m ary ju d g m en t t o t h eh o s p it al o n t h i s g ro u n d ; (2 ) fi n d i n g t hat th e h o s p it a l d e f e n d an t s were en t i t l ed to

s u m m ary ju d g m en t i n th ei r fav o r b as ed u p o n an al leg ed l ack o f ad m i s s i b l e cau s at i o n

ev i d en ce; an d (3 ) en t eri n g an o rd er ex cl u d i n g t h e o p i n i o n o f M eg W arren

, R.N.,

p u rs u an t t o OCGA § 2 7 -7 -7 0 2

, wh i ch g o v ern s t he ad m i s s i b i l i ty o f ex pert t es t i m o n y

.

Fo r t h e reas o n s ex p l ai n ed b el o w, we affi rm

.

Su m m ary ju d g m en t i s pro p er wh en t h ere i s n o g e n u i ne i s s u e o f

m at eri al fact an d t h e m o van t i s en t i t l ed to ju dg m en t as a m at t er o f l aw.

In rev i ewi n g a g ran t o r d en i al o f s u m m a r y j u d gm en t, w e o w e n o

d efere n c e t o t h e t ri al co u rt ’ s ru l in g an d we rev i ew d e no v o b o t h th e

ev i d en ce an d t h e t ri al co urt ’ s l eg al co n cl u s i o n s. M oreo v er, we co n s t ru e

t h e ev i d en ce an d al l in feren ces an d co n cl u s i o n s ari s i n g t h erefro m m o s t

fav o rab ly t o ward th e p art y o p p o s i n g t h e m o t i o n

. In d o i n g s o

, we b ear i n

m i n d t h at t h e p art y o p po s i ng s u m m ary ju d g m en t i s n o t r eq u ired t o

p ro d u ce ev id en c e d e m an d i n g ju dg m en t fo r i t

, b u t i s o n l y req u i red t o

p res en t ev i d en ce t h at rai s es a g en u i n e i s su e o f m at eri al fact

.

(Ci t at i o n s an d p u nct u at i on o m it t ed .) S wi n t v. Al p h o n se

, 3 4 8 Ga. A p p

. 1 9 9

, 1 9 9 -2 0 0

(8 2 0 SE2 d 3 1 2 ) (2 0 1 8 ). So v i ewed

, 1 t he ev id en ce s h o ws t h at o n J u ne 2 8

, 20 1 6

, M s

.

Ch y b i ck i

, wh o was 5 7 y ears o l d

, was ad m i t ted t o t he h os p i t al aft er s h o wi n g

1 W h i l e al l o f th e s am e ev i d en ce su b m i tt ed to t h e t ri al co u rt ap p ears i n t h e

reco rd b efo re u s

, i t do es n o t i ncl u d e t h e d ep o s i t io n s o f n urs e Bel k an d an em erg en cy

ro o m phy sic ia

n, ev en th o u g h t h ei r tes t i m o n y i s referen ced in th e d ep o s i t i o n s th at were

s u b m i t t ed fo r t h e t ri al co u rt ’ s rev i ew.

2“ s i g ns / sy m

p to m s o f s ep s i s.” Fo r m an y y ears

, M s

. Ch y b ick i h ad b een d i ag n os ed wi th

h y p ert en s i o n

, d i ab et es

, an d h ig h ch o l es t ero l ; s h e was al s o m o rb i d l y ob es e. A CT s can

rev eal ed k i d n ey s to n es

, an d s he u n d erwen t s u rg ery

, p erfo rm ed b y Dr. Al fred W al t er

M azu r, t o rem o v e t h em

.

Dr. Iv es was t h e an es t h es i o l o g i s t fo r M s. Ch y b i ck i’ s s u rg ery

. He s tart ed wo rk

at 7 : 0 0 a.m

. o n t h e d ay o f t h e su rg ery

, an d h er s urg ery was t he l as t cas e o f t h e d ay

. Dr.

Iv es s tat ed i n h i s i n t erro g at o ry res p o ns es th at “ a cert i fi ed reg i s t ered n u rs e an es t h et i s t

[“ CRNA”] was n o t n eces s ary d u ri n g [t h e] s u rg ery [b ecau s e h e] p ers on al l y at t en d ed

t o M rs

. Ch y

b i ck i fo r an es t h es i a care.” H e ex p lai n ed t h at t he h os p i t a l t y p i c a l l y h ad

fo u r o p erat i n g ro o m s ru n ni ng wi t h t h e an es t h es i o l o g i s t s i n an d o u t o f t h e o p erat i n g

ro o m i n wh i ch CRNAs d el iv ered an es t h es i a. As t h e d ay wi nd s d o wn

, h i s p ract i ce was

t o l et o t h er p ro v i d ers (CRNAs an d t h e o th er an es t h es i o l o g i s t) go h o m e. Aft er t h e

o t h er an es t h es io l o g i s t an d CRNAs l eft fo r t h e d ay

, t h e o n l y o t h e r m ed i cal p ro v i d er

i n t h e h o s p i t al wh o co u l d hav e at t em p t ed an i n tu b at i o n o f a p at i en t i n ad d it i o n t o Dr.

Iv es w as an em erg en cy ro o m p h y s i ci an

. Si nce M s

. Ch y b i ck i was t h e l as t cas e o f t h e

d ay

, Dr. Iv es p ro v i d ed her an es t h es i a b y h i m s el f. He d es cri bed h er as b ei n g

“ m o d erat el y d iffi cu l t ” to i nt u b at e b efo re t h e s u rg ery

, b u t was ab le to d o i t o n h i s fi rs t

3t ry

. He ex p l ai n e d t h at s he w as h ard er t o i n tu b at e b ecau s e o f “ red u n d an t ti s s u e

. . .

ev ery wh ere” s eco n dary t o h er o b es i ty

.

Fo l l owi n g h er s u rg ery an d aft er d et erm i n i n g t h at s h e m et al l o f t h e res p i rat o ry

cri t eri a, Dr. Iv es ex t u b at ed M s

. Ch y b i ck i i n th e o perat in g ro om aro u n d 4 :3 2 p .m

. Dr.

Iv es t es t i fi ed t h at h e d id n o t bel i ev e h er res p i rat i o n s were s h al l o w or lab o red i n an y

way aft er h e ex t u b at ed h er, b u t h e n o n et h el es s p laced a n as al ai rway d ev i ce o n h er

wh i le s h e was s t i l l i n t h e o p erat in g ro o m

, p erh ap s b ecau s e s h e was s n o ri ng o r m ak i n g

u p p er ai rway n o i ses

. A t 4 : 3 9 p .m

., s h e was ad m i tt ed t o t h e p o s t -an es t h es i a care u n i t

(“ PACU”), wh i ch was l o cat ed ap p ro xi m at el y 3 0 feet away fro m th e op erat i n g ro o m

.

Dr. Iv es “ i m

m ed i at el y ” rem o v ed t h e n as al ai rway d ev i ce an d rem ai n ed at her b ed s i de.

A v i t a l s i g n rep o rt co m

p l et ed at 4 : 3 9 p .m

. s t at ed t h at M s. Ch y b i ck i h ad a fev er o f

1 0 2 .7 d eg rees Fah ren h ei t, an el ev at ed h eart rat e (1 6 0 ) an d b l oo d p res s u re (1 5 2 / 1 2 2 ),

an d “ lab ored ” res p i rat i o n s. A n o t e i n di cat ed t h at an o xy g en sat u rat io n percen t ag e

(“ O2 Sat ”) was un ab l e t o b e o bt ai n ed ev en t h o u g h “ m u lt ip l e s i t es ” were at t em

p t ed

.

W h i l e Dr. Iv es d id n ot k n o w wh y th i s read in g co u l d no t b e o b t ai n ed

, h e t h o u g h t t h at

o n e ex p l an at i o n co ul d be t h at earl y i n M s

. Ch y bi ck i ’ s p o s t o p erat iv e co u rs e i n t h e

PACU, s h e b eg an co m

pl ai n i n g o f fl an k p ai n an d b ecam e ag i t at ed

, “ [n ] o t h o l d i n g s t i l l

,

p u l l i ng o ff m on i t o rs

, p ul l i n g o ff o x y g en .” Dr. Iv es ack n o wl ed ged t h at o t h er t h an an

4en d -t i d al CO2 m eas urem en t

, w h i ch was n o t av ai l ab l e i n t h e P A C U

, t h e O2 Sat

read i n g wo u l d b e th e n ex t b es t way t o d et erm i n e i f a p ers o n was recei v i n g su ffi ci en t

p o s i t i ve v en t i l at i on

.

Fi v e m i n u t es l at er, at 4 :4 4 p

. m

., t h e v i t al s i g n rep o rt s t at es “ u n ab l e t o g et [O2 ]

s at read i n g ” an d M s

. Ch y

b i ck i ’ s res p i rat io n s were s t i l l “ l ab o red ,” h er pu l s e w as 1 5 9,

an d h er bl o o d p res s ure was 17 2 / 1 2 3. By 4: 4 9 p .m

. , h er b l oo d p res s u re was 2 6 3 / 1 2 8,

h er b reat hi n g was “ l ab ored ,” h er p u l s e was 1 6 1, an d h er O2 Sat was 8 0 p ercen t

.

A n o t e o n t h e v i t al s i g n rep o rt s tat es th at at 4 : 4 9 p .m

., Dr. Iv es was b ed s i d e an d

as s i s ti n g v en t i l at i o n s wi th an Am b u b ag

. Dr. Iv es t es t i fi ed t hat ap pro x i m at el y fi ft een

m i n u t es aft er M s

. Ch y

b ick i arri v ed i n t h e PACU, h e d eci ded h e n eed ed t o rei n t u b at e

h er b ecau s e sh e was g et t i n g s ep t i c, h er O 2 Sat s were d i m i ni s h i n g

, an d s h e n eed ed a

d efi n i t i v e ai rway

. Dr. Iv es was u n ab l e t o s ucces s fu l l y rei n t u b at e h er aft er nu m ero u s

at t em p t s

, d o cu m en t ed as an y w h ere b et we e n f o u r an d ei g h t t i m es

. Dr. Iv es t es t i fi ed

t h at h e o n l y act u al l y at t em p t ed t o i n tu b at e M s

. Ch y

b i ck i fo u r t i m es , ex p lai n i n g t h at

“ l o ok s ” were m is ch aract eri zed as an act u al at t em p t

. 2

2 On e o f t he p lai n t i ffs ’ ex p ert s t es t i fi ed t h at “ th i s i d ea t h at th ere’ s l o o k-s ees an d

t h en t h ere’ s real l y at t em

p ts

. Th at ’ s ri d i cu l o u s

. Yo u p u t a l ary n g o sco p e i n s o m eo n e’ s

m o ut h

, t h at ’ s an at t em

p ted l ary n g o s co p y ” t h at s h o ul d n o t b e d o n e w i t ho u t an i n t en t

t o i nt u b at e.

5In b et ween i n t u b at i o n at t em p t s wh i ch l as t ed ap p ro x i m at el y 2 0 t o 3 0 s eco n d s

,

Dr. Iv es us ed t h e Am

b u bag an d M s

. Ch y

b i ck i’ s O2 Sat l ev el s ran g ed fro m 9 6 t o 9 7

b et ween 4 : 5 4 p .m . an d 5 : 0 9 p .m . Dr. Iv es cal l ed a co d e b l u e at 5 : 19 p .m

. wh en M s

.

Ch y b i ck i d i d no t h av e a p u l s e, wh ich h e des cri b ed as “ fa i r l y s u d d en ” an d

“ u n ex p ect ed .” CPR was i m m ed i at el y i n i ti at ed wi t h co n t i n u ed v en t i lat i o n b y Dr. Iv es

.

Dr. Bru l t e, an em erg en cy ro o m p h y s i ci an wh o res p o n d ed t o t h e c o d e, s u cces s fu l l y

rei n u t u b at ed M s

. C h yb i c k i o n h i s s eco nd t ry at 5 : 3 0 p .m

. Dr. Iv es tes t ifi ed t h at h e

t h o u g h t Dr. Bru l t e was ab l e t o su cces s fu l l y rei nt u bat e M s

. Ch y bi ck i “ b ecau s e h e h ad

t w o p ai rs of h an ds b ecau s e [Dr. Iv es ] was hel p i n g h i m wi t h h ead p o s i t i o n an d

s u p p ort i n g h er head ,” s o m et h i n g th at h ad no t b een av ai l ab l e t o h i m du ri n g h i s

at t em p t s b efo re th e co d e was cal l ed ; h e d id n o t k n o w i f n u rs e Bel k co u l d h av e d o n e

t h i s fo r h i m

. Dr. Iv es t es t i fi ed t h at M s

. Ch y b i ck i ’ s O2 “ [S] at s w ere co n s i s t en t l y

s u b o pt i m al b u t n ot

—

t hat ’ s n o t wh at cau s ed t h e co d e. Sh e l o s t h er p u ls e.”

Aft er i n tu b at i o n

, M s

. Ch y b i ck i s t ab i l i zed an d was t ran s ferred t o t h e ICU. Th e

p l ai n t i ffs ’ co m

p l ai nt al leg es t h at s h e was su b seq u en tl y d i ag n os ed as b ei n g i n a

“ ‘ v eg et at i v e s t at e’ ” an d rem ai n ed i n t h e h o s p i t al u n t i l h er d eat h o n J ul y 2 3

, 2 0 1 6,

fro m card i op ul m o n ary

arres t

.

6Dr. Th om as Mi t ro s, a s t an d ard o f care ex pert ret ai n ed b y t h e p l ai n t iffs

, t es t i fi ed

t h at Dr. Iv es n ev er sh o u l d h av e d o n e t h e an es t h es i a fo r t h e su rg ery b y h im s el f a n d

s h o u ld h av e h ad an ot h er an es t h es i o l o gi s t or CRNA at ten d i n g t h e s urg ery wi t h h i m

.

W h en Dr. Iv es was un ab l e t o rei n t u bat e Ms

. Ch yb i c k i o n h i s seco n d at t em p t

, h e

s h o u ld h av e cal l ed fo r ad d i t i o nal h el p fro m a s urg eo n o r t h e em erg en cy ro o m

. He al s o

o p i n ed t h at Dr. Iv es “ s h ou l d h a v e t a k e n t h i s p at i en t b ack in t o t h e [o p erat i n g ro o m

wh ere h e h as b et t er eq ui p m en t ]

. . . wh en he d i d n ’ t g et h i s s eco n d i n t u b at i o n

. . . . It

g i v es y o u s o m

u ch m ore i n fo rm at i o n i n a d i ffi cu l t s i t u at i o n l i k e t h i s.” Bu t t h i s wo u ld

h av e b een d iffi cu lt t o d o wi t h o n l y o n e n u r s e i n t h e P A C U an d Dr. Iv es us i n g t h e

Am b u b ag o n t h e p at i en t ; i f t here h ad been fo u r p eo pl e, s h e co u l d h av e g o n e b ack to

t h e o p erat i n g ro o m

“ l i ck et y s p l i t .”

W i t h reg a r d t o Dr

. Iv es ’ i n ab i l it y t o i n t u b at e M s

. Ch y bi ck i

, th e ex p ert

ex p l a i n ed t h at “ h e d i d n o t p erfo rm t o t h e l ev el of an av erag e, co m p et en t

an es t h e s i o lo g i s t ” d u e t o o n e o r a co m b i n at i o n o f h i s l ack of ex p eri en ce, t h e

d ev el o p m en t o f t u n n el v i s io n d u e t o p an ic, o r fat i g u e. “ Al l I k n o w i s [an em erg en cy

ro o m d o ct o r] wh o i s n o t s up p o s ed t o b e as s ki l l ed as h e i s , y o u k n o w, as we v i ew i t

i n t h e m ed i cal co m

m u n i t y

, cam e u p an d eas i l y i n t ub at ed th i s p at i en t, d i d i t i n a co u p l e

m i n u t es .”

7He al s o cri t ici zed t h at t he PACU w as s t affed wi th o n ly Dr. Iv es an d n u rs e Bel k.

If t h ere h ad b een an o th er an es t h es i a p ro v i d er th ere an d an o th er n u rs e, Dr. Iv es wo u ld

n o t h av e h ad t o cal l fo r h el p

. In h i s v i ew, i t w as a v i o l at i o n o f t h e Am eri can So ci et y

o f Po s t A n es th es i a Nu rs es fo r n u rs e Bel k t o b e i n t h e PACU al o n e

. A n o t h er n u rs e

wo u l d h av e en ab l ed t h em t o g et an o x y g en m o n i t o r read i n g fas t er. W h i l e h e b el i ev ed

t h e l ack o f an o t her n urs e “ w as n ’ t go o d ” fo r M s

. Ch y b ick i

, h e c o u l d n o t s ay “ h o w

m u ch t h e d el ay co n t ri b u t ed t o t h e u l t i m at e o u t co m e.” He al s o as s ert ed t hat nu rs e Bel k

i m p ro p erl y s co red M s. Ch y

b ick i o n an A l d ret e sco re u s ed to ap p rai s e a p at i en t i n t h e

p o s t -o p erat i v e, p o s t-an es t hes ia en v i ro n m en t

, b u t ack n o wl ed g ed t h at i t pro b ab l y d id

n o t co nt ri b u t e t o h er i n

ju ri es

.

He al s o h ad n o cri t i c i s m o f t h e t i m i n g o f Dr. Iv es ’ d eci si o n t o ex t u b at e M s

.

Ch y b i ck i aft er s u rg ery

o r t h e t i m i n g o f h is d eci s i o n t o at t em pt t o rei nt u b at e h er. He

ag reed th at a fai lu re t o i n t u b at e o n t h e fi rs t t ry is n o t n eg l i g en ce an d t h at b ag g i n g t h e

p at i en t bet ween i n t u b at i o n at t em p t s i s ap p ro p ri at e, wh ich was do n e fo r M s

. Ch y b i ck i

.

He co u l d n o t s ay

, h o wev er, wh et h er s h e ad eq u at el y ven t i l at ed wi t h t h e A m b u b ag

b ecau s e h e d i d n ot h av e en d -t i d al carb o n d io x i d e (“ CO2 ”) read i ng s

. CO2 read i n g s are

i m p o rt an t b ecau s e wh en a p ers o n i s n o t b reat hi n g wel l t h ey wi l l h av e

8a ri s in g CO2 an d a fal l i n g b l o o d p H

. Th o s e t wo h ap pen co n co m i t an t l y

,

an d t h at cu l m in at es i n ci rcu l at o ry co l l ap s e becau s e as t h e b l o o d p H

s t art s t o fal l

, t he heart an d t h e ci rcu l at i o n s t art s t o g et i r ri t ab l e an d i t

cu l m i n a t es i n a card i ac rh y t h m di s t u rb an ce, o ft en v en t ri cu l ar

t ach y card i a, ven t ri cu l ar fi b ri l l at i o n

, an d t h en ci rcu l at o ry

. . . . Wh e n

yo u ’ re i n a v en t ri cu l ar fi b ri l l at i o n, y o u are i n ci rcu lat o ry co l l ap s e;

t h ere’ s n o effect i v e b l oo d fl o w.

Dr. J o h n Kres s

, a cau s at i o n ex p ert ret ai n ed b y t h e p l ai n t iffs

, tes t ifi ed t h at M s

.

Ch y b i ck i “ h ad p os t op erat i v e res p i r a t o ry fai l ure th at cu l m i n at ed i n ci rcu l at o ry

co l l ap s e. Sh e was res u s ci t at ed

, b u t i n t h e t hro es o f t he ci rcu l at o ry co l l ap s e an d t h e

CPR an d ad v an ced l ife s u pp o rt t h at s h e recei v ed

, sh e s u ffered an ox i c b rai n i n ju ry .”

Th e an ox i c b rai n i n

ju ry o ccu rred wh en her h eart s t o pp ed b eat i n g

. He ex p l ai n ed t h at

y o u can o nl y g et an o x i c brai n i n ju ry o ne w ay

, an d t h at i s i f t he b rai n g et s

n o b l o o d fl ow.

. . . So as l o n g as t h ere i s b l oo d fl owi n g

, y o u r b rai n wi l l

n o t s u ffer an o x i c i n

j u ry

. . . . So s h e s u ffered a card i ac arres t

, an d w h i l e

s h e was g et t i ng CPR, t h ere was a p eri o d wh ere s h e w as n ’ t g et t i n g CPR.

Sh e’ s an o x i c fo r t h at b i t o f t im e.

He o p i n ed t h a t h er po s t-o perat i v e res p i rat o ry fai l u re was cau s ed b y h er m o rb id

o b es it y, a m as s i n h er g l o t t i c o p en i n g

, h er p o s it i o n o f ly i n g o n h er b ack

, an d t h e

ad m i n is t rat i o n o f fen t an y l

, an o p i at e t hat s up p res ses th e b rai n s t em ’ s d ri v e to b reat he.

9In Dr. Kres s’ v i ew, by t h e t i m e Dr. Iv es fi rs t s t art ed u s i n g a m an u al Am b u b ag

t o lo wer M s

. Ch y

b i ck i ’ s CO2 l ev el s

, i t was t o o l at e t o p rev en t h er ci rcu l at o ry

co l l ap s e. Bu t

, i f s h e h ad recei v ed “ m o re effect i v e Am b u bag g i ng th an wh at was

g i v en

, earl i er p l acem en t o f an en d o t rach eal t u be, s h e co u l d h av e b een res cu ed fro m

t h at t i p pi n g p o in t

. . . . So i f y o u g o t t h e t u b e in fas t er, I th i n k t h e t i p pi n g p o i n t m ay

n o t h av e b een reach ed .” He ad m i t ted t h at t h ere was no d a t a t o s h o w t h at M s

.

Ch y b i ck i was n o t b ei n g v en t i l at ed s u ffi ci en t ly wi t h t h e A m b u b ag

, an d th at s h e was

v en ti l at ed t o s o m e d eg ree b et ween t h e i n t u b at io n at t em p t s

.

In h is ex p eri en ce, t h e “ d eg ree o f an ox i c b rai n i n ju ry t h at M s

. Ch y

b i ck i h ad i s

d ev as t at i n g an d t h e p ro g no s i s fo r m ean i n gfu l reco very i s di s m al .” H e ex p l ai n ed t h at

t h e an o x i c i n

ju ry o ccu rred i n co n n ect io n wi th t h e card iac arres t

, i n w h i ch al l b l o o d

s t op s fl owi n g t o t h e brai n

. He b el i ev ed h er o u t co m e “ wo u l d h av e b een v as t l y

d i fferen t” i f h er h eart h a d n o t s t o p p ed

. He d i s ag reed wi th a t heo ry “ in t h e p ro g res s

n o t es ” t h at s ep s i s m ay h av e cau s ed h er h eart t o s t o p

. Dr. Kres s ex p res s ed n o op i n i on s

as t o t h e “ ex t en t [n u rs e] Bel k ’ s act io n s co n t ri b u t ed to t h e i n ju ri es ” su s t ai n ed b y M s

.

Ch y b i ck i

.

Dr. Kres s tes ti fi e d t h at b ecau s e n o au t op s y was p erfo rm ed

, “ we can ’ t s ay

ex act l y wh at t h e cau s e o f [h er lat er] d eat h i s

. Th ere’ s a l i s t o f p o s s i bi l it i es

. . . . [S] h e

10co u ld h av e h ad a p u l m o n ary em b o l i s m

, . . . a m

u co u s p l u g,

. . . a m

y o card i al

i n farct i o n

, . . . [o r] a card i ac rh yt h m p ro b lem

. . . .” In hi s v iew, t h es e fo u r p o s s i b l e

cau s es of d eat h “ co u l d co n cei v ab l y b e co n n ect ed t o t h e p r i m ary ev en t ; ” an d i t was

“ m o re pro b ab ly t ru e t han no t ” t hat her d eat h was cau s ed b y “ h e r in it i al p ri m ary

res p i rat o ry

an d ci rcu lat o ry

co l l ap s e.”

M eg W arren

, a b o a r d

- c ert i fi ed

, reg is t ered n u rs e an d cert i fi ed p eri an es t h es i a

n u rs e ret ai n ed b y th e p l ai nt iffs

, t es t i fi ed t h at n u rs e Bel k v i o lat ed t h e s t an d ard o f care

b y fai l i n g “ t o es c a l at e u p t h e ch ai n o f co m m [a] n d wh en M s

. Ch y

b ick i w as h av i n g

i s su es wi t h n o t b ei n g ab l e t o ob t ai n a p u l s e o x an d di ffi cu lt y o f Dr. Iv es i n

. . . rei n t u b at i n g.” W i th reg ard t o es cal at i n g

, W arren o p i n ed t hat n urs e Bel k “ co u l d h av e

cal l ed a rap i d res p o n s e t o g et m o re h el p t o as s is tan t [s i c] h ers el f an d Dr. Iv es at t h e

t i m e. So

, s h e co ul d h av e g o n e u p t h e c h a i n o f c o m m an d

, w h et h er i t ’ s t o h er

s u p erv i s o r, wh o i s o n cal l o r in t h e h o s p it al t h at d ay

, wh o co u l d h el p i n terv en e t o g et

t h e h el p s h e n eed ed .” A t h er h o s p i t al

, a r ap i d res p o n se team wo ul d co n s i s t o f a

“ res p i rat o ry th erap i s t

, t h e h o sp i t al i st

. . . , an d n u rs i n g su p erv is ors

, an d m ay b e an ICU

o r CCU n u rs e.” It i s a l o wer l ev el res p o n s e th an a co d e b l u e. W hi l e s o m e fac i l i ti es

al l o w a res p irat o ry t h erap i s t to i n t u bat e a p at i en t

, W arren d i d n ot k n ow wh et h er t h e

h o s p it al i n t h i s cas e al lo w ed res p i rat o ry t h erap is t s t o i n t u b at e. Li k ewi s e, s h e d i d n ot

11k n o w wh et h er an em erg en cy ro o m d o ct o r, wh o wo u l d b e q u al i fi ed t o i n t ub at e, was

o n t h e h os pi t al ’ s rap id res po n s e t eam

. 3

As t o t he p o i n t i n t i m e t h at a rap i d res p o n s e t eam es cal at i o n s h o u l d h av e

h ap pen ed

, s h e s t at ed t h at t w o fai l ed at t em p t s a t i n t u bat i o n m i gh t n o t warran t

es cal at io n

, b u t t h at t h ree fai l ed at t em p t s wo u l d i f a n u rs e o b s erv ed t h e do ct o r h av i n g

d i ffi cu l t y

. W h i l e her affi d av i t s t at ed t h at t h e n u m b er o f at tem

p t s al o ne wo u l d h a v e

warran t ed es cal at io n, s h e al so t es t i fi ed t h at t h e am o u n t o f t i m e t h at p as sed

, reg ard l es s

o f t h e n u m

ber o f at t em

p t s

, al so req ui red es c a l a t i o n

. In h er v i ew, t h e es cal at i o n t o a

rap i d res p o n s e t eam

s h o u l d h av e h ap p en ed “ [w] h en t h ey weren ’ t ab l e t o g et t h e . . .

o x y g en l ev el wi th i n t h e fi rs t t en m i n u t es 4

. . . [p ] ro b ab l y aft er th e s eco n d v i t al s i g n

[fi v e m i n u t es i n ] wh en s h e w as st ru g g l i n g

. ” Sh e wo u l d hav e d o n e so ev en i f an

an es t h es i o l o g i s t was p res en t an d s ai d t h er e w a s n o need an d t h at ev ery t h i n g was

u n d er co n t ro l

.

3 Ou r d e n o v o rev i ew o f t h e re c o r d r e v e al ed n o ev i d en ce reg ard i n g t h e

ex i s t en ce o f o r t y

p e o f p ro v i d ers o n an y “ rap i d res p on s e t eam ” fo r t h e ho s pi t al i n t h i s

cas e.

4 W arren was n o t cri t i cal o f n urs e Bel k ’ s i nab i l i t y t o g et an O2 Sat read i n g as

t h i s can b e d i ffi cu l t fo r a v ari et y o f reas o n s

.

12Earl y i n h er d e p o s i t i o n

, W arren co nfi rm ed t hat t h e affi d av i t at t ach ed t o t h e

p l a in t i ffs ’ co m

p l ai n t i n cl u d ed al l of h er o p i n i o n s i n t hi s cas e, an d t hat it w a s b a s e d

u p o n o n l y h er rev iew o f t h e m ed i cal reco rd s

. Sh e d i d n o t rev i ew Dr. Iv es ’ d ep o s i t i o n

t ran s cri p t b efo re s h e was d ep os ed

, ev en th o u g h s h e ack n o wl ed g ed t h at n u rs i n g care

i s im p act ed b y a p h y s i ci an b ei ng i n t h e r o o m

. Sh e ag reed at t h e co n cl u s i on o f h er

d ep os i t i o n t h at s he had n o “ o t h er o p i n i o n s ” i n t h i s cas e th at sh e h ad no t d es cri b ed in

h er d ep o s i t i o n

. 5 W arren o ffered t h e fo l lo wi n g o p i n io n i n h er affi d av it t h at was

at t ach ed t o t h e p l ai n t i ffs ’ co m p l ai n t :

Th e act s an d o m i s s i on s o f Nu rs e B e l k s et o u t ab o v e fel l b el ow th e

s t an dard s of care an d d i l i g en ce t h at ev en i n at t en t i v e an d c a r e l es s

p ers on s are accu s t o m ed t o ex erci s e an d cau s ed M s

. Ch y b i ck i t o s u ffer

s eri o u s

, d eb i l it at i n g

, an d l i fe th reat en i ng i n j u ri es

, i n cl u d i n g th e

ex t en s iv e an o x i c b rai n i n ju ry

, b rai n d am ag e, an d en cep h al o p at h y t hat

o ccu rred d ue t o h er in ab i l i t y t o recei ve t h e o x y g en req ui red fo r h er b rai n

an d cen t ral n e r v o u s s y s tem t o m ai nt ai n n o rm al fu n ct i o n p o s t -s u rg ery

an d p o s t -an es t h es i a.

In h er affi d av i t , s he s t at ed t h at n u rs e Bel k v i o l at ed t h e s t an d ard o f care b y :

Fai l i n g t o ad v o cat e fo r h er p at ien t b y es cal at i n g a n d rep o rt in g th e

s i tu at i o n an d ci rcu m s t a n ces p res en t ed b y (1 ) M s. Ch y b ick i ’ s

5 In ad d i t i o n t o n u rs e Bel k ’ s fai l u re to es cal at e t o a rap i d res p o ns e t eam

, W arren al s o t o o k is s u e wi t h th e l ev el o f d et ai l i n h er ch art in g i n t h e m ed i cal reco rd

.

13d et eri o rat in g co nd i t i o n an d (2 ) Dr. Iv es ’ ex t en s iv e d i ffi cu l t i es

, ov er

n earl y an h o u r’ s t im e, t o en s u re t h at M s

. C h yb i ck i was recei v i n g

s u ffi ci en t o x y gen

, an d a d eq u at e ai rway m an ag em en t

, u p th e ch ai n o f

co m m an d

.

Th e h os pi t al s u b s e q u en t l y m o v ed fo r part i al s u m m ary ju d g m en t o n t h e i s s u e

o f wh et h er i t co u l d b e h el d v i cari o u s ly l i ab le fo r t h e al l eg ed n eg l i gen ce o f Dr. Iv es

,

an d th e tri al co u rt g ran t ed t h e m o t io n

. Th e h o sp i t al d efen d an t s m o v ed fo r (1 )

s u m m a r y ju d g m en t o n t h e i s s u e o f wh et h er t h ei r al l eg ed act io n cau s ed an y i n ju ri es

t o M s

. Ch y

bi ck i an d (2 ) t o ex cl u d e t h e o p i n i o n s o f W arren co ncern i n g h er “ es cal at i o n

o f care op i ni o n s as s h e i s n o t q ual i fi ed t o ren d er t h e op i ni o n s g i ven .” Th e tri al co u rt

g ran t ed b o t h o f t h es e m o t i o n s as wel l

.

1

. Pl ai nt i ffs co n t en d th at t h e t ri al co u rt erred b y g ran t i n g s um m ary ju d g m en t

i n fav o r o f t h e h o s p i t al o n t h ei r cl ai m ag ai n s t t h e h o s p i t al fo r t h e neg l i gen ce o f Dr.

Iv es b as ed u p on a t heo ry

o f res p o n d eat s u p eri o r. Th ey as s ert t h at a wri t t en co n t ract

fai l s t o u n am

b i g u o u s l y s h o w t h at Dr. Iv es w as an i n d ep en d en t co n t ract or u n d er

OCGA § 5 1 -2 -5 .1 (f) an d t h at ap p l i cat io n o f a m u lt i -fa c t o r a n a l y s i s s h o ws t h at

g en ui n e i s su es o f m at e r i a l f act ex i s t as t o wh et her Dr. Iv es was an i n d ep en d en t

co n tract or.

Ou r an al y s i s b eg i ns wi t h OCGA § 5 1 -2 -5 .1 (b ), p ro v i d i n g t h at

14n o ho s p i t al wh i ch co m p l i es wi t h th e n o t i ce p ro vi s i o n s o f ei t h er

s u b s ect i o n (c) o r (d ) of th i s Co d e sect i o n s h al l b e l i ab l e i n a t ort act i o n

fo r t h e act s o r o m i s s i o n s o f a h eal t h care p ro fes s i o n al u nl es s t h ere ex is t s

an act ual ag en cy

o r em p l o y m en t rel at i o n s h ip b et ween t h e h o s p i t al an d

t h e h eal th care p ro fes s i o n al

.

Pl ai n t i ffs co n ced ed b el ow an d o n ap p eal t h at th e h o s p i t al co m pl i ed wi t h t hes e n o t i ce

req u i rem en t s

, an d t he ev i d en ce i n t h e reco rd s up p o rt s t h i s co n ces s i o n

. O CGA § 5 1 -2

-

5 .1 (f) p ro v i des i n rel ev an t p art :

Wh e t h e r a h eal t h care p ro fes s i o n al i s an act u al ag en t

, an em p lo y ee, o r

an i n d ep en d en t co n t ract o r s h al l b e d e t e r m i n ed b y t h e l an g u ag e o f th e

co n t ract bet ween t h e h eal t h c a r e p ro fes s i o nal an d t h e h o s p i t al

. In th e

ab s en ce o f s u ch a co nt ract

, or i f th e co n t ract i s u n cl ear o r am b i g u ou s

, a

he a lth care p ro fes s i on al s h al l o n l y b e co n si d ered t h e h o s p ita l’ s e m ploy e e

o r a c t u a l ag en t if i t can b e s h o wn by a p rep o n deran ce o f t h e ev i d en c e

t h at t h e h o s p i t al res erv es t h e ri g h t t o c o n t r o l t h e t im e, m an n er, o r

m et h o d i n wh i ch t h e h eal t h care pro fes s i o n al p erfo rm s t he s erv i ces fo r

wh i ch li cen s ed

, as d i s t in gu i s h ed fro m t h e ri g h t t o m erel y req u i re cert ai n

d efi n i t e res ul t s

.

In th i s cas e, a co nt ract b et ween t h e fo ll o w i n g p art i es was si g n ed b y each o f t h em : t h e

h o s p it al

, Dr. Iv es

, d es i gn at ed as “ ‘ Ph y s i ci an ’ ” i n t h e co n t ract

, an d So u t h eas t ern Pai n

Co n s u l t an t s

, P. C., a Geo rg i a p ro fes s i o n al co rp o rat i o n d es i g n at ed as “ ‘ Co rp o rat i o n ’ ”

i n t he co n t ract ; t h e co n t ract s t at ed t h at Dr. Iv es “ i s t h e s o l e s h areh o l der, o ffi cer an d

15d i rect o r of t h e Co rp o rat i o n .” As a c o n t ract cl earl y ex i s ts “ bet ween th e h eal t h care

p ro fes s i on al an d t h e h o s p i t al

, ” we m us t d et erm i ne fro m “ t h e l an gu ag e o f t h e co n t ract ”

wh et h er Dr. Iv es was “ an act u al ag en t

, an em p l oy ee, o r an i n d ep en den t co n t ract o r”

o f t h e h o s p i t al . Id

.

Th e p ream

b l e o f t h e co n t ract s t at es : “ W HER E AS, Co rp o rat i o n i s wi l l i n g to

accep t t h i s Ag re e m e n t an d t ak e on t he res p o n si b i l i t y o f p ro v i d i n g, t h ro u g h t h e

s erv i ces o f Ph y si ci an

, m ed ical s erv i ces i n vo l v ed i n t h e p ro v i s i o n o f an es t h es ia in

co n nect io n wi t h t h e care o f pat i en t s i n t h e Ho s p i t al

. . . .” Un d er a n u m b ered h ead i n g

t i tl ed “ Serv i ces b y Co rp o rat i o n ,” t h e co n tract s t at es : “ In acco rd an ce wi t h an d s u b ject

t o t h e t e r m s an d co n d i t i o ns h erei n aft er p ro vi d ed

, Co rp orat io n s h al l, as an

i n d ep en den t -co n t ract o r, p ro v i d e s erv i ces t h ro u g h qu al i fi ed p hy s i ci an s

, i n cl u d i n g

Ph y s i ci an

, p ro v i d i n g co v erag e o f t h e Ho s pi t al ’ s An es t h es io l o g y D e p art m en t as

h erei n aft er p ro v i d ed

. . . .” In a h ead i n g t i t l ed “ Ph ys i c i an Ob l i gat i o n ,” t h e co n t ract

s t at es t h at “ [t ] h e Co rp o rat i o n s h al l

, t h ro ug h t h e Ph ys i ci an an d o t h er ph y s i ci an s

em pl o y ed o r co nt ract ed b y i t

, p ract i ce m ed i ci n e a s an es t h es i ol o g i s t s i n t h e

an es t h esiology D e pa

r t m e nt at t h e Ho s p i t al ,” an d a s en t en ce co nt ai n ed wi t h in t h e s am e

p ro v is i o n s t at es : “ Th e H o s p i t al s h al l n o t h av e an d s h al l n o t ex erci s e s u ch co n t ro l o v er

t h e m an n er i n w h ich t h es e d u t i e s a r e p erfo rm ed as wo u l d jeo p ard ize Co rp o rat i o n ’ s

16s t at u s as a n i n d e p e n d en t co n tract o r, as fu rt h er o u t l i n ed

. . . b el o w .” (Em p h as i s

s u p p li ed .)

Th ere are v ari o u s referen ces t h ro u g h o u t t h e co n t ract t o p h y s ici an s “ em p l o y ed

b y” t h e Co rp o rat i on

, an d t he co n t ract co n t ai n ed t h e fo l l o wi n g p ro v i s i o n g o v ern i n g

“ M an n er o f Perfo rm an ce”:

In t h e p erfo rm an ce o f pro fes s i o n al An es t h es io lo g y s erv i c e s h ereu nd er

t h e Co rp o rat i o n s h al l at al l t i m es act as a n i n d e p en d en t co n t ract o r

p ract i ci n g i t s p r o f

e s s i o n

, n o t as an em

pl o y ee o r ag en t of t he Ho s p i t al

.

Nei t her t he Co rp o rat i o n n o r ph y s i ci an s p erfo rm i n g s e r v i ces fo r th e

Co rp o rat i on pu rs u an t t o t h i s Ag reem en t wh et h er s ai d p hy s i ci an s be

m em b ers

, p art n ers

, em

pl o y ees

, s u bco n t ract o rs

, o r o t h erwi s e, s h al l h av e

a n y cl ai m u n d er t h i s ag reem en t o r o t h erwi s e ag ai n s t th e Ho sp i t al f o r

v acat i o n pay

, si ck l eav e, ret i rem en t b en efi ts

, So ci al Secu ri t y

, wo rk ers ’

co m p en s at i o n

, d i s ab i l i t y b en efi t s

, u n em pl o y m en t i n s u ran ce b en efi t s

, o r

em p l o ye e b en efi ts of an y k i n d

. Th e Co rp o rat i o n s h al l b e fu l l y

res p on s i b l e fo r p erfo rm i n g an d s eei n g t h at an y as s o ci at es o r o t hers

u n d er i t s d i rect i o n an d co n t ro l p erfo rm s u ch s erv i ces i n co m p l i an ce w i t h

t h e s t an d ard s s et fo rt h herei n

, t h e in t eres t o f t h e Ho s p i t al b ei n g to as su re

t h at A n es t h es i ol o g y Serv i ces are perfo rm ed i n a co m p et en t

, effi ci en t

,

effect i v e, s at i s fact o ry m an ner. Th e Ho s p i tal an d t h e Co rp o rat i o n sh al l

co n t in u al ly s t ri v e t o im

p ro v e t h e q ual i ty an d m ai n t ai n a reas o n ab le co s t

o f m ed i cal care fu rn i s h ed p at i en t s o f t h e Ho s p i t al

.

17W i th reg ard t o “ No n -p h y s i ci an Pers o n n el ” i n th e An es th es i o l o g y Dep art m en t

, t h e

co n tract s t at es t h at t h ey “ s h al l b e em p l o y ed o r as s i g ned b y t h e Ho s p i t a l

, aft er

co n su l t at i o n w i t h t h e Co rp o rat i o n [, ] ” wi t h t h e Ho sp i t al res p o n si bl e fo r pay i n g t h ei r

wag es an d p ro vi d i n g b en efi t s

.

Pl ai n t i ffs as s ert th at t h e l an g ua ge of this c ont ract fai l ed t o u n am b ig u ou s l y s h o w

t h at Dr. Iv es was an i n d ep en d en t co n t ract as i t o n l y e x p r e s s ly d es i g n at es t h e

Co rp o rat i o n as an i n d ep en d en t co n t ract o r. Th e ho s p i t al co nt en d s t h at “ [t ] h e i n t en t o f

t h e co n t ract [was ] t o h o l d b ot h Iv es an d h i s Co rp o rat i o n as i n d ep en d en t co n t ract o rs

rat h er t h an em

pl o y ees o f t h e Ho s p i t al .”

In W h i t a ker v. Zi r

kl e

, 18 8 Ga. Ap p. 7 0 6 (3 7 4 SE2 d 1 0 6 ) (1 9 8 8 ), d i s ap p ro v ed

o n o t h e r g r o u nd s

, Cl ea vel a n d v. Ga n n o n

, 2 84 Ga. 3 76

, 3 8 0 (1 ) (6 67 SE2 d 3 6 6 )

(2 0 0 8), a cas e d eci d ed b efo re t h e en act m en t o f OCGA § 51 -2 -5

. 1

, we co n cl u d ed t h at

a d o ct o r an d h i s p ro fes s io n al co rp o rat i o n were cl earl y i n dep en d en t co n tract o rs o f a

h o s p it al b as ed

, i n p art

, u p o n a co n t ract b et ween t h e h o s p i t a l an d a p ro fes s i o n al

co rp o rat i o n, o f w h i c h t h e d o ct o r was t h e s o l e m em b er, d es cri b i n g t h e p ro fes s i o n al

co rp o rat i o n a s a n i n d ep en d en t co n t ract o r. Id

. at 70 8 (2 ). Si m il ar t o t he co n t ract at

i s su e h ere, t h o u g h s t a t e d a l i t t l e d i fferen t l y

, t h e co n t ract al s o p ro v i d ed t h at t h e

h o s p it al w o u l d no t d i rect o r co n t ro l t h e w o rk o f t h e p ro fes s i o n al em p l o y ees o f t h e

18p ro fes s i on al co rp o rat i o n

. Id

. Bas ed u p o n o u r deci s i o n i n W h i t a ker

, as we l l as o u r

rev i ew o f t h e co n trac t l a n g u a g e a s a wh ol e in th e cas e n o w b efo re u s

, we co n cl u d e

t h at Dr. Iv es was an i n dep en d en t co n t ract or o f t he h o s p i t al rat h er t h an an em p l o y ee. 6

Ac c o r d i n g l y

, th e h os p it al can n o t b e h el d l i ab le fo r hi s co n d u ct u n d er a t h eo ry o f

res p o n d eat s u p eri o r, P a r k er v. Ho s p

. Au t h

. , 2 1 4 Ga. Ap p

. 1 1 3

, 1 1 4 (2 ) (4 4 6 SE2 d

7 6 6 ) (1 9 9 4 ), o v erru l ed o n o t h er g ro u n d s, S h er i f f v. St a t e

, 2 7 7 Ga. 1 82

, 18 8 (2 ) (5 8 7

SE2 d 2 7 ) (2 0 0 3), an d t h e t ri al co u rt d i d no t err b y g ran t i n g p art i al s um m ary ju d g m en t

i n fav o r o f t h e h o s p i t al o n t h i s t h eo ry o f l i ab i l i t y

. 7

6 Bas ed u p on ou r rev i ew o f t h e p l ai n t i f f s ’ b ri ef, t h ey d o n o t ap p ear t o b e

as s ert i n g t h at th e co n t ract s h o wed t h at Dr. Iv es was b o t h an i nd ep en d en t co n t ract o r

an d an act u al ag en t o f t h e h o sp i t al

. To t h ey ex t en t t h ey d o

, su ch a cl ai m has n o m eri t

. See Fo s t er v. S

o u t her n Reg i o n a l Hea lt h S ys tem

, 3 1 8 Ga. Ap p. 5 4 1, 5 4 4 (3 ) (7 3 4 SE2 d

2 6 8 ) (fi n d i n g d o ct o r was n ot ac t u a l a g e n t o f h o s p i t al b as ed i n p art u po n co n t ract

b et ween h o s p i t al an d t h e do ct o r’ s em p lo y er d es i g n a t i n g t h e em p l o y er as an

i n d ep en den t co n t ract o r o f t he h o s p i tal ).

7 O u r o p i n io n in Th o ma s v. Ten et Hea lt hs ys t em GB

, 3 4 0 Ga. Ap p

. 7 8 ( 7 9 6

SE2 d 3 0 7 ) (2 0 17 ), d o es no t req u i re a d i fferen t res ul t b ecau s e i n t hat cas e, t h e d o ct o rs

were n o t p art i es t o t h e co n t ract b et ween th e p ro fes s io n al co rp o rat i o n an d t he h o s p i t al

. In s t ead

, “ [t h e d oct o rs ] h ad co n t ract s wi t h t h ei r ph y s i ci an g ro u p s wh o i n t u rn h ad

co n tract s wi t h [t h e h o s pi t al ] .” Id

. a t 8 1 (1 ). W e t h erefo re co n cl u d ed t hat “ t h es e

co n tract ual rel at i o n s hi ps d o n o t fal l u n d er O CGA § 5 1 -2 -5

. 1 (f).” Id

. In t h i s cas e, t h e

co n tract ex p res s l y pro vi d ed t h at i t was “ b y an d bet ween ” t h e ho s pi t al an d D r. Iv es

. Th e fact t h at Dr. Iv es ’ pro fes s i o n al co rp o rat i on was al s o a p art y t o t he co n t ract d o es

n o t t ak e i t o ut s i d e t he s co p e o f OCGA § 5 1 -2 -5

. 1 (f).

192

. Pl ai n t i ffs as s ert t h at t h e t ri al co u rt erred by gran t i n g t h e h o s p i t a l ’s m o t i o n

fo r s u m m a r y j u d g m e n t b as ed u p o n a l ack o f ev i d en ce s ho wi n g t h at an y al l eg ed

d ev iat i o n s fro m t h e s t an dard of care b y t h e h o s p i t al o r n u rs e Bel k cau s ed an y i n ju ri es

t o t h e d eced en t

. Th ey as sert t ha t t h e cau s at i o n o p in i o n o ffered b y W arren i n h er

OCGA § 9 -1 1 -9 .1 affi d av i t

, an d affi rm ed by h er i n h er d ep o s i t i o n

, creat es a g en u i n e

i s su e o f m at eri al fact o n t he i s s u e. W e d i sag ree.

To reco ver i n a m ed i cal m al p ract i ce cas e, a p l ai n ti ff m u st s h o w

n o t o n l y a v i o l at i o n o f t he ap p l i cab l e m ed i cal s t an d ard o f care b u t al s o

t h at t h e pu rp o rt ed vi o l at io n o r d ev i at i o n fro m t h e p ro p er s t an d ard o f care

i s th e p ro x i m at e cau s e o f t h e i n ju ry s us t ai n ed

. In o th er wo rd s

, a p l ai n ti ff

m u s t pro v e t h at t h e d efen d an t s ’ n eg l ig en ce was bo t h t he c a u s e i n fact

an d t h e p ro x i m at e cau se o f h i s i nju ry

.

(Ci t at i o n an d p u n ct u a t i o n o m i t t ed

. ) Kn i g h t v. Ro b er t

s

, 31 6 Ga. Ap p

. 5 99

, 6 0 3 (1 )

(7 3 0 SE2 d 7 8 ) (2 0 1 2 ). In Fr eema n v. LTC Hea l t h ca re o f S t a t es b o r o

, 3 2 9 Ga. Ap p.

7 6 3 (7 6 6 SE2 d 1 2 3) (2 0 14 ) (p h y s i cal preced en t o n l y ), we s t at ed t h at “ i t i s ax i o m at i c

t h at n o ex p ert can t es t i fy o u t s i d e t h e l i m i t s of h i s area o f ex p ert i s e, an d Geo rg i a l aw

co n si d ers o p i n i o n s ab o u t m ed i cal d i ag n o s es t o fal l o u ts i d e t h e l im i t s o f t h e ex p ert i s e

o f a n o n-p h y s i ci an .” ( C i t at i on s an d p u n ct u at i o n o m i t ted .) Id

. at 7 6 6. W h i l e we

“ d ecl i n e[d ] t o ad o p t a ‘ b ri g h t l i n e’ ru l e t h at n u rs es m ay n ev er t es t i fy t o cau s at i o n in

20m ed i cal m al p ract i ce cas es ,” we n o n et h el es s co n cl ud ed t h at t he ev i d en ce “ s h o w[ed ]

t h at t h e nu rs e’ s cau s at i o n o p in io n i n t h i s cas e fel l o u ts i de h er real m o f ex p ert i s e.” Id

.

at 7 6 4

. W e reach a s i m i l ar co n cl u s i o n h ere.

Rel y i n g u p o n F

r a u s t o v. Y

a ki ma HMA

, 39 3 P3 d 77 6

, 7 8 0 ( Wa s h

. 2 01 7 ), t h e

p l ai n t i ffs u rg e u s to ad o pt a p u rp o rt ed m ajo ri t y v i ew al lo wi n g nu rs es t o t es t i fy

reg ard i n g cau s at i on i n m ed i cal m al p ract i ce cas es gen eral l y

. Bu t t h i s d eci s i o n was

l at er ex p l ai n ed a t l e n g t h b y a fed eral d i s tri ct co u rt i n a w el l -reas o n ed o p i n i o n as

fo l l o w s :

Th e cour t f i n ds p lai n t i ffs ’ au t h o ri t i es u n p ers u as i v e. Fr au s t o do es i n d eed

p o i n t t o a v ery s l ig ht m ajo ri t y am o ng s t at e co u rt d eci s i o n s

— wh en t h e

q u es t i o n i s wh et h er n u rs es are ab so l u tel y an d cat eg ori cal l y b arred fro m

ev er ad d res s in g t h e i s s u e o f cau s at i o n

. Bu t th e cas e d o es n o t su p p o rt th e

co n cl u s i o n t h at reg i s t ered n urs es o r l i cen s ed n u rs e pract i o n ers m ay

t es t i fy as t o m ed i cal c a u s a t i o n i n g en eral

, let al o n e, as h ere, g iv e an

o p i n i o n as t o t he cau s e o f d eat h i n cas es wi t h a co m p l icat ed et io lo g y

. .

. . W h en pres en ted w i t h p ro po s ed ex p e r t tes t im o n y by n u rs es as t o th e

cau s at i o n o f m ed i cal co n d i t i o n s

— ot h er th an b e d so res

— m o s t co u rt s

h av e ex cl u ded i t

. A nd

, m o re p art i cu larl y

, wh en t h e i s s u e i s t he cau s e o f

a p ers on ’ s d eat h , t h e ex cl u s i o n ap p ears v i rt ual l y u n i v ers al

.

(Ci t at i o n s an d fo o t n o t e s o m i t t ed .) Fu n k v. P i n n a cl e Hea lt h F a ci l it i es XXXII

, 3 5 3

FSu pp .3 d 1 13 8

, 1 1 3 9 -1 1 4 2 (D. Kan

. 2 0 1 8). Th e o t h er deci s i o n u p o n wh i ch t h e

21p l ai n t i ffs p ri m ari l y rel y i n v ol v ed a n urs e’ s ab i l i t y t o o p i n e ab o u t t h e cau s e o f

b e ds o res an d was d i s t i n g ui sh ed b y t h e Fu n k co u rt o n t h at g ro u n d. Id

. at 1 1 4 1

, n

. 5

,

d i s t i n gu i sh i n g Fr eed

v. Gei s i n g er

Med . Ct r

. , 9 71 A2 d 1 20 2 (Pa. 2 0 09 ).

I n t h i s cas e we co n cl u de, b as ed u p o n t h e p art i cu l ar fact s an d ci rcu m s t an ces

,

t h at t h e pl ai n ti ffs h av e fai led t o s h o w t h at W arren was q u al i fi ed t o d et erm i n e t h at t h e

cau s e o f M s

. Ch y

b i ck i ’ s an o x i c b rai n i n

j u ry

, b rai n d am ag e, an d en cep h al o p at h y was

n u rs e Bel k ’ s fai l u re t o es cal at e an d req u es t a rap i d res p o ns e t eam

, p art i cu l arl y wh en

p l ai n t i ffs h av e p res en ted no ev i d en ce s ho wi n g t h at a rap i d res p o n s e t eam at Co ffee

Reg io n al M ed i cal Cen t er wo u l d h a v e i n cl ud ed a m ed i cal p ro v id er t rai n ed an d

au t h o ri zed t o i n tu b at e. 8

8 Ou r recen t o p i n i o n i n Eva n s v. Med

. Cen t er o f Cen t ra l Ga

. , 3 5 9 Ga. Ap p

. 7 9 7

(8 6 0 SE2 d 1 00 ) (2 0 2 1 ), d o es n ot req u i re a d i fferen t res u l t

. In t hat cas e, we co n cl u d ed

t h at a n u rs e’ s o p i n i on i n co m b i n at i o n wi t h a m e d i c a l d o ct o r’ s o p in i on creat ed a

g en ui n e i s s u e o f fact wi t h reg ard t o wh et her a ho s p i t al co u l d b e l i ab l e fo r a p at i en t ’ s

d eat h fro m an acu t e m

y o card i al i n farct i o n aft er an al l eg ed p rem at u re d i s ch arg e t h e

p rev i o u s d ay

. Id

. at 1 04

. Sp eci fi cal l y

, a do ct o r t es t i fi ed t h at t h e p rem at u re d i s ch arg e

l ed t o th e p at i en t ’ s d eat h

, an d t h e n u rs e t es ti fi ed t h at v ari o us n u rs i ng fai lu res wi th

reg ard to t h e pat i en t’ s sy m p t o m s co nt ri b ut ed t o th at p rem at u re di s ch arg e. Id

. In

Eva ns

, u nlike th is cas e, cau s at i o n was “ es t ab l i s h ed b y l i n k i ng t h e t es ti m o n y of s ev eral

d i fferen t ex p e r t s

. ” ( C i tat i o n an d p un ct u at i o n o m it t ed .) Id

. at 1 0 2. Here, n o m ed i cal

d o ct o r t es t i fi ed t h at es cal at i o n t o a rap i d res p on s e t eam at Co ffee Reg i o nal M ed i cal

Cen ter co u l d h av e res u l t ed i n a d i fferen t o u t co m e fo r M s . Ch y b i ck i

.

223

. Th e p l ai n t i ffs ’ rem ai n i n g e n u m erat i o n o f erro r rel at i n g t o t h e t ri al co urt ’ s

ex cl u s i o n o f W arren ’ s t es t i m o n y reg ard i n g t h e s t a n d ard o f care fo r es cal at i o n i s

ren d ered m o o t b y

o u r h o l d i ng i n Di v i s io n 2

.

Ju d g men t a f f i r med

. Do

yl e, P. J., co ncu r

s

. Di l l a r d

, P

. J., co n cu r

s f u l l y in

Di vi s i o n s 1 a n d 3 , a n d

i n j u d g men t o n l y a s t o Di vi si o n 2

.

23