### NUM BER 13-06- 444- 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 OR P U S C H R I S T I - E D I N B U R G
M IGUE LA

R . GU ERR

A , ETA L., A pp ellan ts,

v . C O R P U S C H R I S T I M E D I C AL CENTER - BA

Y A REA A ND ITS EM PLOYE ES, M ELINDA QUINONE Z, L .V .N ., ES PE RA N C E B IS A N GW A , R .N ., A ND H ILL A RY LOY

A , R .N., A pp ellees
. On ap pe al f rom th e 2 8th D istrict Co urt of N ue ces Co un ty , T exas . 

## ME MOR A N D U M OP I N I ON Be fo re Ju stice s Y añ ez, R od rigu ez, an d Be na v ide s M emo rand um Opin ion b y Ju stice Ya ñe z This i s an appeal from the g ra nti ng of jud g ment notw it hst andi ng the v erdict ( JN OV) in favor of a ppe llee/d efend ant , Corpus Chri sti Medical C ent er – Bay Area (“the ho spital”)I t i s und i sput ed t hat t he j ur y was pr oper l y i nst r uct ed t hat t he h ospi t al i ncl uded i t s nur ses an d t hat 1 i t coul d act onl y by and t hr ough i t s nur ses i n t he co ur se an d scop e of t hei r em pl oy m ent

. T hus, we r ef er t o t he ho s pi t al an d i t s nu rse em pl oy ee s as “t he ho s pi t al ” and “app el l ee
. ”

Appel l ant s ar e M i guel a G uer r a, i ndi v i dual l y and as next f r i end ofLM G , a m i no r c hi l d, and as 2 rep res en t ati ve o f t he E s t ate of H aro l d J

. G ue rr a, d ec ea s ed , R i c ha rd G ue rr a, M ark A

. G ue rr a, H aro l d J

. G ue rr a J r., A l m a G u e rr a , a n d H o rte n s i a G u e rr a , m o th e r o f H a ro l d G u e rr a (d e c e a s e d ), a n d F ra n k G u e rr a
. A p p e l l a n ts a re th e s u rv i v i n g s p o u s e , c h i l d re n , a n d m o th e r o f th e d e c e a s e d , H a ro l d J . G u e rr a
.

See T EX
. C IV
. P RAC
. & R EM
. C OD E A NN
. § § 7 4 .0 0 1 -.5 0 7 (V e rn o n 2 0 0 5 & S u p p . 2 0 0 8 ). 3
T ri al t es t i m on y es t ab l i s he d t ha t pa t i en t s , l i k e G ue rr a, w ho ha ve ha d su rge ry i n t he ai rw ay area are 4 at hi gh r i sk of

dev el opi ng p ost
- oper at i v e br eat hi ng co m pl i cat i ons du e t o c om pr essi on o ft he a i r way f r om b l e e d i n g
. 2 and i ts nurse employ ees, after a ju ry a ward ed approx imat ely $2.2 mil li on dol lars t o 1 appel lan ts/ pla int iffs i n a m e dic al malpract ic e c ase. Ap pel lan ts sued the h ospi tal for 2 3
m e d ica l m a lp ra ct ice , all e gin g n e glige n ce re su lt in g in th e d e a th o f Ha ro ld Gu e rra . A lt h o u gh the j ur y found i n appel lan ts’ fav or , t he tr ial co urt g ra nted the h ospi tal’s m o ti o n for JN OV and ente red a take -noth ing judgme nt. In a single issue, appe llants conten d the trial court erred in granting the JNOV be cause more than a scintilla of evidence su ppo rts the jury’ s
v erdict. Bec ause w e c oncl ude t he tr ial co urt er re d i n g ra nti ng a J NO V, w e rev erse the g ra nti ng of the J NO V and re mand to the tr ial cour t for entr y of jud g ment i n ac cordance w it h the j ur y ’s v erdict. I. Background On J anuar

y 27, 2003, John Hal comb, M. D. , an orthopaedicsu rg eon, per formed
cerv ical f usion surgery

on Harold Gu erra. Fo llow ing the surgery , Dr. H alcom b saw Gue rra in the recov er

y room; G uer ra w as not h av ing any breathi ng di ff ic ult ies

. Around 2: 20 p. m., 4 Gue rra w as discha rg ed f rom th e recovery room and w as mo v ed to a hosp ital room , w here he was unde r the care of Melinda Qu inon ez, LVN. At trial, Guerra ’s wi f e, Miguela (“M ickie”), testif ied th at arou nd 2 :30 p .m ., she called the n urse and rep orted t hatGuerraT hi s w as G ue rr a’ s se c on d t i m e fo r t he su rge ry , an d h e c om pl ai ne d t ha t he di d n ot “feel ri gh t

. ” 5 3 felt an x iou s, w as hav ing troubl e breath ing , and di d notfeel r ig ht. N urse Qui nonez 5 chang ed Gu er ra ’s nec k d re ss ing and left. Ac cordin g to Mi ck ie, ov er the next hou r and fifteen minu tes , s he repor ted t o the nursi ng st aff

three more ti mes t hat Guer ra co nti nued to ex per ien ce breathi ng di ff ic ult ies and did not feel r ig ht. At t ri al, there w as confli cti ng tes ti mony as to w hen G uer ra first compl ain ed th at he
w as ha v ing trouble brea thing. Nurse Quino nez testif ied th at arou nd 2 :30 p.m ., Gue rra
re por ted feel ing anx iou s, but t hat n eit her Guer ra nor

hi s famil y co m p la ine d tha t he w as hav i n g b r e a t h i n g d i ffi c u l t i e s o r s h o rt n e s s o f b re a t h u n t i l 3 : 2 5 p
. m. M i c k i e t e s t i fied th at
around 3:20 or 3:25 p.m., she pres sed the “c all button” and ag ain repor ted that Guer ra w as still hav ing trouble brea thing. T here w as no im me diate respon se. She called for a nurse
a s econd ti me and a sk ed for hel p. At 3 :40 p.m., Hi ll ar y Loy a, R N, respon ded and ch eck ed Gue rra’s oxy gen lev el. Espe rance Bisangw a, th e cha rg e nu rse for the f loor, w as also present

. By

thi s t ime, Guer ra w as g aspi ng for air and los ing cons ci ousne ss
. By 3:45 p.m., he w as in acut e respi ra tor y di stress and a respi ra tor y “ code” w as cal led

. Dr . H alc omb w as cal led at home at 3:45 p.m.; he ar ri v ed at t h e h o spital at 4:05 p.m. Dur ing the code,
sev eral doct ors, inc lud ing an a nest hesi olo g is t and an e merg ency room phy si ci an, t ri ed
u n s u c c e s s fu l l y t o i n t u b a t e G u e r ra
. A ro u n d 4 : 0 5 p
. m. , a n e me rg e n c y t ra c h e o s t omyw as per formed. By

that time, how ev er , G uer ra had been de pr iv ed of oxy g en for suc h a l ong ti me thathe w as “b ra in dead.” G uer ra di ed el ev en day s l a te r a fter l ife s uppor t w as ter minat ed. I I
. S t a n d a r d o f R e v i e w a n d A p p l i c a b l e L a wSee T EX
. R. C IV
. P. 3 0 1 ; Ti ll er v
. M c Lu re , 1 2 1 S .W .3 d 7 0 9 , 7 1 3 (T e x . 2 0 0 3 ). 6
See C i t

y of Kell er v. W i lson , 16 8 S

. W

. 3d 80 2, 82 7 (T ex
. 20 05 ). 7
Id

. at 819

. 8
Id

. at 820

. 9
I d. at 820
- 21. 10
K P H C on s oli da ti on , I nc
. v. R om ero , 10 2 S

. W

. 3d 13 5, 14 5 (T ex
. 20 03 ). 11
I d. 12
I d. 13 4 T he trial cou rt may disreg ard a j u ry' s v erdict an d rend er a JNOV if no evidence supp orts one or more of the jury 's f indings or if a directe d v erdict w ould have been prope r. 6 T o de term ine w het her the trial court erred in rende ring a JNOV, w e revi ew t h e entire record, cred iting fa v orab le evi den ce if reason able jurors could an d disregarding contrary
ev ide nce unl ess reason abl e j urors c oul d not

. 7 The ju ry i s t he s ole j udg e of w it ness es’ credi bil ity , and it maychoose to be li ev e one wit n e s s o ve r a n o t h e r; a re vie win g c o u rtm a y n o t im p o s e it s o wn o p in io n t o t h e co n t ra ry. 8 Jurors may

di sreg ard ev en unc ontradi cte d and uni mpeached tes ti mony from di si nterest ed
w it ness es. “ [W ]henev er rea so n a ble j urors c oul d dec ide w hat t est imony to dis card, a 9
re v iew ing co urt mus t as sume t hey di d s o i n fav or

of thei r v erdict, and di sreg ard i t i n the
course of leg al suffici ency rev iew .” 10 Circumsta ntial evidence may p rov e any m ate rial fact, so long as it transcen ds me re
s u s p ic io n
. T h e m a t e ri a l fa c tm u s tb e re a s o n a b ly i n fe rr e d f ro m t h e kn o wn

11 ci rc umstan ces
. It may not be prov ed by unreason abl e i nferenc es from othe r facts and 12 circumsta nces o r by

piling inferen ce up on inf eren ce. W hen claims or def ense s are 13C i t y of Kell er , 1 6 8 S .W .3 d a t 8 1 3

. 14
Id

. ( quot i ng Tubeli t e, a D i v. of I ndal , I nc. v. R isi ca & Sons, I nc. , 81 9 S

. W

. 2d 80 1, 80 5 (T ex
. 19 91 ))

. 15
I d. at 813
- 14 ( quot i ng Loz ano v. Loz ano , 52 S

. W

. 3d 14 1, 16 7 (T ex
. 20 01 ))

. 16
I d. a t 8 1 4

. 17
I d. a t 8 2 7

. 18
I d. a t 8 2 2

. 19
I d. 20 5 supp orted bymea ger ci rcumst ant ial ev iden ce, th e evidence is legally insuf f icient if jurors
w ould have to guess w het her a vi tal fact exists. “ ‘W hen the circum stan ces are equa lly 14
cons is tent w it h ei ther

of tw o facts , nei ther f a ct m a y b e i nferred.’ ” I n s uch cas es, the 15
rev ie w ing court must“v iew each piece of

circumsta ntial evidence , notin isolation, but in li g ht of all the know n ci rc umstan ces .” “Thus , w hen the ci rc umstan ti al ev ide nce of a v it al 16 fact i s meag er , a re v iew ing court m ustconsi der

not jus t fav orabl e butal l the c ircums tanti al
ev ide nce, and compet ing i nferenc es as w ell .” 17 “The final tes t for leg al suffici e n cy mustal w ay s b e w hether the ev ide nce at t ri al
w oul d enable rea sonab le and fair-mi nded people to re ach the v erdict und er rev iew .” I f

18 the ev iden ce “w ould ena ble reaso nab le and fair -m in d e d pe ople to dif fer in their
conc lus ion s, then jurors mus t be al low ed to do so. ” W e do not s ubst it ute o ur j udg ment 19 for thatof

the trier-of-fact if

the evidence falls wi t h in t h is z one of reason able dis ag re ement. 20 In i ts moti on for

JNOV , the hospi tal arg ued t he ev ide nce w as leg all y i nsuffici ent t o suppo rtthe caus ati on ele ment of ap pel lan ts’ neg li g ence cl aim. The order g ra nti ng JN OV “s et as ide th e j u ry’s answ er to Ques ti on 1, ” w hic h as ked, “ [d]i d the neg li g ence, i f any , ofT he h ospi t al asser t s t hat pr oxi m at e cau se i s t he o nl y el em ent of neg l i gence on w hi ch i t s m ot i on 21 fo r J N O V w a s b a s e d

.

Lei t ch v. H or

nsby , 9 3 5 S .W .2 d 1 1 4 , 1 1 8 (T e x . 1 9 9 6 ). 22
P a r kP la c e H o s p . v . E s ta te o f M ilo , 9 0 9 S .W .2 d 5 0 8 , 5 1 1 (T e x . 1 9 9 5 ). 23
I d. 24
See G uevar

a v. Fer rer , 247 S

. W

. 3d 662, 667 (T ex. 2007) ( ci t i ng L e n g e r v . P h y s i c ia n 's G e n . H o s p ., 25 I nc. , 4 5 5 S .W .2 d 7 0 3 , 7 0 6 (T e x . 1 9 7 0 ))

.

Bur roughs W el

l com e Co. v. C r

ye , 9 0 7 S .W .2 d 4 9 7 , 5 0 0 (T e x . 1 9 9 5 ). 26 6 Co rp us Christi Medical Cente r—Bay Area p rox ima tely cause the de ath of Harold Guer ra ?” 21 To est abl is h prox imat e c ause, the p la int iff must prov e ( 1) fores eeabi li ty , and ( 2)
caus e- in- fact. I n c ases i nv olv ing medi cal negligen ce, ca use- in- fact req uires that the 22 plaint if f prove “by a prep ond eran ce of the ev iden ce, [th at] th e ne gli gent act or om ission is shown to be a sub stan tial facto r in bring ing abou t the harm , and w ithou t w hich th e ha rm
w oul d nothav e occur re d.” The pla int iff must est abl is h a c ausal co nnect ion betw een t he 23 d e fe n d a n t ' s n e gl ig e n c e a n d t h e in ju ri e s b a s e d u p o n a re a s o n a b le m e d ic a l p ro b a b il it y. 24 T he trier of

f act m ay decid e the issue of proxi ma te cau se in me dical ma lpractice
case s b a s ed u pon : (1) general experience and comm on se nse f rom which reason able persons ca n det er mine caus ati on; ( 2) sc ien ti fic p ri nci ple s p ro v ide d by ex per t t est imony allowi ng the fact f inde r to establish a tracea ble chain of causa tion from the cond ition ba ck t o t h e e ve n t ; o r ( 3 ) a p ro b a b le ca u s a l r e la t io n s h i p a s a rt i c u la t e d b y e xp e rtt e s t im o n y. 25 Ex per t t est imony

reg ardin g a caus al conne cti on rest s u pon reason abl e medi cal probabi li ty that must be det er mined by the subs tanc e and cont ext of the te st im ony rather than
s e m a n t ic s o r u s e o f a p a rt ic u la r t e rm o r p h ra s e
. An e xp e rt ' s o p in io n is wit h o u tp ro b a t ive 26Id

. at 499
. 27
See Par

k Pl ace Hosp. , 9 0 9 S .W .2 d a t 5 1 1

. 28
D r. D l a b e l te s ti fie d b y d e p o s i ti o n
. 29 7 v alu e and canno t s u p p ort a v erdict or j udg ment w hen i t i s b ased on as sumed facts that
v ary mat erially

f rom th e actu al, un dispu ted facts. 27 III
. A nal ysis In t his case, ex per

t medica l tes ti mony

based on re asona ble probabi li ty w as re q uired to establ is h either

a “t ra ceabl e chain of

causat ion ” base d upon g eneral sc ien ti fic p ri nci ple s or a “proba ble ca usal relatio nship ” between the hosp ital’s failure to tim ely not if y Dr. Hal comb reg ard in g Guerra’s pos t- operati v e respi ra tor y di ff ic ult ies and Guer ra ’s deat h. Spec ific all y , app ell ants ’ burden w as to establ is h, t hroug h ex per t t est imony , t hat t here w as
a reason abl e medi cal probabi li ty thatthe hospi tal ’s failu re to ti mely noti fy Dr

. Hal comb w as
a s ubst anti al factor

i n br ing ing aboutGuer ra ’s deat h and w it hout w hic h the har m w oul d not hav e oc cur re d. 28 A
. A pp ellan ts ’ Ev id ence W ith respe ct to cau sation , app ellant s cite the te stimo ny of : (1) their ex pert wi tne ss, Dav id J. Cu ll en, (2) Dr. Halc omb, (3) a sec ond ex per t w it ness , Paul W il li am D lab el, M .D ., 29 (4 ) Qui nonez , and ( 5) Bi sang w a, an R N and t he c harg e nurse ass ig ned t o the floor w hen Guer ra w as a pat ien t. W e ex amine the t est imony of thes e w it ness es in tur n. 1. Dr. Cullen Dr . C ull en, a n ex per

t in a n est hesi olo g y

and cr it ic al care medi ci ne, t est ified as follo w s: Q [ appe lla n ts ’ counsel ]: If a nurse or so mebody

tak ing ca re of a pat ien t8

p o s t o p e ra t i v e l y , a pa t i e n tl i k e M r
. Gu e r ra , i s co n fro n t e d w i t h a c o mp l a i n to f, I don’ t feel ri g ht, hav ing troubl e breathi ng , say at 2:30 in th e afte rn oon, specif ically

in Mr . Gue rra’s case, w hat w ould y ou ex pect to occu r as a result of that? A [D r. C u l l e n ] : F i rs t t h i n g I w o u l d d o i s e x p e c t t h e n u rs e t o g e t a n oxy g en maskon t he pat ien t i mmediat ely and cal l the s urg eon.

. . . . Q: If a nurse w ait ed until [3:25 p.m.] in this kind of si tuati on, w it h ev ide nce of anx iety , t ro ubl e brea th ing before hand, is there any g uarantee, or

ev en probabi li ti es [si c] that Mr . G uer ra co uld hav e bee n s a ved , if y ou w aitthat lo n g? A: W ell, if y ou w ait tha t long to notif y som ebo dy, y ou really have take n mo st of the oppo rt uni ty

for d eal ing w it h i t aw ay

bec ause w e k now

i n retrospect t hat w it hin 20 mi nutes he a rrest ed. And t o getpeople mobil iz ed and deal ing w it h thi s p roblem, may be i t c oul d be done w it hin that20 mi nutes before he ar re ste d and he c oul d hav e been broug ht do w n to the o perati ng room or som eth ing done to ope n up the airw ay, buty ou’re run ning a v ery , v eryshort ti me. And I can’ t t ell y ou w hether thatw oul d hav e been more li kel y than not to ha ppen i n that 20 minut es from maki ng a phone cal l to g etti ng ev er ythi ng done. Q: But if the cal l w as made at 2 :3 0, or ev en as l ate a s 2 :45, w hat i s y our opi nio n aboutw hether or not Mr . Gu e rra , in thi s c ase, co uld hav e been sav ed? A: If the call had bee n ma de at tha t time , the re w ould have bee n time for Dr. Halco m b t o get in, bec ause he to ok 20 mi nutes to g et i n w hen he did g et called, there would be tim e for him to get in, look at the pa tient . Th ere w ould also be time for him to call the op eratin g room and rush the patie nt, if he felt thi s w as neces sar

y , br ing the p ati ent d ow n to the o perati ng room w here the y hav e proper

eq uip ment ac ces s, all the tec hnol og ic suppo rt that they need to g et hi m in tubat ed or

to hel p D r. H alc omb open up the neck and tr y and dea l w it h the probl em that w ay
. And there w oul d be, y ou k now , i t w oul d be ru sh, ru sh , b u t t here i s p len ty of ti me for t he th ing s t hat n eeded t o be done t o hap pen if you had an ho ur a nd a quarter to an hou r, let ’s sa y . And th is w hole thing could be do ne f rom th e f irst call unt il things g et ta ken ca re of , I w ould say probabl y

w it hin a ha lf hour

. If the s urg eon w as righ t u p st a irs i n the operati ng room and ra n dow n the st airs a nd di d i t, I hav e s een t his tak en care of w ithin f iv e min ute s. Q: And be caus e of the ti me frame as y ou hav e des cr ibe d and k now ing w hat9

Dr. Halc o m b ’s testimo ny—and again th e facts of the case , w ould in all probabi li ty

M r. Guer ra hav e at lea st not d ied as a resul t of thi s c ondi ti on? A : W e ll , I t h in k n o t o n ly— ye s
. He wo u ld n o t h a ve d ie d

. He wo u ld n o th a ve g otten hy pox ic. H e wo u ld not h av e brain damag e. He w oul d hav e been s u c c e s s fu l l y

t a k e n c a r e o f. Q: A l l r i g h t

. I f I ’ m r e a d i n g y o u r i g h t , t h e l o n g e r t h e w a i t , t h e m o re r i s kt h at that is not g oin g to happen? A: R ig ht.

. . . . Q [ on c ro ss -e x aminat ion , by hos pit al’ s c ounse l] : An d s o y ou hav e to ki nd of b e abl e to loo k a t i t bot h w ay s. One, i f y ou l is ten t o the famil y , one , i f y ou li ste n to the n urses
. If the s hor tnes s o f breat h i n fact w as firs t re por ted a nd assesse d at [3 :25 p.m .], th en in y our opin ion tha t’s w hen Dr. Halcom b sho uld hav e been cal led , r ig ht? A: R ig ht.

. . . . Q: All rig ht. Now , let me ask y ou if y ou a gree wi th th is: Assumin g tha t the re had been earl ier

inter v enti on in M r. Guer ra ’s ca se, i f there had been ea rl ier ass ess ments and repor ti ng of shor

tnes s o f breat h o r di ff ic ulty breathi ng re s u lt in g in an ea rlier call to the physici an, a chan ge of ev ent s thatdidn’t occ ur here, r ig ht? A: R ig ht. Q: W e c an ag re e on that. As far a s w hat the outc ome w oul d hav e been had thi ng s s tar

ted e a rlie r, t h e tr uth o f the matt er i s, in y our

opi nio n, no ne of us w oul d k now

w hat w oul d hav e happe ned, ri g ht? A: I n a d etai led se nse, w e w oul d notkn ow w hat h appened, that ’s co rrect

. Q: Okay. T han k you. T o know w hatwould hap pen o r try to say w hatw ould happen, I thi nk y ou to ld us in y our depos it ion i s j ustsp ecul ati on, r ig ht? A: Yes. Q: And I thi nk y ou al so told us i n y our depos it ion thaty ou hav e no w ay of know ing i f they

w oul d hav e tr ied to int ubate Mr . Guer ra earl ier , y ou hav e no10

w ay of know ing i f they

w oul d hav e been abl e to do i t, ri g ht? A : I t h in kI have a pretty g ood idea th at th ey w ould have been able to do it un de r t he r i g htc i r c um s ta nc es , w i th a pp rop r i at e to ol s i n th e op erat i ng roo m, w it h appropr iat e paraly si s and anest hesi a. I thi nk, more l ik ely than not they w oul d hav e been abl e to int ubate. I f they came up to the floor and tr ied the same t hin g on t he floor , I don’ t t hin k t hey w oul d hav e—I co uld n’t t e ll y ou w hat mi g ht ha v e happe ned. Q: Doctor , do y ou hav e a c opy of y our depos it ion up t here? A: Yes. Q: And I’m g uess ing sinc e y ou hav e done thi s b efore, y ou probabl y rev iew ed itfa ir ly r e c e n t ly. Is t h a tfa ir t o sa y? A: I did, y es. Q: L e t me t e l l y o u w h y I a s k e d t h a t

. I f y o u c a n t u r n t o P a g e 6 2 of y our depos i t i o n
. A c t u a l l y , w e a re g o i n g t o h a v e t o s t a rte v e n b e fo re t h a t, prob ably—let me se e if I can f igure out w here the— [Coun sel for hosp ital]: May I app roach , Your Honor? [Court] : Yes, sir

. Q [ Cou nsel for h ospi tal ]: Doctor , l et me see if I can hel p y ou g et t here. Ri g ht here on Pa ge 63. Rig ht he re, line 12 , tha t’s part of y our an sw er. It’s a v ery lon g di sc uss ion that ’s g oin g on b ut y ou s ay thathe mi g ht hav e been int ubateab le ear li er , on or before they g ot to the poi nt w here the y g o t wi th him, I don’ t k now if—and the q uest ion then is , “Y ou jus t coul dn’ t say one w ay or the other ?” Y ou s ay , “ Huh ?” “Y ou jus t coul dn’ t say one w ay or the o ther ?” A n d yo u sa y o n L in e 1 9 , “I ca n ’tsa y o n e wa y o r t h e o t h e r i f h e co u ld h a ve been i ntubat eabl e ear li er ,” r ig ht? A: R ig ht. And I w oul d as k y ou to c onti nue, “A ll I can say i s t hat t he s ooner y ou address i t t he better ch ance y ou hav e of deal ing w it h i t.” Q: And I ’m n ot arg uin g w it h y ou on that. Y our testi mony

at y our depos it ion wa s , yo u d o n ’tkn o w. Yo u ca n ’tsa y o n e wa y o r t h e o t h e r i f h e wo u ld h a ve been i ntubat eabl e ear li er , r ig ht? A: R ig ht. Butthe cont ext, w e hav e to put t he c ontext of thi s a nsw er in for th e pre vi ous fewpag es. An d thi s w as in the c ontext of, i f they had noti fied at [3:25 p.m.] , and then had t hat s hor t per iod of ti me. The q uest ion y ou as ked11

me here w as about an ear li er i nter v enti o n
. A n d w hat I w as say ing , i f they had know n at 2:30 or 2:45, they w oul d hav e had ple nty of t ime to de al w it h the i nter v enti on i n a v er

y different w ay than they are deal ing w it h i t w hen t hey onl y hav e a fewm inu tes , as sumi ng thatthe cl ock st arts at [ 3:25] w it h the shor tnes s o f breat h. I f t h e sh o rt n e s s o f

b re a t h c lo c ks t a rt s a t2 : 3 0 , a t[ 2 : 3 0 ] , t h e n t h e y h a ve a l ot more ti me to do a lotof thi ng s t hat I thi nk the o utc ome w oul d hav e been mo re likely

than not, accep tab le. Th ere are two d iff eren t cont exts. This is in the c ontext—i f y ou g o back to Pag e 60, thi s i s i n c ontext of a q uest ion that st a rt s o n a [ 3 : 2 5 ] ba sis . A n d th a t’ s h o w I was an swer in g th a t a ll t h ro u gh here. Q: So when you saythathe m ay have bee n, “Mig ht ha v e be en int uba tea ble ear li er on o r before h e g ot to the poi nt w here he g ot, I don ’tkn ow .” An d the n y ou g o on to s ay , “ I c an’ t s ay one w ay or the other .” A: That w a s m y

t h i n k i n g i n t h e c o n t e xtt h a ti f t h e y h a d g o t t e n s o me b o dy there, y ou k now , by

ca ll ing at [3:25 ] and somebody came ri g ht up and they got started . A fe w

lines before I talke d ab outthe fact th at you had an inte rn wh o co u ld n ’tp o s s ib ly b e e xp e c t e d t o d e a l wi t h t h is ki n d o f d ir e e m e rg e n c y. So t hat’ s t he c ontext t hat t his q uest ion w as bei ng ans w ered i n.

. . . . Q [ on r e - d i r e c t , b y a p p e l l a n t s ’ c o u n s e l ] : A n d h a v e y o u t o l d u s w h a t y ou bel iev e w oul d happen if thi s man [Guer ra ] had been proper ly as ses sed and doct ors time ly

n otif ied of

t he anxiety or the trou ble brea thing? You have told us about that. A: R ig ht. As I sai d, I thi nk he w oul d hav e had t ime to g et as ses sed, i f they thoug ht, y ou k now , t hey may hav e made a complet ely i ncor re ct ass ess ment and not hin g w oul d hav e ch a n ged

. B u t t he nurse w oul d hav e done her j ob in g etti ng so mebody

there w ho can deal w it h the probl em. But if they made a correct assessm enta nd got him do w n to th e op eratin g room or the PACU w here there is equipm ent , w here the re are personn el w ho ca n de al w ith this, g et hi m in to a proper

pos it ion , extra hands, extra hel p. If they ca n’ti ntubat e him, w e hav e enoug h ti me—the y hav e enoug h t ime that they ca n g et a surgeon th ere to d o a trach eot om y , notwhen he is already i n cardiac a rrest but w ell before he i s i n c ardia c arrest , open up his trachea

. It is eas y to open t h e in c is io n , ju s tcu tt h e s u t u re s a n d yo u ’ve go tt h e in c is io n o p e n , ge td o wn to th e trach ea q ui c k l y an d g et a tu be i nt o th e trac he a. Tha t’ s w hy I think I have a prett y

g o o d i d e a thatw ith en ough tim e, th ey w ould have been able to s olv e the probl em.12

Q: Con si ste nt w it h w hat D r. H alc omb has t o ld t h e j ur y , t hat i f he had be en time ly n otif ied, th is man w ould not ha v e at lea st notdied be cause of this condi ti on? A: C or re ct. Q: And to evaluate y o ur opinio n on e step f urthe r, if you look at what Dr. Halcom b ha s said and w hathe can and w ould have don e, kno w ing his ski ll level, know ing the caring that h e h a d for the p atien t, kno w ing the hero ic efforts that the c ode t eam us ed to tr y to sav e thi s man, i s t here real ly any q uest ion thati n al l probabi li ty , w it h ti mely int er v enti on, M r. Guer ra w oul d not hav e pas sed at t hat t ime? Is there any real q uest ion aboutthat ? A: R ig ht. If y ou frame the q uest ion the w ay y ou did , w hat y ou’ re sa y ing , w it h all p ro b a bility , the n I think th at is a v eryeasy one. In fact, wi th reaso nab le me dical prob ability or all p roba bility , howev er you w antto say it, the re w ould h a ve b e e n e n o u gh t im e gi ve n t h e a t t e n t io n Dr

. Ha lc o m b s a id h e wo u ld gi ve t o t h e p ro b le m a n d ge tt h e h e lp , a n d so o n a n d s o fo rt h , d o a ll t h e t h in gs we tal ked about, and he w oul d hav e been sav ed. Q: Al l ri g ht. A: W hat y ou don’ t hav e s tar ti ng at [3:25 ] is ti me. Y ou don’ t hav e ti me to g et all thatto happen. That’ s w hy I sai d i t w as spec ula ti v e.

. . . . Q [on re-cross, by

h o s p it a l’ s c oun sel]: An d y ou go on to say , “But just all it wo u ld d o wo u ld g ive h im a b e t t e r c h a n c e a t

— ” Q u e s t io n , “ S o itwo u ld gi ve him a bett er chan ce of

surv iv ing i nta ct buty ou ca n’t s a y w ithin reaso nab le medic al probabi li ty

the ear li er int er

v enti on w oul d hav e—w oul d hav e c aused him to s ur

v iv e i ntac t.” An d y our

ans w er w as w hat? A: “ Cor re ct. ” Q : Do yo u st a n d b y t h a tt e s t im o n y? A: I do i f I am al low ed to ex pla in w hy I sai d tha t. Am I ? Q: Docto r, I think it is prettyclear. A: No, I do n’t thin k it is as clear as y ou want it to be, so I w ould like to be ab le to explain m y

an s we r. My answer is tha t if —I don ’t know w hatthey w ould hav e ac tual ly

done. I don’ t k now

if the anest hesi olo g is t w oul d hav e done any b e t t e r i n t h e o p e ra t in g ro o m o r n o t

. I d o n ’tkn o w if t h e su rg e o n wo u ld h a ve13

g otten the tracheo tomy so oner
. W hat I ’m s ay ing is that if thos e thi ng s t hat I w ent ov er tw o or

three di ff erent t imes here tod ay had happened in the w ay t h e y sh o u ld h a ve h a p p e n e d , I t h in km o re li k e ly t h a n n o th e wo u ld su rvi ve int act

. No w so m e o f

t h o s e t h in gs m ig h tn o th a ve h a p p e n e d in t h e ri gh twa y. T hey might have g otte n stuck on the ele v ato r, they m ight h ave g otte n him d o wn t o t h e P A CU a n d co u ld n ’tf in d t h e ri gh te qu ip m e n t , t h e y m ig h tn o th a ve found an anes thes iol og is t w ho w as capab le of intu bati ng hi m, the y mig ht have gotten him on the op eratin g room t a b le a n d started ope ning up his in cis io n a n d so m e th in g wou ld h a ve h a p p e n e d . I d o n ’tkn o w. I’m ju stsa ying, if st eps th a t I hav e out li ned w ere tak en, I thi nk he w oul d hav e a v er y g ood chan ce of

surv iv ing i nta ct Q: Y ou say , they

w oul d—t hese ear li er

thi ng s, “W oul d i mprov e the ch ances he w oul d s ur

v iv e i ntac t thi s cr is is

. W hether it w oul d hav e happe ned or not, I hav e no ide a.” A: R ig ht. H ow

ca n I know

w hat they

—eac h of

thes e peopl e w ho need ed to act , w hat t hey

w oul d hav e done? I don’ t know that. But if they did w hat t hey shoul d be ab l e to do , th at ’ s ho w I an s w ered th e q ue s ti on
. I th i nk i t’ s f airly straig ht for

w ard to me. 2. Dr . H alco mb Dr. Halcomb ’s videota ped dep osition testim ony w as prese nte d to th e jury . Dr

. Halcom b no ted thathis physici an’s orde rs fo r Guerra st ate d tha t he sho uld be called if Gu er ra ex pe r i en c ed

— am on g o th er t hing s — an y

“ res pi rat or

y d i s tres s .” D r
. H al c om b te s ti fi ed t ha t he re c ei v ed a cal l at ho me f rom hi s offic e s ta ff reg ardi ng Gue r ra at3 :4 5 p. m. He r e t u r n e d t h e c a l l i mm e d i a t e l y , a n d w a s t o l d t h a t a “ c o d e t e a m” h a d b e e n c all ed for Gue rra. Dr . Halcom b arriv ed a t the hosp ital at 4:0 6 p.m . W hen he arriv ed a t Gue rra’s bed side, he assisted Dr. Kerm ian, an ENT physici an, in performin g a trache osto my. D r. Hal comb t est ified : Q [ appel lan ts’ c o u n s e l ] : D o c t o r , i f y o u h a d b e e n c a l l e d b y t h e n u rs i n g s t a ff there at 2- W estw hen mi ste r— w hen i t w as re por

ted b y M rs . G uer ra thather husba nd s tar

ted c omplai nin g , or

co mplai nts of shor

tnes s o f brea th around 2:30 that afternoo n, do y ou hav e an opi nio n, based on re asona ble medi cal14

p ro b a b il it y, a s t o wh e t h e r o r n o tMr

. G u e rr a wo u ld st il l b e a li ve t o d a y? A: I be liev e I do a nd I would have to qualif y that . W hen y ou sa y , tod ay, e v i d e n t l y h e d i d h a v e s o me s i g n i fi c a n th e a rtp ro b l e ms , b u tI a m b e y ond a re asona ble medi cal probabi li ty i f he w oul d hav e had appropr iat e ti mely ca re ; w ith ap prop riate prot ection of his airw ay and oxy genatio n, th en he certain ly w oul d hav e notdi ed of a n o xic encep hal opathy at that ti me. S o, do I know w het her he w ould be aliv e tod ay or not ? No. Do I believe tha tif t im ely intervention w ould have been p erforme d, he would nothave died of ano x ic ence pha lopa thy? Y es.

. . . . A: I thi nk that in a post operati v e patient , after a maj or su rg ic al procedu re , a re g is tered nurse needs to tak e pr imary respon si bil ity and ass ess ment and not s hift t hose re spons ibi li ti es off to a low er train ed personne l. Iti s l ik e i n the mi li tary , y o u c a n d e l e g a t e a u t h o r i t y , y o u c a n ’ td e l e g a t e re s p o n s i b i l i t y . I f a w ell
- trai ne d, reg i s te r ed n urs e ha d ev al ua te d th i s p at i en t, I a m a bs ol utely confide nt t hat t he al ar m w oul d hav e been sound ed s ooner
. Dr . H alc omb al so tes ti fied th at he did not know w hy the phy si ci ans w ere unabl e to
suc ces sfull y

i ntubat e Gue rra. 3. Dr . D lab el Paul W il li am D lab el, M .D ., a s peci ali st in cardio vas cul ar di seas e, t est ified for app ellant s byv ideo tap ed d epo sition. He test if ied, in relevant pa rt, as follows: Q [ appel lan ts’ co unsel ]: At w hat poi nt in ti me do y ou bel iev e tha t i nter v enti on w oul d hav e s av ed M r. Guer ra ? A: Ac co rd in g to the s eq uence of ev ents i n thi s c li nic al re cord, i nter v enti on suf f icient to restore airw ay f unct ion an d oxy gen s t atu s prior to brain deter iorati on w oul d hav e c omplet ely rev ersed thi s s it uati on, o r near ly so
. Q: Ok ay
. And w here—w hat t ime w oul d tha t hav e been? A: W ell, I don ’t h ave e nou gh informa tion on the record to giv e y ou a n exact minut e bec ause I can’ t tell w hat his oxy g enati on status w as in the h our pr ior to ar re st or ev en the 16 minut es pr ior to ar re st. Bu t c ertai nly anythi ng done before [ 3:45 p.m.] w oul d hav e prev ented the s eq uence of ev ents from t hat ti me forw ard, an d I w oul d as sume t hat s inc e he w as compl ain ing of shor tnes s o f breat h and difficul ty bre a thing , he w as sti ll co nsc iou s p ri or to15

[3:45 p.m.]

. Q: W hat k ind of int er

v enti on w as needed pr ior to [3:45 p.m.] ? A: Apparentl y , ai rw ay

manag ement. Q: Butthat—y ou c annot say w it hin reason abl e medi cal probabi li ty thatfor thi s p arti cul ar

pati ent t hat e a rlie r inter v enti on w oul d hav e c aused hi m to sur v iv e i ntac t? A: Rel y ing upon sta ndard medi cal i nfo rm a ti on, p ati ents w ho s uffer respirato ry

dif f iculties po st-ope rativ ely and we re norm al f rom a respiratory sta tus pre- operati v elyh a ve an extremely hi g h s ur

v iv al ra te w hen t re ated appropr iat e ly, better

than 95 p er cent

. So i n al l medic al probabi li ty , had he been t re ated promptl y

and appropr iat ely so as to prev ent respi ra tor y ar re st, he w oul d nothav e di ed atthe ti me and p lac e nor i n the manner

he d id. 4. Nu rse Qu in on ez Nurse Quino nez testif ied th at Gu erra did notco mp lain of shortne ss of

breath until 3:25 p.m. She s tated that i f h e or hi s famil y

had compl ain ed th at he w as sufferin g from shor tnes s o f breat h any

ti me before 3:25 p.m., she w oul d hav e as ked the c harg e nurse to
ass ess hi s s tatus

. She t est ified thatthe entr ies sh e made i n Guerra’s records re flectthat he was ex pe r i en c i ng un us ua l “ an x i ety ” at 2: 30 p. m. Sh e ad mi tt ed th at s he di d not ask Guer ra w h y h e w a s fe e l i n g a n x i o u s , b u t b e l i e v e d t h a t i t w a s re s o l v e d b e c a u s e h e w as sl eepi ng
. She a lso s ta ted t hat t he c harg e nurse came i n at 2:30 p.m. a nd c heck ed Guer ra ’s st atus

. Acc ordin g to Nurse Qui nonez , at 3:15 p.m., Guer ra ag ain co mplai ned t hat he felt v eryanxious a nd had a dry throat ; she bro ught him ice chips. At 3:2 5 p.m ., Nurse Qui nonez ’s note s reflectthatGuer ra ’s famil y ca ll ed th e nurses ’ sta ti on and re por ted t hat Guer ra “ cont inu es” to hav e pain and short ness of breath. Nonet hel ess , N urse Qui nonez tes ti fied th at t he first compl ain t of sh ortnes s o f breat h w as at 3:25 p.m. Nurse Qui nonez and Nurse Bisangw a w entto the room . T h e d e cision w as ma de to g iv e Gue rra16

supp lem ent al oxy gen, bu t the nece s s a ry equipme nt ha d to be retriev ed f rom th e sup ply
room . Fo r th e next tw ent y m inute s, betw een 3 :25 p.m . and 3:45 p.m ., Nurse Quin one zdid not k now

w hether t h e d o cto r w as cal led

. Nurse Qui noneztes ti fied reg ardin g the fo re s e e a b il it y o f

G u e rr a d e ve lo p in g a n o c c lu d e d a ir wa y: Q [ap pellan ts’ coun sel]: If a pat ient such as Mr. Gue rra and his fa mily ma ke compl ain ts li ke that, that bei ng , I’ m hav ing troubl e breathi ng , I don’ t feel ri g ht, af ter th is kind of

surgery , and it is not—and thatcomp laint is not p rope rly assesse d, pe r the stan dard of care as y ou a nd I ha ve t a lk e d a bou t, it is forese eabl e, i s i t not , t hat o ne of the cons eq uence s cou ld b e a n oc cl uded a ir wa y? A: Yes.

. . . . Q: An oc cl uded air

w ay in a si tuati on in w hic h w e hav e been dis cus si ng ca n lead to w hat , f rom your knowl edge as an LVN? A: The pati ent w on’ t g et an y ai r and he w il l hav e a respi ra tor y co de. Q: A respi ra tor

y co de? A: M eani ng he i s n ot breathi ng and emerg e n cyprocedu re s w il l hav e to be sta rt ed. Q: A nd u nl es s t ho s e em erg en c yp roced ur es a re s uc c es s ful , ag ai n, from a nursing stand poin t, w hatcan occu r? A: D eath. Q: Coma? A: Yes. Q: Brain deat h and ult imat ely deat h, c or re ct? A: C or re ct.

. . . . Q: From a nursi ng standpoi nt, y ou knew , did y ou not, that t hat [ brain deat h]B R I EF OF A PPEL LE E a t 2 0 , M i guela G uer

r a, et al

. v. C or

pus Chr isti Med. C tr
. — Bay Area , N o. 13- 06- 30 0 0 4 4 4 -C V (T e x . A p p .– C o rp u s C h ris ti a rg u e d N o v . 2 8 , 2 0 0 7 ).

See C i t y of Kel l er , 1 6 8 S .W .3 d a t 8 1 3

. 31 17 is a po tenti al forese eabl e c onseq uence ? A: O f a re spi ra tor

y co de? Y es. 5 . N u rs e B i s a n g wa Nurse Bi sw ang a tes ti fied th at i f Nurse Qui nonezw as tol d tha t G uer ra w as hav ing troubl e breath ing and did not “feel rig ht,” it w oul d hav e been appropr iat e to hav e a d oct or assess h is s t a t u s
. She agreed thathad Nurse Quino nez done so, “w e w ould n’t be here today .” Nurse Bi sw ang a tes ti fied that becau se Guer ra w as v er y anx iou s, Nurse Qui nonez shoul d hav e c all ed th e doc tor

. She al so sta ted t hat t ra gic c onseq uence s— suc h as the
re spi ra tor

y ar re st and brain deat h s uff ered by Guer ra —w ere fores eeabl e as a resul t of the fa il u re t o n o t ify t h e d o c t o r o f G u e rr a ’s a n xie t y. B. The H ospital’ s A rgument T he h ospita l arg ues th at th e trial court prop erly g rante d a JNOV be cause there is
a c omplet e abs ence of ev ide nce of a v it al fact—i .e., thatan e ar li er ca ll to the d oct or

and
an e arlier-attem pte d intu bat ion of Guerra w ould have p re ve n ted his deat h. T hus, accord ing to the ho spital, “an y ex pert op inion pred icated o n the a ssum ption t hatMr . Gue rra
w ould have b een in tub ate d up to an h our ea rlier is (a) an u nsup porte d assu mp tion co ntrary to t he ac tual ev ide nce, and (b ) pure s pecul ati on and conj ect ure.” 30 T he h ospita l also cites City of Keller for the proposi ti on that “e v ide nce that mig ht be ‘s ome ev ide nce’ w hen consi dered in iso lat ion is nev erthel ess rendered ‘no ev ide nce’ w hen cont ra ry ev ide nce show s i t t o be inc ompetent .” Thus, ev en thoug h Dr

. Cul len opi ned t hat 31B R I EF OF A PPEL LE E a t 2 6

. 32
See Jea v. C ho , 1 8 3 S .W .3 d 4 6 6 , 4 6 9 (T e x . A p p .– H o u s to n [1 4 th D i s t.] 2 0 0 5 , n o p e t.). 33
Id

. a t 4 6 8

. 34
Id

. a t 4 6 9 (e m p h a s i s i n o rig i n a l ). 35 18 the n urses ’ failu re to noti fy Dr

. Hal comb ear li er w as a prox imat e caus e of G uer ra ’s deat h, the hosp ital cont end s othe r ev iden ce esta blished tha t Dr. Cullen’s opinion s “w ere legally inc ompetentbec ause (a ) they w ere based on improper ass umpti ons that v ar ied from t he act ual , und is puted facts; ( b) they w ere bas ed on a s er ies of poss ibi li ti es, g uess w or k, and spec ula ti on; a nd ( c) they co nsi ste d l arg ely

of Dr . C ull en’ s o w n s ubj ect iv e bel iefs. ” 32 The hospi tal al so arg ues that Dr . C ull en’ s o pin ion s o n c ausat ion merely co nst it ute “a series of

‘ifs’,” like t he series of

p ossibilities rejecte d by the Ho usto n Court of Appe als in Jea v. Cho

. I n Cho , the plaintif f (the v ictim o f

a r o bbe ry

w hile w orking at a grocery 33 store) ap pea led f rom a JNOV, arguing tha t he pre sent ed m ore tha n a scintilla of ev iden ce tha tt h e d e fe n d a n t ’ s n e g l i g e n ta c t s c a u s e d h i s i n j u r i e s b y fa i l i n g t o ( 1 ) p ro v i d e h i m a k ey to l ock the sto re from i nsi de, ( 2) prov ide adeq uate exter ior l ig hti ng , and (3) prov ide a
sec ond empl oy ee to as si st dur ing cl osi ng
. The H oust on c our t hel d tha t al thoug h 34 the s e me asure s might have theo reticallymad e the store som ewhat mo re d if f icu ltto rob , a n d po ss ib ly even pre ven te d th e rob b e ry f ro m oc cu rrin g in the m ann er that

it did , t here i s n o empi ri cal data , ex p e rt o p ini on, o r other ev ide nce that suc h meas ures hav e actu ally had any effecton p re v enti ng or re d u cing su ch cr imes w here the y hav e been impl emented, l et al one a re a s o n a b le p ro b a b il it y t h a tt h is p a rt ic u la r ro b b e ryo r s h o o t in g wo u ld h a ve be en d et er r ed o r

t hw ar te d by u s i ng t he m. 35 W e disagree w ith the hosp ital’s argumen ts. Dr. C ul le n t e s t if ied th at “in all prob ab i l i ty ,” G ue r ra w ou l d no t ha v e di ed i f th e nu rs es ha d c al l ed D r
. H al c om b at2 :3 0 p. m. or even as late as 2:4 5 p.m
. Altho ugh on cross-examin ation , Dr. C ullen a dm itted he didC i t y of Kell er , 1 6 8 S .W .3 d a t 8 1 9

. 36
B R I EF OF A PPEL LE E at 18. 37 19 notknow w hatw ould have happ ene d “i n a d eta iled sen se,” he sta ted thatGuerra “mo re likely than not” cou ld have bee n succe ssf ully intub ate d w ith a ll t h e a p prop riate too ls
av ail abl e i n the operati ng room. He further tes ti fied th at i f

G u e rra’ s b re athi ng di ff ic ult ies
w ere first re por

ted a t 2:30 p.m.—as Mic ki e told the j ur y —D r. H alc omb sh oul d hav e been not if ied an d in all proba bility , Gue rra w ould not ha v e died

. He conce ded thatif—a s Nurse Quino nez claimed —Gue rra’s shortness o f breath w as no t reporte d un til 3:25 p.m ., an d Dr. Hal comb w as cal led at that ti me, th e out come b ecomes more “ spec u l a t i v e ” becau se “[w]hat y ou don’ t hav e s tar

ti ng at [3:25 p.m.] i s t ime. ” W e n o te thatthe jur y i s t he s ole j udg e of
w itnesse s’ credibility

and may choose t o believe one witness over an oth er. T hus, the jury 36
w as enti tl ed to bel iev ed that Mi ck ie re por ted Guer ra ’s anx iety and breathi ng di ff ic ult ies at 2:3 0 p.m ., an d w as en titled to reject N urse Quin one z ’s testimo ny tha t Gue rra’s shortness of brea th w as not repo rted until 3:2 5 p.m
. Nurse Quino nez’s tes t im o n y e x pressly esta blished thatGuerra’s dea th w as a forese eab le conse quence o f t he failure to a ddre ss his co mplai nts of breathi ng di ff ic ult ies

. The hosp it al emphasi z es that becau se none of the p h ysici ans coul d ex pla in w hy atte mp ts to intub ate G uerra w ere unsu ccessf ul, any a ssum ption t hata n earlier call to Dr. Halcom b w ould h a ve r e s u lt ed in a p ositive outcom e is “contraryto the und ispute d facts, conclu sory , and base d on specu lation and guess.” Accordin g to th e ho spital, “[t]h e record cont ain s n o direct or

ci rc umstan ti al ev ide nce prov ing that , ev en i f the nurses had cal led a doct or an h our ear li er , an int ubati on or othe r air w ay acc ess w oul d hav e been achi ev ed for Mr

. G u e rr a , w ithin a rea sona ble m edica l probab ility .” W e disagree. Dr. Cullen’s 37See C ho , 1 8 3 S .W .3 d a t 4 6 9

. 38
See C i t

y of Kel l er , 168 S. W

. 3d a t 827

. 39
See Par

k Pl ace Hosp. , 9 0 9 S .W .3 d a t 5 1 1

. 40 20 tes ti mony

es tabl is h e d thati f Nurse Qui nonezhad cal led D r. H alc omb at 2:30 p.m., the
extra hour

an d fifteen mi nutes w oul d hav e al low ed D r. H alc omb to br ing Guer ra to the operati ng room w here, w it h proper eq uip ment and i deal co ndi ti ons, “ more li kel y than not the y w ould have been able to intub ate .” W e also disa gree wi th the h ospita l’s arg um entthatDr. Cullen’s op inions a re me rely “a se ri e s o f

ifs” as in Cho

. In Cho , the Housto n cou rt note d the abse nce o f any ex pert
o p in io n e s t a b li s h in g a r e a s o n a b le p ro b a b il it y t h a tt h e m e a s u re s a tis s u e wo u ld h a ve det erred th e robb ery
. In the pre s e n tc a s e , Dr. C ullen’s te stimo ny const itute s ex pert 38 opi n ion ev ide nce that in all probabi li ty , G uer ra w oul d nothav e di ed i f Dr . H alc omb had be en c al l ed a t 2: 30 p .m
. IV. Conclusion After credi ti ng ev ide nce fav orabl e to the findi ng that a reason abl e fact- finder co uld , and di sreg ardin g ev ide nce cont ra ry to the findi ng unl ess a reason abl e fact- finder co uld not,
w e c oncl ude t he ev ide nce off ered to prov e c ausat ion i s l eg all y su ff ic ien t. W e hol d tha t

39 Dr . C ull en’ s t est imony

—th at i f Dr . H alc omb had been cal led at 2:30 p.m. or ev en 2: 45 p. m., Gue rra in all prob ability w ould not h a ve d ie d—is legally suf f icient to supp ort the jury ’s find i n g t h a t t h e h o s p i t a l ’ s n e g l i g e n c e w a s a p ro x i ma t e c a u s e o f G u e r ra ’ s d e a t h

. The 40
ev ide nce does more than create a mere s ur mis e or su spi ci on th at t he hos pit al’ s fai lure to time ly notif y Dr. Halcom b of

Guerra’s brea thing dif f iculties w as a sub stan t ia l facto r inS e e i d

. 41
W h e n , a s h e re , th e tria l c o u rt r e n d e rs a J N O V , a n d th e l o s i n g p a rty a p p e a l s , t h e p re v a i l i n g p a rty 42 m ay al so ap peal and pr esent poi nt s ori ssues o n an y gr ound t hat woul d ei t her v i t i at e t he v er di ct orpr ecl ude a ff i rm i n g th e ju d g m e n t a n d re i n s ta ti n g th e ju r y's ve rd i c t. Sw ink v. Al esi , 999 S. W

. 2d 1 07, 111
- 12 ( T ex. A p p .– H o u s to n [1 4 th D i s t.] 1 9 9 9 , n o p e t.); see a lso T EX
. R. A PP
. P. 38

. 2(b ) ( pro vi di ng t ha t w he n a t ri al co urt r ender s a JN O V “ t he appel l ee m ust br i ng f or war d by cro ss- poi nt any i ssue or poi nt t hat w oul d hav e v i t i at ed t he v er di ct ort hat woul d ha v e pr ev ent ed a n aff i r m ance oft he j udgm ent i ft he t r i al cour t had r ender ed j udgm ent on t he v er di ct

. F ai l ur e t o br i ng f or war d by cro ss- poi nt an i ssue or poi nt t hat w oul d vi t i at e t he ve r di ct orpr ev ent a n a ff i rm a n c e o f t h e ju d g m e n t w a i v e s th a t c o m p l a i n t.”); T EX
. R. C IV
. P. 3 2 4 ( c ) ( s ta tin g t h a t w h e n a J N O V is r e n d e r e d th e a p p e lle e “ m a y b r in g f o r w a r d b y c r o s s - p o in t c o n ta in e d in h is b r ie ff ile d in th e C o u r t o fA p p e a ls any gr ound whi ch woul d hav e vi t i at ed t he ve r di ct or w oul d hav e pr ev ent ed an aff i r m ance oft he j udgm ent had one been r ender ed b y t he t r i al cour t i n har m ony wi t h t he v er di ct , i ncl udi ng a l t hough not l i m i t ed t o t he g r ound t hat one orm or e of t he j ur y ' s f i ndi ngs h av e i nsuff i ci ent supp or t i n t he evi de nc e or are aga i nst t he o v e rw h e l m i n g p r e p o n d e r a n c e o f th e e v i d e n c e a s a m a tte r o f f a c t.

. . .”). “T h e p u rp o s e o f th e s e ru l e s i s to r e q u ir e a f in a l d is p o s itio n o fth e c a s e b y th e a p p e lla te c o u r t, w h e r e a ju d g m e n t n o tw ith s ta n d in g th e v e r d ic t is e rr o n e o u s l y re n d e re d b y th e tri a l c o u rt, o n th e b a s i s o f t h e re c o rd b e fo re i t, a n d to o rd e r a re m a n d o n l y a s to qu es t i on s t ha t requ i re t he t ak i ng of ad di t i on al evi de nc e, s uc h as j ury m i s c on du c t

. ” Al esi , 999 S. W

. 2d a t 112

. H e r e , t h e h o s p ita l p r e s e n te d n o c r o s s - p o in ts o n a p p e a l. W e al so no t e t hat al t hough t he r ecor d con t ai ns appel l ant s’ pr oposed “ M ot i on f or Judg m ent , ” whi ch r ef er ences appel l ant s’ pr oposed j udgm ent as “ Exhi bi t A, ” no “ Exhi bi t A ” i s i ncl uded i n t he r ecor d be f or e us. A c c o rd i n g l y , w e re m a n d to th e tri a l c o u rt fo r e n try o f ju d g m e n t.

21 br ing ing about his death, and w it hout w hic h hi s d eath w oul d nothav e oc cur re d. 41 Acc ordin g ly , w e s ust ain appel lan ts’ i ss ue, rev erse the t ri al co u rt’s j udg ment not w ithsta ndin g the v erdict, an d rem and to t h e t ria l court solely for entry of jud gmen t in
acc ordance w it h the j ur y ’s v erdict. 42

LINDA REYNA Y AÑEZ, J u s t i c e

Me moran dum Opi nio n del iv ered and filed thi s t he 20t h day

of Nov ember , 200 8.