### TEXA S C OU R T OF A PPEAL S, THIR D DIST R ICT , AT AU STIN

NO. 03-0 5 -00 454 -CV

Ce c e lia Le de sm a , A ppe lla nt

v. G e or ge L. Sh as houa , M .D .; Oak wood W om e n's C e nr e , P .A . a t R ound R oc k; Joseph Ed din gs; B. John s, CRNA; and Rou nd Rock Medical Center , Appellees

F ROM THE DISTRICT CO URT OF WI LLIAM SO N COUNTY , 277TH JUDICIAL DISTRICT

NO. 05- 489- C277 , HO NORAB LE KEN ANDERSON, JUDGE P RESIDING

M E M O R

A N D U M O P I N I O N
Ce c e lia L e de sma a pp e a ls the dis tr ic t c ourt ’s dis mis sa l of he r h e a lthc are lia

bi lity claim ag ainst Certified Reg istered Nurse Anesthetist, Br uce J ohns, for failure to make an objective, g ood faith ef

fort to timely

serve an expert re port that compl ies with the requir ements in section 74.351 of the c ivil practice s and re medies code
. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351 (We st Supp . 200 6)
. L e de sma argue s tha t the dis tr ic t court e rr e d in hold ing that the e xpe rt re po rt s that sh e ha d s e rv e d f

a ile d to c omp ly

wi th s e c tio n 7 4. 35 1 a

nd by no t allo wi nghe r a 30 -d ay tim e extension t o cure an y d efic iencies. L edesma also asser

ts that chapter

74 of the c ivil practice and
re me die s c od e is unc on sti tut ion a l. We a ff ir m th e dis tr ic t c ourt ’s jud g me nt.
BACK GR OUND I n N ov e mbe r 2 00 1, L e de sma un de rw e nt s ur g e ry

a t Roun d Roc k Med ic a l Ce nte r t o
remove her r ight ova

ry and h er ap p en d ix . She filed this lawsuit on J anuar y 14, 2004, ag ainst theL edesm a a lso a lle g e d th a t th e surg e ry wa s unn e c e ssa

ry and the re su lt o f a

mis dia g no sis 1 of he r a bd omi na l pa in. Th e se c la ims do no t pe rt a in t o Joh ns . 2 hospital, her surg eon, his profe ssional association, the anes t h esi ologist, and Johns, the certifie d reg istered nurse anesthe tist, alleg ing in pa rt that she suffe red perma

nent injury to her lef

t arm, hand, and wr ist as a re sult of incorre ct place ment of the I V in he r left fore arm and improper place ment and
m o n i t o r i n g o f

h e r ar m d u r i n g t h e s u r g e r

y. 1 On M ay 1 4, 2004, L edesma serve d J ohns’s counsel with four expert repor

ts that purported to c omply

with the require ments of sec tion 74.351(a). See id . § 74.351 (a ) ( “ I n a he a lth
car e liability

claim, a c laimant shall, not later than the 120th da y afte r the date the orig inal petition was filed, se rve on e ach p ar t y or the pa

rty ’s attorne y

one or more expert repor ts . . . for ea ch p h y s i ci an or health ca

re pr ovider a g ainst whom a liability claim is asserte d.”). The repor ts were prepa red by the following experts: (1) Dr. D inner, a b o ar d cer tified ane sthesiologist; (2) Dr
. Hamilton, a boar d cer

tified obstetrician/g y

necolog ist; (3) Stephanie Tate, a certified ope rating room
nurs e and c e rt if ie d le gal n

ur se c on su lta

nt; and (4 ) T ho ma s Sh aro n, a

re g ist e re d nur se c e rt if

ie d in i n t r a v e n o u s t h e r a

p y. On June 4, 20 04 , a ft e r L e de sma ’s 12 0-d ay de a dli ne fo r s e rv inghe r e xpe rt re po rt s expir e d , Jo h n s f

il e d a mo ti o n to d is mi s s an d s e v e r th e c la im s a g a in s t h im o n th e g r o u n d s th a t the expert repor

ts did not satisfy

the re quirements of se ction 74.351. Se e id . § 74.351 (a) -(b) , ( l ), (r )(6)
. I n her r espons e t o t h e motion to di smiss, L edesma asser ted that the re ports wer e ade quate a nd alt er n at i vely , she aske d the cour t to gr ant her

a 30-da y extension t o cure any

defic iencies. See id
. § 74.351(c) (“I f an expert repor t has not been served within the period specified by Subsection (a) beca use ele ments of the report are found defic ient, the cour t may g rant one 30-day

extension t o the3

claimant in orde r to cure the def iciency .”). The district court gra nted J ohns’s motion to dismiss (but
no t his mot ion to se ve r) and dis mis se d a ll o f L e de sma ’s c la ims a g a ins t John s. John s su bs e qu e ntl y filed a se cond motion to sever, whic h the district court gra nted, m aking the dismissal order re g arding John s f ina l. L e de sma

a pp e a ls f ro m th e or de rs dis mis sin g and se ve ri nghe r c la ims a g a ins t John s.
DI SCU SSIO N Adequacy of

the exper t re ports I n h er fi rst issue, L edesma asser ts that the district court er red in holding that the expert repor

ts that she serve d failed to c omply with se ction 74.351’s require ments. The e x pert re port
or re ports require d under se ction 74.351(a) must provide “a fair summary of the e x pert’s opinions
as o f the date of

the re port reg ardingapplicable standards of car e, the manne r in which the c are rende red by

the phy sician or he alth car e provide r fa iled to meet the standa rds, and the c ausal relationship betwee n that failure and the injury , harm, or da mag es cla imed.” Id. § 74.351(r) (6). A trial court must “g rant a

motion challeng ing the adequa cy of an e x pert re port only

if it appea

rs to the
c ourt , a ft e r h e ari ng , th a t th e re po rt do e s no t r e pr e se nt a

n o bje c tiv e g oo d f

a ithe ff or t to c omp ly ” wi th this definition of an expert repor t. Id . § 74.351( l ). To c on sti tut e a

“ g oo d f a ithe ff or t” the re po rt

mus t pr ov ide e no ug h in fo rm a tio n to fulfill two pur

poses: (1) it must inform the defe ndant of the spe cific c onduct the plaintiff ha s called into question; and (2) it must p ro v i d e a b as is for the trial c ourt to conclude that the claims have merit. Bowie Mem ’l Hosp. v. W right , 7 9 S. W.3 d 4 9, 52 (T e x. 20 02 ); Am e ric an Tra ns iti on al C ar e Ctrs. of Tex., Inc . v. Palacios , 4 6 S.W .3d 873, 875 (Tex. 2001). Althoug h an expert re port “ne ed
no t ma rs ha l a ll the pla int if

f’ s p ro of ,” it mus t in c lud e the e xpe rt ’s op ini on on e a ch of t he e le me nts4

identified in section 74.351. Palacios , 46 S.W. 3d a t 87 8. I t is no t e no ug h fo r the re po rt me re ly to
s t at e t he expert’s c onclusions about the statutory elements. Id
. a t8 6 9
. “ R a t h e r , t h e e xp e rtm us t explain the basis of his statements t o link his conclusions to t he fa cts.” Bowie Mem ’l Hosp. , 7 9 S
. W
. 3 d

at 5 2 (q u o t i n g Ea rlev . R atl iff , 998 S.W .2d 882, 890 (Tex. 1999)). Be cause the statute dictate s what is require d in the repor t, the only

information
re le va nt t o d e te rm ini ngwh e the r a re po rt c omp lie s w ith the statut e is that with in “the fo ur c or ne rs ” of the re port. Palacios , 4 6 S. W.3 d at 87 8. Th is re qu ir e me nt pr e c lud e s a court fr om fi lli ngg a ps in
a re p o rt by

draw ing inf

ere nces or

g uessing as to what the e x pert likely meant or intende d . B owi e Mem ’l Hosp. , 79 S.W .3d at 53.

We review

a tria l c ourt’s dec ision to di smiss a health ca re liability

claim under

section 74.35 1 for a

n abuse of

discretion. Palacios , 46 S.W .3d at 875. A trial c ourt abuses its discre tion when it ac ts in an arbit ra ry or unre asonable manner or ac ts without refer ence to any g uiding r ules
or principles. Downer v. Aquamarine Operators, Inc. , 701 S.W .2d 238, 241 (Tex. 1985). A cle ar failure by the trial court to analy

ze or apply

the law c orre ctly

also constitutes an abuse of discre tion. W alker v . Pack

er , 827 S.W .2d 833, 840 (Tex. 1992). Withthe se pr inc ipl e s in

min d, we re vie w t

he fo ur e xpe rt re po rt s th a t L e de sma fu rn ish e d in c on ne c tio n w ithhe r s uit
. Dr . D inne r’ s re po rt Dr
. D i n n e r , a b o ar d c e rt i f i e d an e s t h e s i o l o g i s t , b e g i n s h i s r e p o rt b y r e c o u n t i ng his qu a l i f i c a t i o n s an d

p r o f e s s i o n a l e x p e r i e n c e an d

s t a t e s “ B y v i rtu e o f

m y t r a i n i n g i nan e s t h e s i o l o g y,
. . . as we ll as 20 y ear s of experienc e in the oper ating room, Iam v er y fa m i l i ar wi th the5

circ umstances a

nd standards of

car e rele vant to the proce eding s in this case .” He then summarizes L e d e s m a ’ s m e d i c a l h i s t o r

y an d d e s c r i b e s t h e i n

j u r i e s t h a ta

p p e ar e d a f t e r h e r N o v e mb e r

2 0 0 1 s u r g e r

y. He notes that, while in the p o s t an es t hesia c are unit, L edesma “complaine d of numbness and discomfort in her le ft wrist” that wa s later diag nosed as “ a ra dial nerve palsy .”

Dr . D inn e r t

he n c on c lud e s:
B y vir tue of the fa c t tha t Ms. L e de sma ha d no pre vio us c omp la int s of l e ft arm pa in or par esthesia on 11/01/01 y et left the hospital with a sig nificant injury to that extremity , it is without question that this damag e wa s sustained during the cour se of her pe riopera

tive period. I t is my

position t hat t he inj ury

could only

have oc curr ed as a c onsequenc e of imprope r and traumatic pla ceme nt and inappropr iate positioning an d / o r r e s t r a i n i n g o f

t h e e x t r e m i t y.
Dr. Dinne r obser

ves that L edesma

complained a

bout “sig nificant p ai n at the int ra ve no us sit e ” up on

ini tiatio n o f t

he int ra ve no us lin e . H e no te s:
The individual who plac ed the line ha s the responsibility to do so in a manner which will not cause tra

uma to the s urrounding tissues. A porti on of the super ficial bra nch of the ra dial nerve runs throug h the location whe re the intravenous line wa s place d and as suc h, was “ spear ed” by the sharp stylet that serve s as an intro d u ce r fo r the ang iocath. This mecha

nism of injury

is fully consi stent with the post operative diag nosis of tenosy

novitis and my ositis and the MRI finding s point to inj ury in the are a of the co rre sponding muscle . Customarily , the individual who place s the int ra ve no us lin e is i de nti fi ed in the me dic a l r e c or d a nd pla c e s a no te a t th e tim e positioned. No such note is in the cha rt. . . . I t was esse ntial that the clin ician pe rf or min g thi s p ro c e dure po sse ss t he ne c e ssa

ry sk ill to ca

rr y thi s out p ro pe rl y . T his was not the c ase in this situation and the individual who established the iv ac cess wa s neg lige nt in the perfor

mance of their duties by causing sever e trauma to the bra nch of the ra dial nerve in that location. Had the individual who star ted the intrave nous lin e a c te d in a mo r e c a

u ti o u s , s k il lf

u l an d a p p r o p r iate ma

n n e r in k e e p in g w it

h the standard of car e, it is more likely than not that the injury

that Ms. L edesma

sustained would not have oc curr ed.6 Dr . D inn e r n e xt ad dr e sse s th e a c tio ns of the ane sth e sia

te a m:
Ihave a lso care fully revie wed the actions of the anesthesia t eam in this case from the preope rative a ssessment all the way throug h to the post ope rative r ecove ry course [.] Th e patie nt w a s in

the litho tomy

po sit ion wi th h e r l e g s r e str a ine d in sti rr up s and bo th arms plac ed on ar

m boards at a cute a

ng les to the body ax i s . T h e ane sthesia team consisting of

Dr. Joseph Eddings a

nd Br uce Johns CR

NA tog ether

with the nurses including but not li mited to the circulating nur se and sc rub nurse as we ll as the surg e on , D r. Sha sh ou a , h a d a du ty to e ns ur e the sa fe ty of the pa dd ing , r e str a int , place ment, and positioning of the patients arms a rmboard, a

nd restra ints prior to and duri ngthe pr oc e dure . E ve ry he a lthc are pr ov ide r i n the s urgi cal su ite ow e d a du ty of ca re to M s . L ed esm a to ensure her sa fety during the proc edure due to the administration of the ane sthesia, which wo u l d preve nt the patient from pr otecting herse lf with protective r efle x es. The healthca re provider placing the re straints failed to document the manne r in which the patients ex tremities wer e restrained or place d on the boar d. The standa rd of c are requir es such doc umentation in the patient’s re c or ds . T he re fo re the re was a vio la tio n in the sta nd ard of c are wi th r e sp e c t to d o cu m en t at i o n . T h e i n

j u ry i s co n s i s t en t wi t h i mp ro p er p l ac em en t , b adp o s i t i o n i n g, inattentive applica t ion of pressur e on the patient’s arm duringthe proc edure , or re str a int s bei ng pla c e d too tig htl y and re str ic tin g the blo od fl owin t his are a . I t w ou ld vio la te the sta

nd ard of c are fo r a ny he a lth c a re pr ov ide r in the surg ic a l su ite to fa il t o notice, addr ess, and doc ument any such occ urre nce.
Dr . D inn e r c on c lud e s:
B a s e d u p o nr e a s o n a

b l e m e d i c a l p r o b a

b i l i t y , t h i s i n

j u r y o c c u r r e d d u e t o i mp r o p e r

IV p l ac em en t , p o o r t ec h n i qu e i n I V p l ac em en t , o r i mp ro p er p l ac em en t , b adp o s i t i o n i n g, inattentive application of pressure on the arm, or re straints being improperly place d so tha t th e y we [r]e too c on str ic tiv e . T he oc c ur re nc e of any on e or mor e of the se events would violate the standard of car e for patient safe ty d u ring anesthe sia. Dr. J oseph Edding s as t he ane sthesiologist, Br uce Johns, CR

NA, the surg eon, Dr
. Sha sh ou a , a

nd the nurs e s and e mpl oy e e s of Round Roc k Med ic a l Cen te r o we d a du ty of ca re to Ms. L edesma

for patient safety

in the above r eg ard dur ing a nesthesia. The radia l nerve palsy

would not have oc curr ed but for the neg lige nce a nd violations of the sta nd ard of c are a pp lic a ble to e a c h o f t

he se he a lth c are pr ov ide rs .7 Dr . Ha milton’

s re po rt L edesma ’s sec ond expert repor t was pre pare d b y

Dr. Ha milton, a board ce rtified obstetrician a

nd g y necolog ist. Most of Dr. Hamilton’s repor t f ocuses on L edesma ’s alleg ations that h e r o b s te tr ic ia

n , D r . Sh a s h o u a , mi s d ia g n o s e d th e c a u s e o f h e r a

b d o mi n a l p a in an d

perf ormed
un ne c e ssa

ry surg e ri e s. Dr . H a mil ton

op ine s th a t: [Dr. Shashoua] and Dr. Wex ler, the surg eon who pe rfor med the appe ndectomy , wer e n e g l i g e n ti nn o ti n s u r i n g p r o p e r p o s i t i o n i n g o f

t h e p a t i e n t o n t h e o p e r a t i n g t a b l e . It wa s the ir ne g lig e nc e a lon g wi th that of Dr . Jose phEd din g s MD , th e ane sth e sio log ist , an d B r u c e Jo h n s , Ce rti f

ie d Re g is te r e d

N u r s e A n e s th e ti s t, th a t p r o d u c e d a s e v ere ine xcu sa ble inj ur y to t he ra dia l ne rv e in M rs . L e de sma ’s le ft arm . Nur se Shar on’ s re po rt L e de sma ’s t hir d e xpe rt

re po rt wa s p re pa

re d b y Th oma s Sh aro n, a

re g ist e re d nur se lic e ns e d to pr a c tic e in F lor ida . N ur se Sha ro n d e sc ri be s h is q

ua lif ic a tio ns a s f

oll ow s: During the past twenty -five y ear s, I have worked as a staff nurse, nur sing supe rvisor, nurs inge du c a tor in vari ou s hosp ita ls an d as a ch ie f exe c uti ve of fi c e r of a c or po ra te provider of

nursing service s. . . . I am experience d and familiar with the standard of car e ordina rily exercised by

nurses in hospitals. I am specific ally experience d and familiar with the deg ree and skill of car e exerc ised by

nurses in hospital operating suit es or fre e st anding surg ical ce nters with reg ard to the dutie s an d responsibilities of the circ ulating nur se duringthe intraoper ative phase of surg ery . Nurs e Sha

ro n th e n li sts the me dic a l r e c or ds and re po rt s h e re vie we d a

nd state s: [I ]t is my

opinion with a rea sonable d egr ee o f professional ce rtainty that the circ ulating nur se on duty in the operating r oom depar ted from go o d an d acc epted standards of

nursing prac tice in failing to preve nt prolong ed pre ssure a g ainst the left r a d i a l n e r v e p l e x u s d

u r i n g s u r g e r

y.8

The c irculating nurse owed a duty to the patient to chec k the patient’s body position, body alig nment and application of positioni ng device s such as ar m boards to assure t h a tb o n y p r o m i n e n c e s an d n e r v e b u n d l e s ar e n o tp r e s s u r i z e d d u r i n g s u r g e r

y. * * * I t should b e n o te d th a t u s e o f

th e ar m b o ar d w a s p art o f

th e p la nto p r e v e n t injury related to surg ical interve ntion. W hen using the ar m boards the circ ulating nurse or anesthe tist usually

wra ps adhesive ta

pe ar ound th e u pper a

nd lower a

rm and unde r the arm bo ard in o rd e r t o ke e p it

in p la c e . D ur ingthe surg e ry , th e c ir c ulatin g nurs e must freque ntly

chec k the t[a] pe to make c erta in that it is not too t i gh t
. The tape must never be applied around the wrist or elbow joints and these are the two place s most susceptible to nerve da mag e if the ta

pe is applied too tightly

or bec omes tighte r later on due to peripher al ede ma (swe lli n g). T here fore it is m y opinion with a rea sonable de g ree of prof essional ce rtainty

that the improper a

pplication of the ar

m board and fa ilure to che ck the lef t upper e x tremity

wer e the pr ox imate ca

use of the radia l palsy

of the lef t wrist and hand.

* * * I t is my opinion with a rea sonable deg ree of profe ssional c erta inty th at t h e r ad i al nerve compre ssion injury was c aused by

taping the left wrist to the arm boa rd so as to cause compre ssion entrapment of the ra dial nerve plexus . The c ircumfe rential taping of the wr ist to an arm board is c ontraindicated beca use of the proximit y

of the ra dia l ne rv e ne ar t

he sk in s ur fa c e . E ve n if

ano the r s ta ff

me mbe r t a

pe d t he wr ist , it was incumbe nt upon the circ ulating nurse to insist that the tape be remove d from the wrist and that the a

rm board be secur ed by taping over the mid forea rm or the ha

nd (if the wr ist needed to be immobil ized). Fur thermore , the circ ulating nur se also owe d a du ty to the patie nt to ch e c k the ha nd and wr ist a t f re qu e nt i nte rv a ls t o ma

ke c e rt a in that th e c ir c umf

e re nti a l ta pe wa s no t c a

us ingpr e ssu

re and wa s n ot i nte rf

e ri ngwi th periphe ral blood flow.
Nur se Ta te ’s re po rt L edesma ’s fourth e x pert re port was pr epar ed by Stephanie Tate, an oper ating room
nurs e c lin ic ian a

nd le g a l nu rs e c on su lta

nt. Nurs e Tate e xpla ins he r q ua lif ic atio ns a s f

oll ow s:
Iam cur rently licensed to pra ctice Reg istered Nursing in the s tate of California. . . . I have be e n p ra c tic ingop e ratin g ro om n ur sin g sin c e 19 81 , a

nd Isc ru b a nd c ir c ulate a ll s pe c ia lti e s in c lud ing tr a uma . I a m f

a mil iar w iththe sta

nd ard s o f c are re le va

nt t o the fa cts of this case
.9 Nurs e Tate the n d isc us se s th e sta nd ard of c are that th e cir c ulatin g nurs e s o we d to L edesma with respec t to the placeme nt of the I V:
Eac h cir culating RN had a r esponsibility to actively

advocate for Ms. L edesma
. Whichever one broug ht her to the room ha d the re sponsibili ty to conduct a pr e-op a sse ssm e nt a

nd in ter vi e w, do c ume nt a nd a dd re ss a ny c on c e rn s Ms . L e de sma verba liz ed about pa in at her I V site, document her assessment of the I V site and what int e rv e nti on s w e re un de rt a ke n to tr ou ble sh oo t th e pr ob lem as we ll a s p ro vid e pa in relief and docume nt to whose attention the matter w as direc ted. None of this was done, in spite of the f

act the f act that Ms. L edesma

is adamant that she complaine d a bo ut pain at her I V s ite a s so on a s it wa s st art e d. Th is i s in

vio la tio n o f b a sic nurs ingfu

nd a me nta ls, AO RN [As so c ia tio n o f P e ri op e rativ e Re g ist e re d N ur se s] Recommende d Principals and Prac tices, and ANA [ Americ an Nur ses Association] Standards. . . .
Nu r s e T a te n e xt d is c u s s e s the standar d of ca re that circulating nur ses owe w ith respec t t o t h e p o s i t i o n i n g o f

t h e p a t i e n td

u r i n g s u r g e r

y:
The c irculating nurses a lso had profe ssional respons ibilit ies involving patient po sit ion ingand

patie nt s a fe ty , a c c or din g to A OR N. Ihave a tta c he d th e 20 01 AO RN Standards of Car e addr essing the per ioperative nurse’ s re sponsibili ty in patient positioni ng . Iwill quote an excerpt fr om the standard he re: Stand ard of Care (per AORN:) Th e c ir c ulatin g RN (p e ri op e rativ e nurs e ) i s th e surg ica l pat ie nt’ s a dv oc a te , a nd is responsible for

ensuringpatient safe ty

while under his or

her c are . The pe rioperative nurs e sh ou ld a c tiv e ly pa

rt ic ipate in s a fe ty

and a pp ro pr ia te ly

po sit ion ingthe patie nt, continuously

monitoring body

alig nment and ti s s u e int eg rity based on sound phy sio lo g ic p r in c ip a ls , an d c o mm u n ic a ti n g s p e c if

ic p a ti e n t n e e d s to th e r e s t of the surg ic a l te a m. * * * Once the surg ical tea

m is s cr u b b ed i n , it is an ongoingresponsibility of both the circ ulating RN ( or RNs) and a nesthesia t o continually

chec k—and docume nt—the p at i en t ’s ex t re m i t i es an d

p o t en t i al p re s s u re p o i n t s af t er ch an ges i np o s i t i o n i n g.10

Although a

nesthesia doc umented “a ll press u re p o i nts chec ked and pa dded” at the beg inning of

the proc edure , it is likely that her position wa s chang ed af ter intubation, perha ps more than onc e. The documentation conc erningpositioni ng on the par t of the circ ulating RNs is minimal; in fac t it is limit ed to the anatomical diag ram of the patient, and is uncle ar. The periope rative ( circ ulating) RN’s responsibilities include do c ume nti ngbo th t

he po sit ion ing and ty

pe of pa dd ingus e d in tr a op e ra

tiv e ly , a s w e ll. The fa ct that the ane sthesia provider documented “ all pressure points checke d and padded” does not exempt the circulatingRN from his or her own re sponsibili ty for acc urate and thorough documentation. The ty pe of padding use, and the spec ific sites wher e it was plac ed, should have been do cumented in the intraopera tive nursing notes. The fac t that it is not documented is in violation of 2001 AORN standa rds of car e addr essing the per ioperative (circ ulatin g ) RN’s re sponsibili ty in documenting peri o p e r a ti v e n u r s in g c ar e , a s w e ll a s th e A N A Co d e f

o r N u r s e s w it

h I n te r p r e ti ve Statements, with Ex plications for Periope rative N ursing . This states, in pa rt, that the pe ri op e rativ e (c ir c ulatin g ) R N i s re qu ir e d to “ Com

ple te op e rativ e re c or ds a c c ur a te ly and in an ob

je c tiv e and no n-

jud g me nta l man ne r” and “ Ma int a in r e c or ds in a n o rd e rl y manner .” * * * Thi s co n t i nuous lack of nur sing doc umentation in the medical r ecor d violates the sta nd ard of c are and re sult ed in harm

to t he patie nt. Th e c omp la int of pa in s ho uld have be en addr essed a

nd repor ted to the surg eon and the anesthe siologist befor e the start of the sur g ery

to rule out I V ac cess a s the ca u s e o f t h i s injury . Also, in 2001, nurs e s w e re re qu ir ed by

JCAH O ( and

sti ll a re ) t o a sse ss a

nd do c ume nt p a tie nts ’ complaints of p ai n o n a s ca le of 1 to 10—10 beingthe most severe . This was not do ne and vio la te s th e sta

nd ard of c are fo r p a in a sse ssm e nt.
Anal y sis We c on c lud e that th e dis tr ic t c ourt did no t a bu se its dis c re tio n in

ho ldi ngtha

t th e se four e x pert re ports did not satisfy the re quirements of se ction 7 4
. 3 5 1 wi t h respe ct to J ohns. The expert repor

ts prepar ed by Nurse Tate and Nurse Sharon are inadequate beca use they fail to identify J ohns at all. Both nurse repor ts a ddress g ener ally the standard of car e applicable to reg istered nur ses or circ ulating nur ses, of whic h J ohns is neither. “We ha ve held that whe re the identity of a de fenda

nt11

is not ex plicitly

mentioned within the ‘four corne rs’ of the report, the report is, for that rea son alone, de fi c ie nt a s to that de fe nd ant b e c a us e it w ou ld r e qu ir e the re a de r t o in fe r o r m a ke an e du c a te d g ue ss
as to w hose ac tions the ex pert is complaining .” Bo ga r v . E sp ar za , ___ S.W .3d ___, ___ No. 03-07- 00037-CV, 2007 Tex. App. L EXI S 5088, at * 1 9 (Tex. App.—Austin J une 28, 2007, no pet. h.) (citing Austin Heart, P .A. v. W ebb , ___ S.W .3d ___, ___; No. 03-06-00607- CV, 2007 Tex. App. L EX I S 36 00 , a t *1 5 (T e x. Ap p. —A us tin Ma y 9, 20 07 , n o p e t. h .) ; Ap od ac a v . R us so , ___ S.W .3d ___, ___ No. 03-06-00258- CV, 2007 Tex. App. L EXI S 3467, at *13 (Tex. App.—Austin May 2, 2007, no pet. h.)). F urthermor e, the nur se reports are inadequate to satisfy the ca usation element of section 74.351(r )(6) beca use only a qualifie d phy sician can rende r expert opinion testimony
r e g ar d in g th e c a

u s a l r e lati o n s h ip b e tw e e nth e in ju r y , h ar m, o r d a ma g e s c la im e d

an d th e a ll eg ed depar ture from the applicable s tandar d of ca re in a health ca re liability

claim. See Tex. Ci v. Prac. & Re m. Code. Ann. § 74.351(r) (5)( C).

The two e x pert re ports that d o m en t i o n J ohns—Dr. Dinner ’s re port and Dr
. Ha mil ton ’s re po rt

—d o no t su ff

ic ie ntl y ide nti fy the sta

nd a rd of c are a pp lic a ble to Joh ns or

e xpla in how J ohns brea ched that standard. Dr . Dinner’ s repor t broadly states t hat the entire surg ical team including Johns “had a duty to e nsure the safe ty of the padding , restra int, plac ement, and positioning of the patients arms armboard , and re straints prior to and duringthe proc edure ” and that “[e]very he a lthc are pr ov ide r i n th e surg ic a l su ite ow e d a du ty of c are to Ms. L edes ma

to e ns ur e he r s a fe ty during the proc edure ,” but Dr. D inner doe s not ex plain what Johns, as the CRNA, should have done differ ently

to p ro v i d e for L edesma ’s safe ty
. See Pa lac ios , 46 S.W .3d at 879-80 (c onclusory state me nt t

hat “ pr e c a uti on s to pr e ve nt [p a tie nt’ s] f a ll w e re no t pr op e rl y

uti lize d” did

no t su ff ic ie ntl y apprise phy sician whe ther expert believed that the standard of car e require d him “ to have monitored12

[t he patient] more close ly , restra ined him more sec urely , or done s o mething e lse entirely”). L ikewise, the statements in D r. Hamilton’s repor t that Dr. Shashoua a

nd Dr. Wexl er “ wer e neg lige nt in n ot i ns ur ingpr op e r p os iti on ingof the patie nt o n th e op e ra tin g ta ble ” a nd that “ [i]t w a s th e ir
ne g lig e nc e a lon gwi th t

hat of Dr . Jose phEd din g s MD , th e anest hes io log ist , a nd B ru c e John s, Certified Reg istered Nur se Ane sthetist, that produced a sever e inexcusable injury to the radia l nerve in Mrs. L edesma ’s left arm” do not ide ntify the standard of car e applicable to Johns. See id. at 880 (statement that r estraints to preve nt fal l we re n o t proper ly used is not a statement of the standard of

car e). Ha vin g re vie we d th e fo ur

e xpe rt re po rt s, we c on c lud e that th e dis tr ic t c ourt c ou ld have re a so na

bly c on c lud e d th a t th e re po rt s do not re pr e se nt an ob je c tiv e g oo d fa ith e ff

or t to c omp ly with the definition of an e x pert re port in section 74.351(r) (6).
Extension of

tim e under 74.351(c) L edesma also argues that the trial c ourt err ed by not g ranting her request for a 30-da y
e xten sio n o f t ime to c ur e any de fi c ie nc ie s in

he r e xpe rt

re po rt s. Se c tio n 7 4. 35 1( c ) s ta te s th a t if
e le me nts of

an e xpe rt re po rt are fo un d to be de fi c ie nt, “ the c ourt may g ra nt o ne 30 -d ay

e xten sio n to the claimant in order to cure the deficiency .” Tex. Civ. P rac . & Re m. Code Ann. § 74.351(c) . The extension allowed under 74.351(c) i s discretionar y , not mandatory
. See Bo ga r, ___ S.W .3d at ___, 20 07 Te x. Ap p. L EX I S 50 88 , at *9 ; Austin Heart, ___ S.W .3d at ___, 2007 Tex. App. L EXI S 3600,
a t *1 9- 20
. No thi ng in the re c or d in dic a te s th a t th e dis tr ic t c ourt a c te d a rb itr ari ly or un re a so na

bly in exercising its discretion not to al l o w L ed esm a a 30- day extension t o cure the def iciencie s in her repor t. We overrule L edesma ’s sec ond issue.13

Constitutional chal lenges to chapter 74

L edesma argues that cha

pter 74 is unconstitutional, citing summarily to the due proce ss and equa l protection g uara ntees o f t h e federa l and state c onstitut ions, as well as the ope n courts provisions of the Texas Constit ution. See U.S. Const. amend. XI V; Tex. Const. art. I , § 13. She c on te nd s th a t t he req uir e me nts of

c ha pte r 7 4, pa

rt ic ula rl y the e xpe rt

re po rt re qu ir e me nt i n sect i on 75.351 and the r estriction on the applica tion of the doctrine of

res ipsa loquitur in sec tion 74 .2 01 c on sti tut e arb itr ary and un re a so na

ble re str ic tio ns on

he r c la im. When review ing the constitutionalit y of a statute, we beg in w ith a presumption that it is constit utional. W

alker v . Gutierrez , 1 11 S.W. 3d 56 , 6 6, (T e x. 20 03 ); see also Tex. Gov’t Code Ann. § 311.021(1) ( West 2005). The wisdom or expedien cy o f the law is the leg islature’s prer og ative, not ours. Te

x as W or k e rs C om p. Com m’n v . G ar c ia , 893 S.W .2d 504, 520 (Tex. 1995). Th e pa rt y c ha lle ng inga

statut e ’s c on sti tut ion a lity ha s th e burd e n of p ro vin g that th e statut e fa ils to meet constitutional require ments. W alker , 111 S.W .3d at 66. I n c ha lle ng ingthe c on sti tut ion a lity of a statut e , a pa rt y may sh ow that the statut e is unconstitutional on it s fac e or as applied to that pa rty
. Ga rc ia , 8 93 S.W. 2d

a t 51 8 n .1 6; se e als o Ci ty of Corpus C

hristi v. Public Util. Comm’n of Tex

. , 51 S.W .3d 231, 240-41, (Te x . 2001) (Ow en, J.,
c o n c u r r i n g )
. T o s u s t a i na

f a c i a l c h a l l e n g e , t h e p art y m u s t s h o w t h a t t h e s t a tu t e , b y i t s t e r m s , a l w a ys operates unconstitutionally
. Id. To sustain an “a s applied” c halleng e, the pa rty must show that the statute is unconstituti onal when a pplied to that particular

person or set of fa cts. Id. Her e, L edesma

did not cite any authority or make any argument that would support a fa cial cha lleng e to the constitutionality of cha pter 74. She mer ely asserts that the restrictions section 74.351 imposes on claimants are “unrea sonable and/or arbitra ry .” B eca use L edesma

failed14

to demonstrate that c hapter 74 alway s operates unconstitutionally , her c h al l en ge t o the statute as fac ially unconstitutional is not persua sive. L edesma did challeng e the c onstitut ionality of sec tion 7 4
. 351, as applied to he r,
asser ting that the r equire ments of section 74.351 constitute an ar bitrary and unre asonable restric tion on her c laim in violation of her constitutional rights to equa l p ro t ec tion, due proce ss, and open courts. With reg ard to L edesma ’s due pr ocess c hal l en ge, the supreme court ha s held that the dismiss al of a

suit due to a claimant’s failure to file a compliant expert repor t does not violate due proce ss gua

rante es, eve n in the absenc e of notice of the re port’s noncomplianc e bef ore the motion to dismi ss. W

alker , 111 S.W .3d at 66 (a pply ing f ormer a rticle 4590i). The court re asoned that due proce ss does not require “prior notice that the law is ser ious about a cle arly stated consequence .” Id. L edesma ’s open c ourts argument is equally misguided. Aclaima nt who bring s an op e nc o u rt s c h a l l e n g e h a s t h e b u r d e no f s h o w i n g t h att h e e xp e rt
- r e p o rtr e qu i r e m e n t s a c tua lly preve nted her

from pursuing her c laims. McG lothlin v. Cul lingt on , 989 S.W .2d 449, 453 (T e x. Ap p. —A us tin

19 99 , p e t. d e nie d) . The op e n c ourt s p ro vis ion is p re mis e d u

po n th e ratio na le that the leg islature has no pow er to make a re medy by due cour se of la w co n t inge nt upon an “impossible condition.” Moreno v

. Sterling Drug, Inc. , 7 87 S.W. 2d 34 8, 35 5 ( Te x. 19 90 ). L e de sma ha s n ot p ro ve n h owthe pr ov isi on s o f t he se c tio n 7 4. 35 1 it se lf , a s o pp os e d to he r o wn

fa ilure to provide a n adequate re port, preve nted her fr o m pursing he r cla im ag ainst J ohns. See M arquez v. Pr ov ide nc e Me m’ l H

os p ., 57 S.W .3d 585, 595 (Tex. App.—El Paso 2001, pet. denied)
.15 CO NC LU SION We a ff ir m th e jud g me nt o f t

he dis tr ic t c ourt
.

__________________________________________ Bob Pembe rton, J ustice Be fore Chief J ustice L aw, Justi ces Patter son and Pemberton Affir med Filed: August 3, 2007