CHS is a“comm unity hospital” under Mississ ippi Code Secti on 41-13- 15 (Rev. 2009). So 1 thi s ca se i s g ov ern ed

bytheMis sis sippi Tort Claim s A ct, which m an datesthat suitsag ain st government entities be decided by a j udge, sitti ng without a jury. Miss . Code Ann. § 11-46-13(1) (Rev. 2002). I N T H E SUPR EM E C O UR T O F M I SS I SS I PPI NO. 2 0 1 0 - CA- 0 0 6 5 4 - S CT T HE ES T A T E (T HR OU GH

T HE A DMI NI S T RA T R I X I DA C A MP B EL L ) A ND T HE W RONGFUL DEATH AND SURVI VAL BEN EF ICIAR I ES O F JO H

N EA RL SYK

ES, DE CEA SED: I

DA CAM

PBELL, J

EFF I E EZELL, DON NI E DRAI NE, S AM M I E J OE S YKES

, RICKY W AYNE S YKES

, BRENDA FAY HARDW ICK, TER RY S YKESAND J AM ESE. S YKES
v. CAL HO UN H

EAL TH S

ERVICES D A T E O F JU D G M E N T : 03/ 22/ 2010 TRI AL J UD GE: HO N. AN DR EW K. HO W OR TH COURT F ROM W HI CH APP EAL ED: CALHOUN COU NTY CI RCUI T COURT AT T ORNE YS F OR AP P E L L ANT S : DAVI D A. BO W L I NG SUSAN NA H C . M CK I NN EY ATTO RN EY FO R A PP ELLEE: J OH N G . W HEELER NA TUR E OF THE C ASE: CI VI L - W RO NG FUL D EATH D I SPO SI T I O N : A FFIRM E D - 07/ 21/ 2011 M OT I ON F OR RE HE AR I NG F I L E D: M ANDAT E I S S UE D: B E F O R E D I C K I N SO N , P . J. , L A M A R A N D K I T C H E N S, JJ. DI CK I NSON, PRES I DI NG J UST I CE, FOR TH E COU RT: ¶1. A f

t erJ ohn S yk es died in t he em ergency room ( E R ) of C al houn H eal th Servi ces ( C H S) , hi s es t at e s ued the ho spi t al f orw r ongf

ul death, cl ai m i ng Sykes s houl d have be en h o o k e d u p t o a c a r d i a c mo n i t o r . T h e tr i a l j u d g e h e l d th e e s t a t e h a d f a i l e d t o p r o v e th a tCH S 12

h ad d ev iat ed from the a p p li ca b le st an d ard o f ca re, a n d h a d fa il ed to p rov e tha t use o f a
c a r d i a c mo n i t o rwo u l d h a v e ma d e a d i f f e r e n c e . W e a f

f i rm. F ACT S AND B ACKGROUND ¶2. C H S ’s tri age pol i cy – a process used t o pri ori t i ze em ergency -r oo m care – requi res a
r egi st er ed nur s e t o obt ai n i nf orm at i on f

r om emer gency- r oom pat i ent s and ca t egor i ze them
as em ergent , urgent, or non urgent. T he p oli cy a lso p rovi des that a nurse m ay “requ est
as s i s t ance f

r om [ other ] empl oyees , ” but“[ t ] he nur se i s r es pons i bl e f ordet erm i ni ng the p a tie n t’ s a c u ity le v e l.” ¶ 3 . W h e n S y k e s a rriv e d a t C H S ’s e m e rg e n c y ro o m o n J a n u a ry 1 , 2 0 0 7 , at a p p ro x im a tely 5 :5 0 p .m ., h e to ld th e E R cle rk h e w a s e x p e rie n c in g “h e a rt rac in g .” T h e E R w a s u n u su a lly bus y w i th m ul t i pl e “e m er gent ” pat i ent s w ho r equi r ed the att ent i on of the ER phys i ci an and tw o r egi s t er ed nur s es on duty. ¶4. T en m i nut es a f

t erSykes ’ s a rr i val , T oby L af ayett e, an emer gency medi cal t echni ci an, t o o k S y k e s ’ s v i t a l s i g n s , a s k e d h i m q u e s t i o n s a b o u th i s c h i e f c o mp l a i n t , a n d a s s e s s e d h i m. A ccor ding to L af

ayett e, Sykes s ai d hi s ches tw as “s or e, ” butdeni ed thathe f el tpr es s ur e, ra d iatin g p a in , o r sh a rp o r d u ll p a in ; he m e re ly rep e a ted tha t his ch e st w a s “ so re .” S y k e s d id notappea rt o be i n dis t re s s , w as nots hor tof br eath, and w as nots w eat i ng; and he de ni ed hav i ng any othersym ptom s. ¶5. L af

ayett e r el ayed thi s i nf

orm at i on t o h i s bo s s , Ron Eva ns , a pa r a medi c , w ho i ns truct ed L af ayett e t o f

ol l ow up w i th addi t i onal ques t i ons . A f t erdoi ng s o, L af

ayett e w r ot e dow n the3

“pert i nenti nf

orm at i on” o n a st i cky not e and ga ve i tt o one of the tw o E R nur s es , J oan M a rsh a ll. ¶6 . A f

t e rr e c e i vi ng the i nf

ormat i on f

r om Laf a ye t t e a nd l earni ng aboutSykes ’ s chi ef
c o m p lain t o f “ h e a rt ra c in g ,” N u rse M a rsh a ll d e ter m in e d th a t –b e c a u s e S y k e s w a s n o t in dis tres s, had “essent i al l y st able” vi t al si gn s, and had com plai ned on l y o f chest“soreness”
ra th e r th a n “ p a in ” – h e w a s a n o n u rg e n t p a tien t. A c c o rd in g ly , N u rse M a rsh a ll d id n o t in iti a te the hos pi t al ’ s A dvance d C ar di ac Li f e Suppor t( A C L S) pr ot ocol , w hi ch w oul d have i nvol ved the u se o f a c ard iac m o n it o r. ¶7. W hen D ebbi e St r oup R us s el l – al s o an E R nurs e – arr i ved at 6:00 p. m . forher7: 00 p. m . s hi f t , s he f ound “a v ery he ct i c si tuat i on” i n the ER
. She w entt o r eeva l uat e the f our pat i ent s i n the w ai t i ng r oom , as ki ng w hetherany of them fe l tt hey n eeded t o be s een im m e d iate ly . O n e o f th e fo u r
– n o t S y k e s – ra ise d h is h a n d . A fte r c a rin g fo r th a t p a tien t, N urse R ussel l asses sed S yk es, w ho repeat ed h i s com plai nt of “chestsoreness. ” N urse R us s el l obs erved thatSykes w as nots hor tof br eath ors w eat i ng, w as noti n di s tr es s , butw as l aug hi ng and t al ki ng w i th the otherpat i ent s i n the w ai t i ng r oom . B as ed on hereval uat i on a n d o b se rv a tio n s, N u rse R u ss e ll also d e ter m in e d th a t S y k e s w a s a n o n u rg e n t p a tien t. ¶ 8 . It is u n d isp u ted th a t so m e o f th e re q u ire d triag e in fo rm ati o n w a s o b tain e d “ p iec e m e a l” f r om var i ous C H S em pl oyees , and thatSykes d i d no trecei ve a “ t ar getas s es s m entof the chi ef compl ai nt ” f

r om a r egi s t er ed nur s e; nordi d a nyone as k hi m abouthi s m edi cat i ons or
m edi cal hi s t ory.4

¶9. A t about 6: 55 p. m . , N ur s e R us s el l hear d a w om an’ s s cr eam i n the w ai t i ng ar ea. She i m m edi at el y r es ponded and s aw a w om an runni ng outt he doori nt o t he parki ng l ot . W hen
a n o th e r p e rso n in d ica ted th a t so m e th in g w a s w ro n g w ith S y k e s, N u rse R u ss e ll ch e c k e d h im
a n d f o u n d hi m u n c o n s c i o u s . Sh e i mme d i a t e l y c a l l e d f o rh e l p a n d b e g a n CPR. Th e ER doct or , anothernur s e, a nd s om e emer gency medi cal s ervi ces per s onnel r es ponded, gotSykes
on t o a stret cher, and m ov ed h i m t o o ne o f the p at i ent r oo m s. ¶10. B l ood w as draw n and Sykes w as connec t ed t o a heart m oni t or , w hi ch re veal ed that he w as i n ventr i cul arf

i br i l l at i on. A t t empt s t o r es us ci t at e hi m us i ng ches tcompre s s i on s,
m edi cat i on, and el ectr oni c def i br i l l at i on w er e unsuc ces s f ul , and S ykes w as pr onounced de ad
a t 7 :3 2 p .m . A n a u to p sy re v e a led th a t S y k e s h a d “ se v e re c a rd io m e g a ly ” (a n e n lar g e d h e a rt)
a n d h a d d ie d o f “ s u d d e n c a rd ia c d e a th ” re la te d to “ s e v e re . . . h y p e rt e n s iv e h e a rtd is e a s e .” ¶ 1 1 . S y k e s’s e sta te su e d C H S fo r w ro n g fu l d e a th u n d e r th e M iss iss ip p i T o rt C laim s A c t,
a lleg in g th a t C H S ’s “ in a d e q u a te a ss e ss m e n t” h a d p re v e n ted it fro m re c o g n izin g a n d p ro p e rly tre a tin g S y k e s’s c a rd iac e v e n t. ¶ 1 2 . A fte r a b e n c h trial in th e C irc u it C o u rt o f C a lh o u n C o u n ty , th e trial ju d g e fo u n d th a t, d e sp ite C H S ’s f

a ilu re to a d h e re to its o w n triag e p o licy , the e sta te h a d fa iled to m e e t it s bur den of

pr ovi ng thatC H S had devi at ed f r om the appl i cabl e s t andar d of car e. T he j udge al s o found thatt he natur e of S ykes ’ s compl ai nt s and hi s l ack of obs ervabl e s ym pt om s di d not
re q u ire C H S to p e rfo rm a m o re e x ten siv e e v a lu a tio n o r A C L S p ro to c o l; an d th a t, ev e n if S y k es h ad been at t ached t o a cardiac m on i t or ( as the est at e argued he sho uld have bee n ),Un iv. of M iss . M ed . C tr. v. Po un ders , 970 So. 2d 141, 145 (Miss. 2007) (citing Miss. St ate 2 Ta x C omm ’n v. Med

. D evices , 62 4 So . 2d

9 87 , 98 9 (Mi ss. 19 93 ); Ki gh t v. Sh ep

pa rd Bl dg . Sup ply , In c. , 5 37 So . 2 d 1 35 5, 13 58 (Mi ss. 19 89 )). Ci ty o f Ja ck so n v . P owell, 9 17 So . 2 d 5 9, 68 (Mi ss. 20 05 ). 3 5 there w as in su ffi cien t evid en ce that an y effo rt s at d efibril lat ion w o u ld h av e sa v ed S y k es’s l i fe. A ccordi ng l y, the tri al co urten t ered j ud gm ent f or C H S , an d S yk es’ s est at e no w app eal s. I S S UES ¶13 . T he est at e rai ses f i ve is sues, w hich w e con den se and rest at e as f oll ow s: I . W as the tr i al courtm ani f es t l y w r ong i n f

i ndi ng thatthe es t at e had f ai l ed to c a rry its b u rd e n o f p ro v in g th a t C H S h a d b re a c h e d th e a p p lica b le s t andar d of

car e? I I . W as the tr i al cour tm ani f es t l y w r ong i n fi ndi ng t hat , even i f C H S had br eac hed the s t andar d of car e, t he est at e di d notcarry i t s bur den of pr ovi ng thatthe br eac h w as the pr oxi m at e caus e of Sykes ’ s death? S TANDA RD O F REVI EW ¶14. W hen re vi ew i ng a j udgm entfr om a bench tr i al , t hi s C our tem pl oys t he “s ubs t ant i al evi dence /m ani f

es terr orrul e. ” T hati s , the tr i al c ourt ’ s f i ndi ngs w i l l be af

f i rm ed “unl es s they 2
a re m a n if

e s tly w ro n g , c le a rl y e rr o n e o u s , o r a n e rr o n e o u s le g a l s ta n d a rd w a s a p p lie d .” 3 A N A L Y S IS I. T he tr ial cour t w as not m ani f es tl y w r ong in f

inding t hat t he es tate had f

ailed to c a rr y its b u r de n o

f p ro v in gth a t C

H Sh a d b re a c h e d

th e a p p lica b le s tandard of

car e. ¶15. T he tr i al courtf

ound that“[ t ] he pl ai nt i f f s i n thi s c as e have f

ai l ed t o m eetthei r bur den
o f p ro v in g , b y a p re p o n d e ra n c e o f th e e v id e n c e , tha t C H S h e a lth c a re p e rso n n e l fa iled to conf orm t o appl i cabl e s t andar ds of car e i n a m annert hatproxi m at el y caus ed orcontr i but edMcC aff rey v. Pu ckett, 7 84So . 2 d 1 97 , 2 05 -06(Mi ss. 20 01 ). 4 Palmer v. Bi

loxi R eg 'l M

ed . C tr. , I nc . , 5 64So . 2 d 1 34 6, 13 54–55 (Miss. 19 90 ); Hal l v. 5 Hilbun , 4 66 So . 2 d 8 56 , 8 73 (Mi ss. 19 85 ). 6 t o the dea th of

J ohn E ar l Sykes
. ” The es t at e ar gues thi s f i ndi ng w as m ani f

es t l y w r ong and
w a s n o t s u p p o rt e d b y “ s u b s ta n tia l e v id e n c e .” ¶1 6 . T h e e stat e b o re the b u rde n o f pro o f at trial, a n d its arg u m en t th at th e tri al co u rt ’s
ver di ctf orthe def

endantw as nots upport ed by s ubs t ant i al evi dence i s m i spl aced. T he d e fe n d a n t, C H S , h a d n o o b lig a tio n to p u t o n a n y p ro o f a t all; a n d , u n les s th e e sta te m e t it s bur den of

pr oof , C H S w as ent i t l ed t o a ver di ct– notbeca us e of s ubs t ant i al evi dence
s upport i ng the def

ens e ver di ct , butbecaus e of i ns uf f i ci entevi dence on behal f of the es t at e. ¶17. So w hetherthe tr i al j udge’ s ver di ctin favor of C H S w as bas ed on any evi dence , s ubs t ant i al orotherw i s e, i s notthe ques t i on. R ather , the ques t i on i s w hetherthe es t at e met its b u rde n o f pr oo f. A nd even w hen a plai nti ff has prod uced eno ug h ev i den ce t o est abli sh
a p rim a fa c ie c as e of

ne gl i gence , the cr edi bi l i ty of the evi dence s t i l l m us tbe det erm i ned by the f act - f i nder
. A def

endantm ay – buti s notr equi r ed t o – r ebutthe pl ai nt i f f’ s evi dence
. 4 So, to j ust i f

y r ever s al , the es t at e mustdemonstr at e that , upon cons i der i ng the evi dence f avor i ng the pl ai nt i f

f , the ver di ctw as m ani f

es t l y w r ong. I thas notdone s o her e. ¶18 . T his C ou rthas defi ned “st and ard of car e” as f oll ow s: [G ]i v e n th e c irc u m sta n c e s o f e a c h p a tien t, e a c h p h y sic ian h a s a d u ty to u se h is orherknow l edge a nd ther ew i th tr eatthr ough m axi m um rea s onabl e medi cal r ecove ry, each pat i ent , w i th s uch r eas onabl e di l i gence , s ki l l , compet ence , and p ru d e n c e a s a r e p r a c t i c e d b y mi n i ma l l y c o mp e t e n tp h y s i c i a n s i n th e s a me s peci al ty orgener al f

i el d of pr act i ce thr oughoutthe U ni t ed St at es , w ho have avail able t o them the sam e g eneral faci l i t i es, servi ces, equ i pm ent and o pti on s. 5Drum mon d v . B uckle y , 627 So. 2d 264, 268 (Miss. 1993) (citi ng Kelle y v. Fred eric , 573 6 So . 2 d 1 38 5, 13 87 (Mi ss. 19 90 ); Palmer v. Bi loxi R eg 'l M

ed . C tr. , I nc . , 56 4 So . 2d 1346, 1355 (Mi ss. 19 90 ); Ph ill

ipsv. Hu ll, 5 16 So . 2 d 4 88 , 4 91 (Mi ss. 19 87 )). Palmer , 564 So. 2d at 1355 (cit ing Hu ll, 5 16 So . 2 d at 49 1; Hal l 46 6 So . 2d

at 8 70-73 ). 7 Palmer , 5 64So . 2 d at 13 54- 55 ; Hal l, 466 So. 2d at 873. 8 7 ¶ 1 9 . T h e b re a c h o f a p p lica b le sta n d a rd s o f c a re in a m e d ica l-m a lp ra c tic e c a se g e n e ra lly
m u st b e es tab lish e d b y ex p e rt t e stim o n y tha t “id e n tif[i e s] th e ac tio n o r in a c tio n [th a t] 6
a lle g e d ly c o n s titu te d a b re a c h o f d u ty a n d [th a t] p ro x im a te ly c a u s e d th e p a tie n t’ s in ju ry .” 7 ¶2 0. T he es t at e mak e s thr e e a r gu ment s i n s up po r to f i t s c l a i m thatt he tr i al cour t w as
m an if estl y w ron g in fi n d ing that the e sta te h ad n o t m et i ts bu rde n o f pro v ing that C H S ’s br eac h of

the appl i cabl e s t andar d of car e pr oxi m at el y caus ed Sykes ’ s death. A . The s t anda r d of c ar e m ay t ak e i nt o a c c ountt he c ondi t i ons e xi s t i ng at t he hospi t al at t he t i m e of t he al l eged negl i gence. ¶ 2 1 . Th e e s t a t e a r g u e s th a tCHS’ s b u s y ER d i d n o te x c u s e i t s f a i l ur e t o i ni t i a t e AC LS p r o t o c o l b e c a u s e th e s t a n d a r d o f c a r e i s th e s a me , r e g a r d l e s s o f th e ER tr a f

f i c a tth e t i me Sykes a rr i ved. B utthe es t at e ci t es no author i ty f orthi s pr opos i t i on, a nd w e fi nd m uch author i ty t o the contr ary. ¶2 2. T hi s C our thas hel d t hatthe mi ni mum s t a nd a r d of c a r e d e pe nd s i n par ton “the circu m stan ce s o f ea ch p ati en t, ” an d i s t o be co m p are d t o m inim all y co m p eten t prac ti ti o n ers

“ w h o h a v e a v a ila b le to th e m th e sa m e g e n e ra l f a c iliti e s , s e rv ic e s , e q u ip m e n t a n d o p tio n s .” 8 I n cons i der i ng the appl i cabl e s t andar d of car e, the tr i al judge pr oper l y cons i der ed the
c irc u m sta n c e s e x istin g a t th e E R w h e n S y k e s a rriv e d . A n d , as d isc u ss e d in m o re d e tail in8

th e n e x t su b se c tio n , C H S p ro d u c e d e x p e rt te stim o n y fr o m w h ich th e tria l co u rt re a so n a b ly coul d have c oncl uded thatC H S had s at i s f i ed the s t andar d of

car e appl i cabl e t o the
c irc u m sta n c e s e x istin g a t th e tim e , so th is a rg u m e n t is w ith o u t m e rit. B . E xp erts d i sagree d ov er w h et her t he s t andard of c are r equi red s t ri ct com pl i ance w i t h t he C H S tri age pol i cy. ¶23. N ext , the es t at e ar gues that C H S’ s tr i age pol i cy cons t i tut ed the obj ect i ve s t andar d of
car e i n thi s cas e. D r . A ndr ew Perr i n – an ex pertin t he f i el d of emer gency medi ci ne – t e s t i f i e d th a tt h e s t a n d a r d o f

c a r e r e q u i r e d th e a d mi n i s tr a t i o n o f a n e l e c tr o c a r d i o g r a m ( E KG)
w i thi n t en mi nut es of

Sykes ’s arr i val
. T he es t at e’ s otherexpert , D r . N ei l Shadof f , agr eed. Fi nal l y, the es t at e ar gues that , “ [ a] ccor di ng t o the nur s e w ho w as s uppos ed t o be per f orm i ng t he tr i age, the s t andar d of car e r equi r e[ d] compl i ance w i th the [ C H S] pol i ci es and p ro c e d u re s .” ¶2 4 . C H S also ca ll ed tw o e x p e rt w itne sses , b o th o f w h o m test if ied to the co n tr ary . D r. W i l l i am C al houn, an expe r ti n car di ol ogy, t es t i f i ed thatC H S’ s as s es s m entof Sykes w as appr opr i at e. D r . R i ck C ar l t on, C H S’ s emer gency- m edi ci ne expe r t , t es t i f i ed that , underthe
c irc u m stan ce s at th e ti m e, th e e v alua ti o n S y k es re ce ived “w as a rea so n ab le pre li m inary
s c re e n .” ¶25. T he es t at e poi nt s outthat , on c r os s exami nat i on, D r . C ar l t on admi t t ed thata “t ar get ed
a s s e s s m e n t” b y a r e g is te re d n u rs e is a “ s ta n d a rd o f p ra c tic e ,” b u t n o t th e “ s ta n d a rd o f c a re .” Bu to n r e d i r e c t , Dr . Ca r l t o n u n e q u i v o c a l l y s t a t e d th a t , “ g i v e n th e t o t a l i ty o f wh a twa s k n o wn a t th e tim e a n d th e c ir c u m s ta n c e s in th e [E R ,] th e y m e t th e s ta n d a rd o f c a re fo r M r. S y k e s .”Hil l v. Mil ls , 26 So. 3d 322, 330 (Miss. 2010) ( citing Bickham v. Grant, 861 So. 2d 299, 9 307 (Miss. 2003) ). Se e a lso Ci ty o f Ja ck so n v . B rister , 838 So. 2d 274, 2 79 ( Mi ss . 20 03 ) (cit ing Yarbrough v. Camphor , 64 5 So . 2d 8 67 , 86 9 (M iss . 1 99 4); Br yan v . Ho lzer , 589 So. 2d 648, 659 (Mi ss. 19 91 ); Bell v

. P ar ker , 563 So. 2d 594, 597 (Miss. 1990)) (“[W ]hen the trialjudge s its as the finder o f f

act , h e h as t

heso le a uth ority f or deter miningthecre dib ility o f witn ess es. ”). 9 ¶ 2 6 . A s fo r N u rse M a rsh a ll’s te stim o n y , w e firs t n o te th a t – a lth o u g h h e r o p in io n w e n t in to the r ecor d w i thoutobj ect i on – s he w as ne verqua l i f i ed orof f er ed as a n e xpertby a ny party. T he es t at e i m pl i es that , becaus e N ur s e M ar s hal l w orked atC H S, hert es t i m ony s hould be gi ven gr eat erw ei ghtthan the t es t i m ony of the otherexpert s . B utthe es t at e pr ovi des no cit ati o n o f au tho ri ty an d no argu m en t w h y th is is so . W e fi n d th at, ev en i f N u rse M arsh all ’s opi ni on t es t i m ony pr oper l y w as i n the r ecor d, thatdoes notc hange the f actthatthe tr i al j udge
w as f r ee t o acc eptthe s ubs t ant i al evi dence thatC H S di d notbr eac h the s t andar d of car e. ¶ 2 7 . C o n flictin g ex p e rt t e stim o n y – o fte n c a lled a “ b a ttl e o f th e e x p e rts” – re q u ire s th e fa c tf i ndert o as s i gn cr edi bi l i ty. T he tr i al j udge, as the f act - f i nderi n thi s cas e, w as f

r ee t o acc ept 9
o rr e j e c ta n y o f

th e e x p e r to p i n i o n s . He f o u n d CH S ’ s e x p e r t s t o b e mo r e c r e d i b l e , a n d we cannots ay hi s deci s i on amount ed t o an abus e of di s cr et i on. So thi s ar gum enti s w i thout
m e rit. C . E xpert s di s agr e e d ov e r whet he r Syk e s ’ s kno wn sy m pt om s r e qui red

C H S to b e g in c a r d ia c life- su p p o r t p r o to c o ls . ¶ 2 8 . F i n a l l y , th e e s t a t e a r g u e s t h a t , e v e n i n th e a b s e n c e o f p r o p e rtr i a g e , th e s y mp t o ms k n o wn t o th e CH S n u r s i n g s t a f f wer e s u f f i c i e n tt o tr i g g e rCHS’ s d u ty t o b e g i n th e i rAC LS pr ot ocol , w hi ch w oul d have sa ved Sykes’ s l i f e. B utD r . C al houn t es t i f i ed thatC H S’ s act i onsPalmer , 5 64So . 2 d at 13 54 -55 ; Hal l, 466 So. 2d at 873. 10 10 w er e appr opr i at e, becaus e none of Sykes ’ s r es pons es r evea l ed s ym pt om s that“s ounded
c a rd io v a s c u la r i n n a tu re .” ¶2 9. D r . C ar l t on t e s t i f i e d tha t , g i ve n Syk e s ’ s s ympt oms , i tw as r eas onabl e under t he
c i r c u ms t a n c e s f

o rCH S t o de l a y gi v i n g Sy k e s a n EK G, w h i c h i s a c o mpo n e n tof th e AC LS pr ot ocol
. I n s um , the tr i al courth eard exper tt es t i m ony thatSykes ’ s s ym pt om s w er e not ty p ica l ca rd iac p re se n tatio n a n d tha t, d u e to th e “m a ss ca su a lty ” situ a tio n , it w a s re a so n a b le f orC H S st af

f nott o begi n the A C L S pr ot ocol
. A s di s cus s ed above , the tr i al j udge r es ol ved th is b a ttl e o f th e e x p e rts in fa v o r o f C H S , so th is a rg u m e n t is w ith o u t m e rit. ¶ 3 0 . O v e ra ll, the es tate h a s n o t es tab lish e d tha t th e tri a l co u rt w a s m a n if e s tly w ro n g to
c o n c lu d e th a t th e e sta te d id n o t p ro v e a b re a c h o f th e sta n d a rd o f c a re . C H S ’s e x p e rts test if ied th at th e stan d ard o f ca re a p p li ca b le t o C H S re q u ir ed a “ rea so n ab le pre li m inary
s cr een, ” and thatS ykes re cei ved one. B eca us e the appl i cabl e s t andar d of car e may be bas ed on the “c i r cumst ance s of eac h pat i ent ” and the “ge ner al f aci l i t i es , s ervi ces, equi pm entand
o p ti o n s” a v ail ab le t o the h o sp it al, a re aso n ab le fact-fi n d er c o u ld co n clud e from the e x p ert 10 tes tim o n y th a t th e sta n d a rd o f c a re fo r a h o sp ital e x p e rie n c in g a “ m a ss c a su a lty ” situ a tio n d id notr equi r e a mor e det ai l ed eva l uat i on than the one Sykes r ece i ved. ¶ 3 1 . M o r e o v e r , t h e t r i a l c o u r th a d h e a r d s u f f i c i e n tt e s t i mo n y t o c o n c l u d e th a t CH S per s onnel di d nothave aduty t o be gi n thei rA C L S pr ot ocol , be caus e Sykes di d notpr es entQu itm an Co un ty. v. St ate , 910 So. 2d 1032, 1045 (Mi ss. 2005) (The party appeali ng the 11 verdi ct “ canno t re tryitscas e o n a pp eal
. . . . ”). McG ee v . R iver R eg

ion Med . C tr. ,59 So. 3d 575, 578, (Miss. 2011) ( citing McD on ald v. 12 Mem’l H osp. , 8 So . 3 d 1 75, 180 (Mi ss. 20 09 ); Barner v. Gorman , 6 05 So . 2 d 8 05 , 8 09 (Mi ss. 19 92 )). (Emphasis added.)

13 11 w i th typi cal s ym pt om s of car di ac di s tr es s . T he es t at e’ s ent i r e ar gum enton thi s i s s ue cons t i tut es an att emptt o i m perm i s s i bl y r ew ei gh the evi dence
. 11 I I . T h e t r i a l c o u r t w a s n o t m a n i f e s t l y w r o n g i n f

i n d i n g t h a t , e v e n i f

CH S breached t he s t andard of c are, t he es t at e di d no t carry i t s burden of pr ov i ng t hatt he br e ac h was t he pr ox i m at e c aus e of Syk e s ’ s de at h. ¶3 2 . P rox im ate c au se in m ed ical-m alpra cti c e c a se s m u st b e e sta b lish ed thro u g h ex p ert test im o n y . T h e e stat e a rgu es th at i t p rod u ce d th e re q u ir ed test im o n y , b u t th at th e tri al co u rt

12 hel d i tt o an i m perm i s s i bl y hi gh burde n of pr oof , and w as m ani f

es t l y w r ong i n f

i ndi ng that i thad notm eti t s bur den. A . T h e tr ial co u rt d id n o t ap p ly a n im p ro p er b u rd en o f p ro o f. ¶33. A ccor di ng t o t he es t at e, t he tr i al cour terr oneous l y re qui r ed i tt o dis pr ove “ a ll p o ss ib le al t ernat i ve theor i es t o pl ai nt i f f s ’ proof of c aus at i on, and thus , [ the tr i al court ’ s ] concl us i on [ w as ] notbas ed on the pr opers t andar d of pr oof. ” In s upport , the es t at e poi nt s t o the fo llo w in g c o n c lu sio n o f la w p e n n e d b y th e trial ju d g e : Iti s e n tire ly p o ss ib le t hatM r . S ykes w as nots uf f er i ng a myocar di al i nf

ar ct i on atthe t i m e of

hi s pr es ent at i on t o the C H S em er gency de partm ent , gi ven the au topsy fi nd i ng s of no acu t e or chronic i nfar ct i on of heartm uscl e, and thu s, hi s e l evat ed car di ac i s oenzymes w er e l i kel y due t o CP R and defi br i l l at i on ef f ort s dur i ng hi s att empt ed r es us ci t at i on. 1312

¶3 4 . W e d o n o t sh a re th e e sta te’ s a ss ign m en t of i m p o rt an ce to the p h ra se “ e n tirely pos s i bl e, ” as i tw as us ed i n thi s cont ext . The tr i al j udge w as f r ee t o obs erve thatm any thi ngs
w er e poss i bl e, so l ong as hi s deci s i on w as bas ed ( as i tw as ) on hi s f i ndi ng thatthe es t at e had f ai l ed t o es t abl i s h i t s cas e by a pr eponder ance of the evi den ce. T his ar gum enti s w i thout
m e rit. B . T he t ri al court w as not requi red t o acce pt t he es t at e’ s t heory of

c aus at i on. ¶3 5 . T h e e stat e a lso a rgu es th at – i n th e fac e o f th e e v iden ce itp rese n ted – the tri al co u rt
w as i n m ani f

es terr ort o f

i nd i n f avorof C H S on the i s s ue of

caus at i on. B ut , as w i th the p rev iou s issue , this argu m en t bo il s d o w n to a b att le of the ex p erts, w h ich th e tri al co u rt
r e s ol ve d i n f

a vo rof CH S. ¶ 3 6 . T h e e sta te’ s th e o ry , as e licite d fro m D rs. P e rrin a n d S h a d o ff, w a s th a t S y k e s w a s in
car di ac di s tr es s w hen he arr i ved att he C H S E R ; t hathi s condi t i on det er i or at ed as he w ai t ed
– unm oni t or ed – i n the w ai t i ng r oom ; and thathi s f at al ventr i cul arf

i br i l l at i on w as caus ed by a hea rtatt ack thatc oul d ha ve been pr event ed had C H S pr oper l y s cr eene d Sykes and begun A C L S pr ot ocol s hort l y af t erhe arr i ved. T he es t at e’ s expert s concl uded thatthe el evat ed tr oponi n l evel s i n Sykes ’ s bl ood es t abl i s hed thathe had s uf f er ed a he artatt ack. ¶37 . O n the o ther h and , C H S ’s theo ry w as that Syk es’ s preexi st i ng hy pert en sive h ea rt di s eas e, nota hea r tatt ack, caus ed hi s f at al ve ntr i cul arf

i br i l l at i on, and thateven i f C H S had d o n e e v e ry th in g th e e sta te’ s w itn e ss e s s u g g e ste d it sh o u ld h a v e d o n e , S y k e s lik e ly w o u ld have di ed anyw ay.13

¶ 3 8 . D r. C a lh o u n e x p lain e d th e sig n ifica n c e o f S y k e s’s e n lar g e d h e a rt a n d o p in e d th a t, i f the el evat ed tr oponi n l evel s r eal l y w er e caus ed by a heartat t ack, t hatw oul d have show n up o n the a u top sy . D r. C arlt o n ag ree d , ad d ing that the e leva ted trop o n in lev els p rob ab ly w ere caus ed by the att empt s t o r es us ci t at e Sykes
. D r . Car l t on c oncl uded hi s t es t i m ony by opi ni ng that , even i f

C H S had done eve rythi ng the w ay the es t at e’ s expert s t es t i f i ed i ts houl d have done, Sykes pr obabl y s t i l l w oul d have di ed. ¶3 9 . In sh o rt , b o th side s p rese n ted co n fl ict ing theo ri es, e a c h su p p o rted b y am p le ex p ert tes tim o n y . U n d e r su c h c irc u m sta n c e s, it is th e ro le o f th e fa c t-fin d e r to re so lv e th e c o n flict. I n thi s cas e, the t ri al judge re s ol ved the conf l i cti n f avorof C H S, and the es t at e of f er s no b a s i s f o ri t s c o n t e n t i o n th a tth e j u d g e ’ s r e s o l u t i o n o f th i s i s s u e wa s ma n i f

e s t l y wr o n g . As
w ith th e sta n d a rd -o f-c a re iss u e , the e sta te’ s a rg u m e n t is n o th in g m o re th a n a n a ttem p t to
re a rg u e its c a se . T h is iss u e is th e re fo re w ith o u t m e rit. C . T h e t r i a l c o u r t c o n s i d e r e d t h e p r o p e r c a u s a l t i me f r a me . ¶4 0 . T h e e stat e’s fina l attem p t t o o v erturn the v erd ictis i ts argu m en t th at th e tri al co u rt
comm i tt ed cl earerrorby onl y f ocus i ng on the cha nces of r es us ci t at i ng the pat i entaf

t erhe col l aps ed. I ti s the l i kel y l os toppor tuni ty t o s ave hi m dur i ng the hourpl us pe r i od of

t i m e he w as w ai t i ng f

oras s es s m entand ca r e bef or e he beca m e unr es pons i ve w hi ch i s the i s s ue i n thi s cas e. ¶41. W hi l e i ti s true thatthe t ri al co urt ’s fi nd i ng s of factm ent i oned “the t i m e of the dis rhythm i c even t , ” there i s no b asi s f or the est at e’s assert i on thatthe tr i al cou rtdidn’tal so c o n sid e r S y k e s’s c h a n c e o f re c o v e ry h a d C H S d o n e e v e ry th in g th e e s ta te c laim s it sh o u ld have – i ncl udi ng ear l i ertr eatm ent . I ndeed, D r . C ar l t on – the l as tw i tnes s t o t es t i f y – st at ed14

th a t, w h e n S y k e s p re se n ted to th e C H S e m e rg e n c y ro o m , ev e n if C H S h a d d o n e a ll th e e sta te
c laim e d it sh o u ldh a v e , S y k e s o n ly h a d a “ 3 0 p e rc e n t” c h a n c e o f su rv iv a l. ¶ 4 2 . T h is a rg u m e n t is w ith o u t m e rit. CO NC L US I ON ¶43 . A l l of

the es t at e’ s i s s ues con cern f actual det erm i nati on s that w ere w i thin the di s cr et i on of the tr i al court . T he es t at e pr es ent s no m eri t or i ous ar gum entthatthe tr i al courtw as
m ani f es t l y w r ong. W e af

f i rm the j udgm entof

the C i r cui tC our tof

C al houn C ounty. ¶ 4 4 . AFF I RM ED . W A LL ER , C . J. , C A R LSO N , P. J. , R A N D O LP H , LA M A R , K I TC H EN S, CHANDL ER , P I ER CE AND KI NG, J J . , CONCUR .