### NUM BER 13-08- 0019 2-CV 

## COURT OF A PP EA LS T H I R T E E N T H D I S T R I C T O F T E X AS C O R P U S C H R IS T I - 

## EDI NBURG
FR ED L. PER EZ , M .D., A pp ellan t,
v . SA NT OS S A LIN A S A ND W IFE, A RGE LIA SA LIN A S, A pp ellees . On ap pe al f rom th e 3 98t h Dist rict C ou rt of H ida lgo C ou nt y , T exas . 

## ME MOR A N D U M OP I N I ON Be fo re C hie f J us tice Vald ez an d Ju stice s R od rigu ez an d Be na v ide s

M emo rand um Opin ion b y Ju stice R od rigu ez Appel lee s, Santos Sal ina s a nd hi s w ife, Arg eli a Sal ina s, filed a he alt h c ar e l iab il it y claim against John T. Han niga n , a c e rtif ied registered nu rse ane sthe tist (CRN A), w ho is not a party to this appe al, and app ellant , Fred L. Pe rez , M.D. In this accelerat ed a ppe al, Dr. Perez cont end s that the trial court ab used its discretion in den y ing his motion to dism iss2

appel lee s' heal th c ar e l iab il it y cl aim becau se thei r ex per t r epor ts did not compl y

w it h
sec ti on 74.351 of t he Tex as Ci v il Pr act ic es and Remedi es Cod e. See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN
. § 74 .3 51 ( Ve r no n Su pp . 20 08 )

. W e affi r m. I. B A CKGRO UND Appel lee s s ued D r. Per ezal leg ing that h e b re ached the sta ndar d of care for an orth o p e d ic sur g eon by al low ing a C RN A to per form an i ntersc ale ne bl ock w hil e he p e rf o rm e d su rg e ry o n Mr

. S a li n a s ' s s h o u ld e r, ca u s in g i n ju ry t o Mr

. S a li n a s . Sp e c if ic a ll y, appel lee s a rg ue th at t he appl ic abl e s tandard of care r equi re s that thi s p ro cedure be per formed by

an a nest hesi olo g is t. Appel lee s t imel y se rv ed Dr . Perezw it h ex per t r epor ts pr epar ed by

Ja mes E . Bu tl er , M .D . and Hecto r J. Her re ra , M.D . Dr . Pe re zfil ed obj ect ion s to a p p e l l e e s ' e x p e rt r e p o rt s a n d a mo t i o n t o d i s mi s s a p p e l l e e s ' l a w s u i t a r g u i n g t hat t he
ex per t r epor ts did not meet t he s tatut or y r eq uirem ents of sec ti on 74. 351( r) (6 ). See i d. Af ter a he aring, the trial court de nied Dr. Perez's motio n to dism iss.

II. S TA NDA RD OF R E V I E W A ND A PPLI C A B LE L AW W e r ev iew a tr ial cour

t' s ru li ng on a moti on to dis mis s a heal th c ar e l iab il it y cl aim for an abus e of di sc re ti on. V a l le y B a p t i s t Me d

. C t

r . v . A z ua , 1 9 8 S

. W

. 3 d 8 1 0 , 8 1 5 (T e x. App.–C or pus Chr is ti 2006, no p et.)

. A tr ial courtabuses it s dis cr eti on w hen i t ac ts "'w it hout
re ferenc e to any

g uid ing r ule s a nd pr inc ipl es' or , s tated another w ay , w hether it s d eci si on
w as ar bit ra ry o r u n re asona ble ." City of S an Ben ito v . R io Gr ande V alley Gas

C o. , 109 S. W .3 d 75 0 , 7 5 7 (T e x. 20 0 3 ) (qu o ti n g Dow ner v. Aqu am arine Operato rs, Inc. , 701 S.W .2d 238 , 242 (Tex. 1985 )).3

In order to compl y

w it h s ect ion 7 4 .3 5 1 (r)(6) , an ex per t r epor t mus t s et ou t t he stan dard of

care for each def end ant , describe h ow each d ef end ant b reach ed tha t stan dard of car e, an d ex pla in how such brea ch caus ed the plai nti ff 's i nju ry . See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74.351 (r )( 6) ; Am . T ra nsiti onal C ar e C tr s. of T ex. , Inc. v. Pal

aci os , 46 S.W .3d 8 73, 8 77 ( Tex . 200 1)

. Sect ion 74.3 5 1 (l) prov ide s t hat, "[a] cour t s hal l g ra nt a moti on c hal len g ing t h e a deq uacy of an ex per

t r epor t onl y i f it appears t o the co urt, after hear ing , t hat t he r epor

t doe s n ot repr esentan objec ti v e g ood fait h effort t o c omply w it h the defini ti on of an ex per

t r epor t i n s ubsec ti on ( r) (6 ). " See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN
. § 74. 351( l) ; Bowie Me m 'l Hosp. v. Wrigh t , 79 S. W .3d 48, 52 (Tex. 2002 ).

III . A N AL Y S IS By one is sue, Dr. Perezcontends that the tri al cour t abu sed it s d is cr eti on i n deny ing his moti on to d ism iss appel lee s' heal th c ar e l iab il it y cl aim becau se the e x per t r epor ts provided by appe lle e s we re not a " good f aith e f fort" to comp ly

w ith the statu tory requireme nts of

section 74.3 51. In four sub-issues, D r. Perez specif ically argues tha t Dr. Her re ra i s n ot q ual ified to re nder an opi nio n and that Dr

. Butl er 's re por t did not setout the sta ndar d o f

c a re , i denti fy any

br eache s o f the s tandard of care, an d di d notes tabl is h a
causa l li nk. In s uppor

t of thei r heal thc ar e l ia b ili ty cl aim, appel lee s p ro v ide d the ex per t r epor ts of Dr. Herrera and D r. B u t le r. D r. Herrera prov ided his opinion regarding the app licable stan dard of

care in the a dm inistration of inte rs c a le n e b lo cks for shou lder surgery . Dr

. Butl er prov ide d hi s o pin ion that( 1) D r. Per ezdev iat ed from the standard of ca re i n al low ing a CRNA, rather tha n an ane sthe sio lo gist, to adm inister the interscalen e block, (2) D r.4

Per ezsh oul d hav e r eq uest ed that a phy si ci an anest hesi olo g is t admi nis ter the int ersc ale ne blo ck , (3) Dr. Perezshould hav e f or eseen the pr obabi li ty of Mr . Sali nas' s i nju ry

by al low ing a C RN A to admin is ter

the int ersc ale ne bl ock , and ( 4) the dev iat ion from t he s tandard of care, in reaso nab le me dical prob ability, w as a proximate cause of Mr. Salina s's injury . Dr

. Butler further

st ates thatD r. Per ezco uld hav e pr ev ented Mr . Sa li nas' s i nju ry by not allowi ng a CRN A to ad min ister the int erscalen e block. In hi s first sub- is sue, Dr

. Per ez cont ends that Dr . H er re ra i s i s n ot q ual ified to re nder an opini on. In his ex per t repor t, Dr . H er re ra st ates thathe i s l ic ensed to pr act ic e medi ci ne in Te x a s a n d i s b o a r d c e rt i fi e d i n a n e s t h e s i o l o g y . H e r e c e i v e d h i s " M

. D

. deg re e from UTBM at Gal v est on and did [hi s] anest hesi olo g y r esi dency

at the U niv ersi ty

of Tex as Hea lt h Scie nce Cen ter

at Hou sto n." Dr . Her re ra is a st aff member of Me thodi st Hos pit al and Tex as Or

thopedi c Hos pit al in Houst on, Tex as. Hi s medi cal pr act ic e i ncl udes g ener al anest hesi a for g ener al surg er y and orthopedi c s urge ry . In hi s p ra cti ce of anesth esi a for
orthopedi c s ur g er

y , he "per

form[s] upper

and low er

extr emit y

bl ock s." D r. H er re ra has been i nv olv ed in ov er

1500 cas es inv olv ing i ntersc ale ne bl ock s for sh oul der

su rg er y , t he proc e d u re performe d by the CRNA on Mr. Salina s. W e con clude that , altho ugh Dr. Herrera is not a ortho ped ic surg eon , the reco rd ref lects tha t his experience an d expertise
re ga rd in g i n t e rs c a le n e b lo c k s d u ri n g o rt h o p e d ic su rg e ry qu a li f y h im a s a n e xp e rt t o gi ve an opi nio n on that subj ect

. See T EX
. R. E V ID . 702 ( pr ov idi ng thatthe tes t i s w hether "the
o f f e rin g pa rt y [ha s] es ta b lis h e d th a t t h e exp e rtha s 'k n o wled ge, ski ll, exp e rie n ce , t ra in in g, or edu cation ' reg arding the sp ecif ic issue b ef ore the court w hich w ould q ualif y the expert to gi v e an opi nio n on that par ti cul ar su bje ct") ; Ehr

lich v. Mi les , 1 4 4 S

. W

. 3 d 6 2 0 , 6 2 4 (T e x. App.–F ort W orth 20 04, p et. deni ed) ( "A medi cal ex per t w ho is not of t he s ame sc hool of5

me dicine, howev er, is comp ete nt to testif y if he has pract ical knowl edge of w hat is usually and c ust omari ly

done by a pract it ion er

under cir cums tanc es si mil ar

to thos e c onfronti ng the d efendant.") ; see a lso T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74.401( a) ( Ver non 200 5) (setting out th at a pe rson m ay qualif y as an expert w itness in a su it against a physi cian if tha t person has "kn owl edge of accep ted stan dard s of me dical care" inv olved in the claim and "is q ual ified on the basi s of t ra ini ng or ex per ien ce to off er an e x per

t opi nio n r eg ar din g tho se acce pte d stan dard s of med ical care"); R ober

ts v. W il li am son , 111 S.W .3d 113, 12 1 (Tex . 200 3) ( pr ov idi ng thatthe cour t "r eje cte d the noti on" th at a phy si ci an g iv ing hi s o pin ion in the ex per

t re por t has to pract ic e w it hin the same s peci alt y ar ea as the defendant i f the off er ing par

ty has est abl is hed that the p hy si ci an has the q ual ific ati ons to g iv e hi s o pin ion on th at pa rticular subject ). Dr . Pe re zarg ues in his sec ond s ub- is sue that Dr . Bu tl er 's r epor t di d notse t fort h the stan dard of

care. How ever, in his repo rt, Dr. H errera opin ed tha t the st and ard of care in Tex as for i ntersc ale ne blo ck s for sh oul der

su rg er y "r eq uires that itbe d one by an ane sthe siologist (medica l docto r) and not by a CRN A." Becau se Dr. Herr era's repo rt est abl is hed t he sta ndar d of c ar e in appel lee s' heal th car e li abi li ty cl aim, Dr . Bu tl er w as not
re qui re d t o es tabl is h the st andard of care. See T EX
. C IV
. P R AC
. & R EM
. C OD E A NN . § 74.351( i) ( pr ov idi ng that"a c lai mant maysati sfyanyreq uirement of thi s s ect ion for s er

v ing
an ex per t r epor t by se rv ing r epor

ts of separ ate ex per

ts" and that "[n]ot hin g i n thi s s ect ion shal l be c onst ru ed to mean t hat a si ngle e xpe rtmustaddr ess al l li abi li ty and caus ati on is sues "); Packa rd v. Guerra , 252 S.W .3d 5 11, 5 31 (Tex

. App.–H oust on [1 4th D is t.] 2008, pet. filed ) ("[ S]ec ti on 74. 351( i) per mits a c lai mant t o s ati sfyany r eq uirement of s ect ion 74. 351 for serv ing an expert report by serv ing repo rts of sepa rate experts." ).6

I n h i s t h i r d s u b
- i s s u e , D r . P e r e z c o n t e n d s t h a tt h e e x p e rt s ' r e p o rt s d i d n o ti d e n t i fy any breache s of

the sta nda rd of

care. Spe cif ically , Dr. Perez argues tha t Dr. But ler's report
r el i es o n th e "c ap ta i n of t he s hi p" d oc tr i ne w hi c h ha s b ee n di s ap prov ed b y t he s up r em e cour t, see Spa rger v. W

orley Hosp., Inc. , 547 S.W .2d 582 , 585 (Te x . 197 7), and that Dr. B u t le r' s re p o rt is co n t ra d ic t o ry. Dr. Perez is correct that Dr. Butle r r ef erred to the " capt ain of the ship" doctrine in his
re por t. Ho wever, Dr . Bu tl er di d notr ely

on t his doc tr ine for h is opi nio n tha t D r. Per ez br eache d the st andard of car e. In f act , Dr . Butl er clear ly states in his re por

t that D r. Per ez dev iat ed from t he s tandard of care by allow ing the CR NA

to admini ste r the i ntersc ale ne block. In his report, Dr. Butler stat es: The r ecords fail to show that an M. D. anes thes iol og is t w as pr esent , or took part in th e an esth esia at all.

. . . In t his ca se, D r. Per ez , t he or thopedi c surg eon, all ow ed a CR NA r ather than an anes thes iol og is t t o admi nis ter the in tersc ale ne bl ock

w hic h, i n my

opi nio n, w as a dev iat ion of the s tandard of care.

. . . [D r. Per ez ] s houl d hav e fores een t hat t he pro b a bil it y of an i nju ry

of the br achi al ple x us by

al low ing a C RN A to admini ste r the int ersc ale ne blo ck on Mr. Salinas. This dev iat ion , i n r eason abl e medi cal probabi li ty , w as a prox imat e c ause of Mr . Sa li nas' br achi al ple x us inj ur y . Dr . Pe re zc o uld hav e pr ev ented the outc ome su sta ine d by

M r. Sal in a s by

si mply not all ow ing an i ntersc ale ne blo ck be p er formed by

a C RN A. Dr . Pe re zarg ues that Dr . Bu tl er co ntr adi cts hi m se lf

b ecaus e he opi nes that an intersca lene block shou ld "ne v er" be adm inistered during should er surgery . How ever, in his re por t, Dr

. Butl er does not sta te that the int ersc ale ne blo ck shoul d not h a ve beenI n a f i nal sub- i ssue, D r . Per ez cont ends t hat upo n a pl ai nt i f f ' s f ai l ur e t o com pl y wi t h sect i on 1 74. 351 (a), t he t r i al cour t m ust awar d at t or ney ' s f ees t o t he d ef endan t

. Because we ha v e con cl uded t hat ap pe l l ee s c om pl i ed w i t h s ec t i on 7 4.35 1(a ), a nd t ha t t he t ri al co urt di d n ot ab us e i t s di s c ret i on by de ny i ng D r. P e re z's m o ti o n to d i s m i s s , w e d o n o t re a c h th i s s u b -is s u e . See T EX
. R. A PP
. P. 47. 1 ( pr ov i di ng t hat we m ust ad dre s s " eve ry i s s ue rai s ed an d d i s po s i t i ve a nd ne c es s ary t o fi na l di s po s i t i on of t he ap pe al " ). 7 adm inistered but th at, b y improp erly

allow ing a CR NA to ad min ister the int erscalen e block, Dr. Perez v iolate d the stand ard of care, w hic h wa s t h e proximate cause of Mr . Salina s's inj ur y . In hi s four

th s u b -is sue, D r. Per ezco ntends thatappel lee s' ex per t r epor ts did not esta blish a cau sal link between Dr. Perez's alleged brea ch of the stand ard of care and Mr

. Sal ina s' s i nju ry . Spec ific all y , D r. Per ezarg ues that "Dr . H er re ra d o e s not ex pla in how hav ing a di ff er ent p erson per form the int ersc ale ne bl ock w oul d hav e prev ented all of the all eg ed i nju ri es. " W e di sag re e. In his repor t, Dr . Bu tl er

ex pla ins that

D r. Per ez 's dev iat ion f rom th e stan dard of

care, in reaso nab le me dical prob ability, w as a proximate cause of Mr

. Sal ina s' br achi al ple x us inj ur y and that Dr . Pe re zco uld hav e pr ev ented th e i n ju ry by not all ow ing a C RN A to per form the int ersc ale ne bloc k on Mr . Sa li nas. D r. H er re ra ex pla ine d Dr. Perez shou ld have forese en th at allowing a CRNA to adm inister the interscalen e block
w ould cause injury

to Mr. Salinas; Dr. Perez's deviation f ro m t he sta nda rd of care in
re asona ble medi cal probabi li ty w as a prox imat e c ause of Mr . Sa li nas' br achi al ple x us injury ; and Dr. Pere zco uld have prevente d the in jury b y n ot allowi ng a CRNA to pe rform the interscalen e block. Therefor e, w e c oncl ude t hat b ecause appell ees' ex per t r epor ts re pr esent ed an obj ect iv e g ood fait h effort t o c omply w it h 74. 351( r) (6 ), the tr ial co urt did n o t abuse i ts dis cr eti on by deny ing Dr

. Per ez 's moti on to di smi ss . See A z ua , 1 9 8 S

. W. 3 d a t8 1 5

. W e ov er ru le Dr . Pe re z 's so le is sue. 18 IV. C ONCL US I ON W e aff ir m the tr ial co urt' s j udg ment.
NE LDA V. RO DR IGU EZ J u s t i c e Me moran dum Opi nio n del iv er ed and filed thi s 2 5th d ay

of Nov ember , 200 8.