## COURT OFAPPEALS SECOND DISTRICTOF TEXAS FORT WORTH NO. 2 - 0 8 -4 6 7 - CV GRA NBU RY M I NO R E M ERGENCY APPE L L AN TS CL I NI C A ND AB E LS AL AS , M . D. V . TEA G A N TH I EL A PPELL EE

----- ----- -- FR O M THE 355TH DI STRI CT CO URT O F HO O D CO UN TY

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----- ----- -- I. I NTR ODUCTI ON T h i sisa n in te rl o c u to rya p p e a l c h a l l e n g i n g (1 ) th ea d e q u a c yo f a n e x p e rt r eportpr epar ed by W i l l i am W . Sp angl er , M . D . , FA C EP ad dr essi ng the al l eged
n e g l i g e n c eo f A p p e l l a n t A b e l S a l a s , M .D . a n d ( 2 ) th etr i a l co u rt ’s fai l u re to a w a rd a tto rn e y ’sfe e sa fte r d i s m i s s i n g w i th p rej u d i c eA p p e l l e eT e a g a n T h i e l ’s cl ai m s agai nstA ppel l antG r anbu ry M i norEm er gency C l i ni c. For t he r easons set f ort h be l ow , w e ho l d t hatt he t r i alco urtdi d notab us e i t s di sc r et i on by2

det er m i ni ng t hatD r . Spang l er ’ s r epo rtw asadequa t e butdi d a bus e i t s di sc r et i on by f ai l i ng t o aw ar d att or ney ’ s f ee s t o t he C l i ni c; ac cor di ngl y, w e w i l l r eve r set he port i on oft he t r i alco urt ’ s or deraw ar di ng no att or ney ’ s f ee s t o t he C l i ni c a nd rem a n d the i ss u eo f atto rne y ’s fee s to the tr i a l co u rt .

II . F ACTUA LAN DP ROCEDURALB AC KG ROUND O n A ugu st 28 , 20 06 , Th i el sought t r eat m entatt he C l i ni c and w as seen by D r . S al a s . T h i e l c o m p l a i n e d o fa b d o m i n a l p a i n a n d v o m i t i n g . W i t h o ut per f or m i ng a phy si cal exa m i n a ti on ordi agno st i c t est i ng, D r . Sal as di agno sed Thi elass uf f er i ng f r om f ood poi so ni ng and se ntherhom e w i t h a pr es cr i pt i on f or an ant i bi ot i c. T h ie l’s s y m p t o m sc o n t in u e d t o w o r s e n , a n d s h ew e n tb a c kt o t h eC lin ic on S ept em ber6, 20 06 . A t t hat t i m e, Th i el w as st i l l suf f er i ng f r om abdom i nal pai n, w hi ch had l oca l i z ed t o he rr i ghts i de. Dr . Sal asdi agn os ed Thi elw i t h a
u ri n a rytra c t i n fe c ti o n a n d g a v eh e r a p re s c ri p ti o n fo r a n a n ti b i o ti c . W he n Th i e l ’ ss ym pt om s s t i l l d i d no ti m pr ov e , s hew e nto n Se pt e m be r14, 2 0 0 6 to s e eh e r pri m a ry c a re p h y sici a n w h o im m e d i a tel yo rde red a C Tsc a n to r ul e outappend i ci t i s. The C T scan con f i r m ed appen di ci t i s, and T hi el w as t aken i nt o sur ger y l at ert hatday. The sur ger y r eveal ed t hatTh i el ’s a p p e n d i x had
r uptur ed and had becom e gangr enou s and t hatshe w as suf f er i ng f r om an i nt r aabdo m i nal abscess caused by t he r upture d a ppen di x. Because t he abscess3

sign i fi c a n tl yi n v o l v e d T h i e l ’s c o l o n , sh e u n d e rw e n t a p a rt i a l h e m i c o l e c to m yw i th anast om i si s. Fol l ow i ng t he sur ger y, Th i el under w entaddi t i onal sur ger i es s e c o n d a ryto th ed e l a y e d d i a g n o s i so f h e r a p p e n d i c i ti s . T h i e l fi l e d s u i t a n d tim e l ys e rv e d a s e v e n -p a g e , sin g l e -s p a c e d e x p e rt rep o rtb yD r. S p a n g l e r al o n g w i th h i s fo u r- p a g e c u rric u l u m v i tae . A p p e l l a n ts fi l e d a m o ti o n to d i s m i s sw i th p rej u d i c e . A p p e lla n tsg e n e ra l l yd e n i e d T h i e l ’s a l l e g a ti o n s a n d sp e c i fi c a l l yd e n i e d tha t t h e C l i n i c i s “ i n an yw a ya l e g a l en ti ty s u bj e c t to l i a b i l i ty .”A p p e l l a n tsa s s e rte d o b j e c ti o n sto D r. S p a n g l e r’s q u a l i fi c a ti o n sa n d to th e s u b s ta n c e o f h i s re p o rt, s p e c i fi c a l l y i ts p u rp o rte d fa i l u re t o a ddr es s t he el em ent s of st and ar d of ca r e, br ea ch, an d c aus at i on c onc er ni ng Th i el ’ s heal t h car e l i abi l i t y cl ai m s. A fte r a h e a ri n g , th etri a l c o u rts u s ta i n e d th eC l i n i c ’so bj e c ti o n sto D r. S pang l er ’ s r eport and di sm i ssed w i t h pr ej udi ce Th i el ’ s cl ai m s agai nstt he C l i ni c; t he t r i alco urtf ound t hatt he r ea so nab l e a nd ne ce ss ary a tt or ney ’ s f ee s f ort he C l i n i c w e r e $ 0 . T h etri a l c o u rt o v e rru l e d D r. S a l a s ’so bj e c ti o n sto D r. Spangl er ’ s r epo rtan d de ni ed hi s m ot i on t o di sm i ss . Thi s app ea l f ol l ow ed.

II I. D R . S PAN GLER ’SR E PORTM EETSC HAPTER74 C R ITER IA I n A p p e l l a n ts’ fi rst i ss u e , D r. S a l a s arg u e s t h a t th e tr i a l c o u rtab u se d i ts d is c r e t io n b yf a ilin g t o d is m i s sT h ie l’s h e a lt h c a r elia b ilit yc la im sa g a in s th im b e c a u s eD r. S p a n g l e r w a sn o t q u a l i fi e d to o ffe r h i so p i n i o n sa n d b e c a u s e D r.4

S p a n g l e r’sre p o rt fa i l sto a d e q u a t e l ys e t fo rth th es ta tu to rye x p e rt re p o rt el em ent s ofs t and ar d ofca r e, br ea ch, an d c aus at i on. A . S t andar d ofRev i ew W e r evi ew a t r i alco urt ’ s den i alof a m ot i on t o di sm i ssf oran ab us e o f d i s c re ti o n . Jer

ni gan v. Langley , 1 9 5 S .W .3 d 9 1 , 9 3 (T e x . 2 0 0 6 ); C tr. f or Ne uro logi

c a l Di s o rder s, P. A. v. G eor

ge , 261 S . W . 3d 285, 290– 91 ( Tex. A p p .— F o rt W o rth 2 0 0 8 , p e t. d e n i e d ); Mari s v. Hendr

i cks , 262 S. W . 3d 379, 38 3 ( Tex . A pp. — FortW ort h 20 08 , p et . d eni ed) . To det er m i ne w het hera t r i al courtabused i t s di scr et i on, w e m ustdeci de w h e thert he t r i al courtact ed
w i t hou tr ef er ence t o any gu i di ng r ul es orpr i n c i p l es; i n ot herw or ds, w e m ust d e c i d ew h e th e r th ea c t w a sa rb i tra ryo r u n re a s o n a b l e . D owner v. A quam ar

i ne Operators, I

nc. , 7 0 1 S .W .2 d 2 3 8 , 2 4 1

– 4 2 (T e x . 1 9 8 5 ), cert. denied, 476 U. S. 1 1 5 9 ( 19 86 ) . M er el y because a t r i al courtm ay deci de a m att erw i t hi n i ts di scr et i on i n a di f f er entm annert han an app el l at e courtw oul d i n a si m i l ar ci r cum st anc e d oesnotde m ons t r at e t hatan ab us e o fdi sc r et i on ha s occ ur r ed. Id . B u ta t r ia l c o u rth a sn o d is c r e t io n in d e t e r m in in g w h a tt h ela w iso rin a p p l y i n g the l a w to th efac ts, an d thu s “a clea r f a i l u re b ythe tr i a l co u rtto a n a l y z eo r a p p l yth el a w c o rre c tl yw i l l c o n s ti tu te a n a b u s eo f d i s c re ti o n .” W al ker v. Packer, 8 2 7 S .W .2 d 8 3 3 , 8 4 0 (T e x . 1 9 9 2 ) (o ri g . p ro c e e d i n g ); Ehr l i ch
v. Mi les , 1 4 4S .W .3 d 6 2 0 , 6 2 4(T e x . A p p .— F o rt W o rth 2 0 0 4 , p e t. d e n i e d ).5

B . S tatu to ry S tan d a rdsfor E x p e rtR e p o rt s A t r ia l c o u rtm u s tg r a n ta m o t io n t o d is m is sa h e a lt h c a r elia b ilit yc la im i fi tf i nds, aft era hear i ng, that“t he [ expert ] report[ f i l ed by t he cl ai m ant ] does not r epr esentan o bj ect i ve goo d f ai t h ef f ortto com pl y w i t h t he def i ni t i on ofan exper trep ort ”i n t hes t a t ut e . Te x. Ci v. Pr a c . & Rem . Cod eAnn . § 74 . 351( l) ( V er non Supp . 2008 ) . W hi l e t he exp ertr epo rt“ nee d notm ar sh alal l t he p l a i n ti ff’sp ro o f,”A m . Transition al Care Ctr

s. of Tex. , I nc. v. Pal

aci os , 46 S . W . 3d 87 3, 87 8 ( Tex . 20 01 ) ( const r ui ng f or m erart . 45 90 i , § 1 3. 01 ) , i tm ust pr ovi de a f ai rs um m ary oft he exp ert ’ s opi ni ons as t o t he “a ppl i ca bl e s t and ar ds o f c a re , th em a n n e r i n w h i c h th ec a rere n d e re d b yt h ep h y s i c i a n o r h e a l th c a re pr ovi derf ai l ed t o m eett he st andar ds, an d t he causal rel at i onshi p bet w een t hat f ai l ur e a nd t he i nj ury, har m , orda m age s cl ai m ed. ” Tex. Ci v. Pr ac . &Rem . Code A n n . § 7 4 .3 5 1 (r)(6 ). T o c o n s ti tu te a g o o d fa i th e ffo rt, th ere p o rt m u s t “ d i s c u s sth es ta n d a rd ofca r e, b r each, an d c aus at i on w i t h s uf f i ci ents pec i f i ci t y t o i nf or m t he def end antof the co nduc tt he pl ai nt i f fha s ca l l ed i nt o que st i on a nd t o pr ovi de a basi s f ort he t r i al courtt o concl ude t hatt he cl ai m s have m er i t . ” Pal aci os , 46 S. W . 3d at875. A r epo rtdoe s notf ul f i l l t hi s r equ i r em enti fi tm er el y s t at est he expert ’ s con cl usi ons ori fi tom i t s any oft he st at ut or y r equi r em ent s. Id. a t879. B u t t h ei n fo rm a ti o n i n the rep o rt “d o e s no t ha v eto m e e t t h esa m ereq u i rem e n ts6

as t he evi dence of f er ed i n a sum m ary-j udg m entpr oceedi ng oratt r i al . ” Id. The c la im a n t ’s e x p e rtm u s tin c o r p o r a t ee n o u g h in f o r m a t io n in t o t h er e p o rtt o f u lf ill t w o pur poses: ( 1) i nf or m the defendanto ft he speci f i c condu ctt he pl ai nt i f fhas ca l l ed i nt o que st i on; an d ( 2) pr ovi de a bas i s f or t he t r i alco urtt o c onc l udet he c l a i m sa rem e r it o r io u s . Id. ; se e al so Tex. Ci v. Pr ac . &Rem . Code Ann. § 74. 351( l), (r )(6 ). W hen r evi ew i ng t he ade qua cy ofa r epo rt , t he onl y i nf or m at i on r el eva nt t o t he i nqui ry i s t he i nf or m at i on co nt ai ned w i t hi n t he f ourco r ner s oft he d o c u m e n t. Pal

aci os , 4 6 S .W .3 d a t 8 7 8 . T h i sre q u i re m e n t p re c l u d e sa c o u rt f r om f i l l i ng ga psi n a r epo rt by dr aw i ng i nf er enc es or gue ss i ng a s t o w hatt he e x p e rt l i k e l ym e a n t o r i n te n d e d . Se eid . How eve r , s ec t i on 74. 351 doe s not p ro h i b i t exp erts , asoppo se d t o c ourt s, f r om m ak i ng i nf er enc esba se d on
m e d i c a l h i s to ry . Marvi n v. Fithi

an , No. 14- 07- 00996

- CV , 2008 W L2579 824, a t * 4(T e x . A p p .— H o u s to n [1 4 th D i s t.] J u l y 1 , 2 0 0 8 , n o p e t.) (m e m . o p .); see al so Tex. R. Evi d. 703 ( pr ovi di ng t hatan exp ertm ay dr aw i nf er enc esf r om t he f act s or dat a i n a part i cul arcase) ; Tex. R. Evi d. 70 5 ( pr ovi di ng t hatexpertm ay te s ti fyi n te rm so f o p i n i o n sa n d i n fe re n c e s ).7

C . D r . Sp angl eri s Q ual i f i ed D r . Sal asco nt end s t hatD r . Spang l erw as not qua l i f i ed t o pr ovi de opi ni ons i n t hi s case because D r . S al as i s a gener al fam i l y pr act i t i onerw hi l e D r . Sp angl er i s a b oar d- ce rt i f i ed em er gen cy r oom phy si ci an. T h ed e te rm i n a ti o n o f a d o c to r’sq u a l i fi c a ti o n sto p ro v i d ea n e x p e rt re p o rt m us tbem adeon t he bas i s of the c on t ent s oft he r epo rtan d hi s cur r i cul um v it a e . Bowi

e Mem ’ l Hosp. v. W

r i ght, 79 S. W . 3d 48 , 52 ( Tex . 20 02 ) . W i th
r espectt o a per son gi vi ng op i ni o n te sti m ony r egar di ng w het hera physi ci an dep art ed f r om ac ce pt ed st and ar dsofm edi ca l ca r e, an ex pertm us t( 1 ) be pr act i ci ng m edi ci ne atthe t i m e o fthe t est i m ony orat t he t i m e t he cl ai m ar ose; ( 2) have know l edge of accep ted s tan dar ds ofm edi cal car e f ort he di agno si s, ca r e, ort r ea t m entoft he con di t i on i nvol ved i n t he cl ai m ; an d ( 3) bequa l i f i ed on t he bas i s oft r ai ni ng orex per i enc e t o of f er an e xpertopi ni on r ega r di ng t he s ta n d a rd o f c a re . SeeT e x . C i v . P ra c . & R e m . C o d eA n n . § 7 4 .3 5 1 (r)(5 )(A ), § 74. 401 ( a) ( V er non 2005) . A phys i ci an i s “q ual i f i ed on t he bas i s of t r ai ni ng or exp er i enc e”i ft he phys i ci an i s boa r d- ce rt i f i ed orha s ot hers ubs t ant i alt r ai ni ng o re x p e r ie n c ein a n a r e a o fm e d ic a l p r a c t ic er e le v a n tt o t h ec la im a n d isa c t iv e ly p ra c ti c i n g m e d i c i n ei n re n d e ri n g m e d i c a l c a res e rv i c e sre l e v a n t to th ec l a i m . Id . § 7 4 .4 0 1 (c ).8

A n expe rtis qual i f i ed t o gi ve opi ni on t est i m ony ab out t he causal
r el at i ons hi p bet w ee n t he i nj ury c l ai m ed and t he al l ege d de part ur e f r om t he app l i ca bl e s t an da r d of car e i fhei s “o t her w i sequa l i f i ed t o r end eropi ni onson such causal r el at i onshi p undert he T exas Ru l es ofEvi dence. ” Se eid . § 74 . 35 1( r ) ( 5) ( C ) , § 7 4. 40 3( a) ( V er non 2 00 5) . Th e T exas Ru l es ofEvi dence pr ovi de t hat“[ i ] fsci ent i f i c, t echni cal , o ro t herspeci al i zed know l edge w i l l assi st th etri e r o f fa c t to u n d e rs ta n d th e e v id e n c eo r to d e te rm i n ea fa c t i n i s s u e , a w i t nes s qua l i f i ed asan ex pe rtby kno w l edg e, s ki l l , ex per i enc e, t r ai ni ng, or e du c a t i on m a y t e s t i f y t he r e t o i n t hef or m o fa n op i ni on o ro t he r w i s e . ”Te x. R. E v i d . 7 0 2 ; se e al

soRoberts v. W

i l l i am son , 1 11 S. W . 3d 113, 121– 22 ( Tex. 2 0 0 3 ) (r e c o g n i zi n g tha t w h i l em e d i c a l l i c e n se d o e s n o t au to m a ti c a l l yq u a l i fy h o l d e r to te s ti fya se x p e rt o n e v e rym e d i c a l q u e s ti o n , te s t i sn o t w h e th e r e x p e rt pr act i ces i n a part i cul arf i el d ofm edi ci ne but r at herw het hero f f er i ng part y has es t abl i sh ed t hatexperthas know l edg e, ski l l , ex per i enc e, t r ai ni ng, ored uca t i on r ega r di ng s pec i f i c i ss ue bef or e cou rtt hatw oul d qua l i f y e xpe rtt o gi ve opi ni on on part i cul arsub j ect , an d hol di ng t hatb ased on qual i f i cat i ons and exp er i ence, p e d i a tri c i a n w a sq u a l i fi e d to o p i n eo n c a u s ea n d e ffe c t o f n e u ro l o g i c a l i n j u ri e s ). W e r evi ew a t r i al court ’ s det er m i nat i on t hat an experti s qual i f i ed und er a n a b u s e o f d i s c re ti o n s ta n d a rd . Benishv. Gro ttie , 281 S. W . 3d 184, 198– 99 (T e x . A p p .— F o rt W o rth 2 0 0 9 , p e t. d e n i e d ); Mem ’ l Her m annHealthcare Sys . v.1 ... D r . Sp angl ergr aduated f r om m edi cal scho ol i n 19 84 an d hel d l i censes

i n N ort h C ar ol i na and Lou i si ana bef or e becom i ng l i censed i n T exas. 9 Bur rell, 2 3 0 S .W .3 d 7 5 5 , 7 5 7 (T e x . A p p .— H o u s to n [1 4 th D i s t.] 2 0 0 7 , n o p e t.) ( ci t i ng Broder

s v. Hei se , 9 2 4S .W .2 d 1 4 8 , 1 5 1

– 5 2 (T e x . 1 9 9 6 )). C o n c e rning h i s q u a l i fi c a ti o n s, D r. S p a n g l e r’ s re p o rtsta tes , i n p a rt : I a m a n e m e r g e n c ym e d ic in ep h y s ic ia n c u r r e n t lyp r a c t ic in g in K at y, Texas atC hr i st us St. C at her i ne’ s H osp i t al . I have been l i c e ns e d t o pr a c t i c em e di c i ne i n t heSt a t eo fTe xa ss i nc e1992 . [ 1 ] I am Boar d Cert i f i ed by t he A m er i ca n Boar d ofEm er gen cy M edi ci ne and am an i nst r uct ori n Advanc ed C ar di acLi f e Supp ortan d A d v a n c e d T r a u m a L if eS u p p o rt . M ya tt a c h e d c u r r ic u lu m v it a eis i n c o rpo rate d h e rei n as p a rto f m yrep o rt . I am cur r ent l y, and w as at t he t i m e D r . Sal as t r eat ed T eagan Th i el , pr act i ci ng m edi ci ne i n an area r el evantt o t hi s case. Th r oug hou tm y car eer , I have w or ked as an em er gency p hysi ci an and ha ve oft en bee n r equ i r ed t o e val uat e a nd di agn os e a pat i ent s u f f e r in g f r o m a b d o m in a l p a in a n d a c u t ea p p e n d ic it is . I a m w e ll f am i l i ar w i t h t he st andar d ofcar e r equi r ed t o di agno se appendi ci t i s. B yv i rtu eo f m ye d u c a ti o n , tra i n i n g , e x p e ri e n c ea n d b o a rd ce rt i f i ca t i on i n e m er gen cy m edi ci ne, I am f am i l i arw i t h a nd ha ve kno w l edg e o ft he ac ce pt ed r equ i si t e sta nda r dsofca r e f ort he di agn os i s and t r ea t m enti n que st i on i n t hi s ca se . I am t hus q u a l i fi e d to o ffe r e x p e rt o p i n i o n si n th i sm a tte r re g a rd i n g t h ec a re th a t T e a g a n T h i e l re c e i v e d fro m D r . A b e l S a l a sa n d th eG ra n b u ry M i norEm er gency C l i ni c. C o n c e rning D r. S a l a s’s c o m p l a i n t t h a t D r. S p a n g l e r w a s n o t qu a l i fi e d to o ffer op i n i o n s i n the ca se b e c a u se h ei s a n em e rge n c yroo m p h y s ici a n , n o t a gener al f am i l y pr act i t i onerl i ke D r . Sal as, w e not e t hatD r. Sal as t r eat ed T hi el ata m i norem er gen cy cl i ni c; D r . Sal asw asnotThi el ’ s f am i l y do ctor , an d s he10

d i d n o t s e e kc a refro m h i m i n th a t c a p a c i ty . M o re o v e r, i n s e ttin g th es ta tu to ry qua l i f i ca t i onsf ora cha pt er74 expert , the s t at ut e d oesnotf ocu s on t he d e f e n d a n td o c t o r ’s a r e a o fe x p e rt is eb u to n t h ec o n d it io n in v o lv e d in t h ec la im . SeeTex. C i v. Pr ac . & R em . C odeA nn. § 7 4. 401 ( a) ( 2) ( r equ i r i ng expe rtt o ha ve “k now l e d g eo fa c c e p t e d s t a n d a r d so fm e d i c a l c a r ef o rt h ed i a g n o s i s , c a r e , or t r ea t m entoft he i l l nes s, i nj ury, or c ondi t i on in vo lve d inth eclaim , ” not k n o w l e d g eo f th ed e fe n d a n t d o c to r’sa re a o f s p e c i a l i ty ) (e m p h a s i sa d d e d ); § 74. 401 ( c) ( 1) , ( 2) ( r ec ogni z i ng t hatex pert s m ay be qua l i f i ed on t he bas i s of t r ai ni ng orexper i ence i ft hey ar e b oar d cert i f i ed orare act i vel y pr act i ci ng “i n an ar ea ofm edi cal pr act i ce rele van tto th eclaim , ” noti n t he sa m e f i el d a s t he def endan tdoct or ) ( em phasi s add ed) . Th ati s, the app l i cabl e “st andar d ofcar e” and an ex pert ’ s abi l i t y t o opi ne on i tar e d i ct at ed by t he m edi ca l co ndi t i on i nvol ved i n t he cl ai m and by t he exp ert ’ s f am i l i ar i t y a nd e xpe r i enc e w i t h i t , not b yth ed e fe n d a n t d o c to r’sa re a o f e x p e rti s e . See, e. g. , McKowen v. Rags ton , 2 6 3 S .W .3 d 1 5 7 , 1 6 2 (T e x . A p p .— H o u s t o n [1 s t D i s t.] 2 0 0 7 , n o p e t.) ( per m i tt i ng i nf ec t i ous di se as e p hys i ci an t o opi ne on s t and ar d ofca r e f ort r ea t i ng i nf ec t i on s t em m i ng f r om art er i ove nusac ce ssgr aftev en t hough de f end ant d o c to r w a s c a r d io lo g i s t); Blanv. A li, 7 S. W . 3d 741, 746– 47 & n. 3 ( Tex. A pp .— H oust on [ 14 t h D i st . ] 19 99 , no pet . ) ( hol di ng t hatboar d- cert i f i ed neur ol ogi stw as notpr ecl uded f r om gi vi ng an op i ni on t hatt w o doctor s— a11

c a rd i o l o g i s t a n d a n e m e rg e n c yro o m p h y s i c i a n — b re a c h e d th es ta n d a rd o f c a re i n a n ar ea i n w hi ch t he neu r ol ogi stha s kno w l edg e, s ki l l , t r ai ni ng, an d e x p e r ie n c ea n d w h e r et h es u bje c to ft h e c la im (s t r o k e s ) f e ll s q u a r e lyw it h in h is
m edi cal expert i se) . Thu s, t o t he ext entD r . Sal as com pl ai ns i n i ss u e one t hat D r . Sp angl erw as notqual i f i ed because he i s nota gener al f a m i l y pr act i ce doctor , w e over r ul e t hi s port i on of i ssue one. D r . Spang l er ’ s r epo rtes t abl i sh est hath e w as qua l i f i ed t o opi ne on t he appl i cabl e st andar d ofcare f orthe di agno si s, care, o rt r eat m entoft he i l l ness, in ju ry , o r c o n d i ti o n (i .e ., a p p e n d i c i ti s ) i n v o l v e d i n T h i e l ’sc l a i m , a sw e l l a sD r. S al as’ s al l eged br eaches oft hat st andar d. D r . S pang l er i s l i censed t o pr act i ce m e d i c i n e i n th eS ta te o f T e x a sa n d w a sp ra c ti c i n g m e d i c i n ea t th eti m eT h i e l ’s c la i m a ro s e . SeeT e x . C i v . P ra c . &R e m . C o d eA n n . § 7 4 .4 0 1 (a )(1 ). D r. Spangl erposses se s kno w l edg e o fac ce pt ed st and ar dsofm edi ca l ca r e f ort he di agn os i s, ca r e, ort r ea t m entofa pp en di ci t i s ( “[ t ] hr ougho utm y c ar ee r , I ha ve w o rke d as a n e m e rge n c yp h y sici a n an d h a v eo ften b e e n req u i red to e v a l u a te and d i a gn os ea p a t i e nts uf f e r i ng f r om a bd om i na l p a i n a nd a c ut ea pp e ndi ci t i s. I am w e l l fa m i l i a r w i th th es ta n d a rd o f c a rere q u i re d to d i a g n o s ea p p e n d i c i ti s ” ). See i d. § § 7 4 .3 5 1 (r)(5 )(A ), .4 0 1 (a )(2 )– (3 ); Kel ly v. Rendon , 255 S . W . 3d 665, 67 4 ( Tex . A pp. — H oust on [ 14 t h D i st . ] 20 08 , no pet . ) ( r ej ect i ng ar gum entt hat e x p e rts w e r e“ n o t q u a l i fi e d to re n d e r o p i n i o n sa g a i n s t [d e fe n d a n t d o c to r]12

bec aus e t hei rm edi ca l s pec i al t y i s i n a di f f er entm edi ca l di sc i pl i ne f r om hi s ow n” a n d h o ld in g t h a t“ t h es t a t u t ed o e sn o tr e q u ir ea m e d ic a l e x p e rtb ep r a c t ic in g in t he exac ts am e f i el d a s t he def end antphy si ci an, buti ns t ea d m us tonl y be ac t i vel y pr ac t i ci ng m edi ci ne i n r end er i ng m edi ca l car e s ervi ce s r el eva ntt o t he cl a i m ” ) . T h u s , Dr . Sp a n g l e rm e e t st h eq u a l i f i c a t i o n r e q u i r e m e n t si m p o s e d by c h a p te r 7 4to o ffe r o p i n i o n so n t h ere l e v a n t s ta n d a rd o f c a rea n d o n D r. S a l a s ’s br ea che s oft hats t and ar d. D r . Spang l er ’ s r epo rtal so es t abl i sh est hathe w asqua l i f i ed t o opi ne on t he i ssue ofcausat i on becau se he i s qual i f i ed t o r endersuch an opi ni on un der th eT e x a sR u l e so f E v i d e n c e . SeeT ex . C i v. Pr ac . &Rem . Code Ann. §§ 74 . 35 1( r ) ( 5) ( C ) , . 40 3( a) ; Tex . R . Evi d. 70 2. D r . Sp angl eri s boar d cert i f i ed i n em e rge n c ym e d i c i n ean d h a s p rac ti c e d em e rge n c ym e d i c i n efor o v e r t w e n ty y e a rs . T h e s ec re d e n ti a l sa n d t h i se x p e ri e n c e , s e t fo rth w i th i n t h efo u r c o rn e rs o f D r . S p a n g le r ’s r e p o rt a n d c u r r ic u lu m v it a e , s u f f ic ie n t ly e s t a b lis h t h a th e is q u a l i fi e d to re n d e r a n o p i n i o n o n c a u s a ti o n in t h i sc a s e . SeeT e x . C i v . P ra c . & R e m . C o d e A n n . § § 7 4 .3 5 1 (r)(5 )(C ), .4 0 3 (a ); T e x . R . E v id . 7 0 2 ; se e, e. g. , Mos ely v. Mundi

ne , 249 S . W . 3d 775, 779– 80 ( Tex. A pp. — D al l as2008 , no pet . ) ( con cl udi ng t hat exp ert had t he kno w l edg e, s ki l l , ex per i enc e, t r ai ni ng, or edu ca t i on r ega r di ng s pec i f i c e m er gen cy r oom phy si ci an’ s sc opeofpr ac t i cean d13

hol di ng t h a te x p e rtw a st h e r e f o r eq u a l i f i e d t o r e n d e ra n o p i n i o n o n c a u s a t i on u n d e r s e c ti o n 7 4 .3 5 1 (r)(5 )). D . D r. S p a n g l e r’sR e p o rt A d e q u a te l yS e tsF o rth th eS ta n d a rd o f C a re and t he A l l eged S t andar d ofC are V i ol at i ons by D r . Sal as D r. S a l a s a rg u e s th a t D r. S p a n g l e r’s re p o rt fa i l s to e s ta b l i s h th es ta n d a rd of c are f ora f am i l y orge ner alpr ac t i t i one r , s uch asD r . Sal as , ort he com m ona l i t y ofs t and ar ds bet w ee n hi s ow n e m er gen cy m edi ci ne pr ac t i cean d th efa m i l yo r g e n e ra l m e d i c i n ep ra c ti c eo f D r. S a l a s . T o th ee x te n t th a t D r. Sal as argu es t hatD r . Spang l erw asnotqua l i f i ed t o opi ne on t he st and ar d of car e f ort he di agno si s and t r eat m ento f a ppen di ci t i s, w e have over r ul ed t hat content i on as setf ort h abov e. D r . Sal as al so ar gue s t hat D r . Spangl er di d not des cr i be w hata “t hor ough hi st or y and ph ysi cal exam i nat i on” r equi r ed orhow D r . S al as f ai l ed t o cond uct t hem ori den t i f y w hatdi agn os t i c t es t i ng s houl d ha ve bee n or der ed. D r . Spang l er ’ s r epo rtco nt ai nst he f ol l ow i ng: S ta n d a rd so f C a rea n d D e v i a ti o n sfro m S ta n d a rd so f C a re In re a s o n a b l em e d i c a l p ro b a b i l i ty , th es ta n d a rd s o f c a re appl i cabl e t o eval uat i on and t r eat m ent of , and t he i nj ur i es sust ai ned by T eagan T hi el ar e as f ol l ow s: 1 . T h esta n d a rd o f ca re req u i red D r. S a l a s to co n d u c t a t hor oug h hi st or y and ph ysi cal exam i nat i on w hi ch w oul d have l ead hi m t o co ns i derf urt herdi agn os t i c e val uat i on t o de t er m i ne t he c a u s eo fh e ra b d o m in a l c o m p la in t s . D r . S a la s ’ d if f e r e n t ia l d ia g n o s is14

shoul d h a v e i ncl uded ect opi c pr egnan cy, gast r i t i s, append i ci t i s, ur i nar y t r act i n fect i on, pyel onep hr i t i s and gast r oenter i t i s. Furt her t est i ng a nd eval uat i on t o det er m i ne t he t r ue cause ofTeag an Thi el ’ s abd om i nal com pl ai nt s sh oul d be bas ed upon a t hor ough and app r opr i at e h i st ory a nd physi ca l ex am i nat i on w hi ch sh oul d ha ve i n c l u d e d Te a g a n Th i e l ’ s v i t a l s i g n s . Ha d Dr . Sa l a s c o n d uct ed a th o ro u g h h i s to rya n d p h y s i c a l e x a m i n a ti o n , a st h es ta n d a rd o f c a re req u i red , h i s fi n d i n g s w o u l d h a v em o re th a n l i k e l yl e d h i m to per f or m addi t i onal t est i ng t o de ter m i ne t he t r ue cause ofher abdo m i nal com pl ai nt s. 2 . W i th o u t c o n d u c ti n g a n a p p ro p ri a tea n d t h o r o u g h h i s to ry and ph ysi cal exam i nat i on on A ugu st 28 , 20 06 , D r . S al as di agno sed Teag an T hi el as s uf f er i ng f r om gast r oenter i t i s, com m onl y a vi r al i l l ness. A l t hou gh acute gast r oenter i t i s i s m ostc o m m o nl y caused b ya v i rus , D r. S a l a s p res c ri b e d an an ti b i o ti c , a m e d i c a ti o n u se d to t r eatb a ct er i al i l l nesses w hi ch i s i nef f ect i ve on vi r al i l l nesses. S ym pt om s ofgast r oenter i t i s al so i ncl ude di ar r hea, a sym pt om t hat Teag an Thi el di d notha ve w hen s he w ass ee n byD r . Sal ason A u g u s t2 8 , 2 0 0 6 . D r. S a l a sfa i l e d to p e rfo rm a th o ro u g h h i s to ry and ph ysi ca l exam i nat i on w hi ch w oul d have l ead hi m t o consi der f urt herdi a g nost i c eval uat i ons t o det er m i ne t he cause ofTeag an Thi el ’ s abd om i nalcom pl ai nt s. D r . S al asbr ea che d t he st and ar d of c a re a n d w a s ne g l i g e n t w h e n h em i s-d i a g n o se d T e a g a n T h i e l w i th gas t r oe nter i t i s w i t houtco ns i der i ng a nd e xcl udi ng ot herca us esof Teag an T hi el ’ s abdom i nal sym pt om s. 3 . O n S e p t e m b e r6 , 2 0 0 6 , w h e n T e a g a n T h ie l a g a in pr es ent ed t o Dr . Sal asat t he G r anb ury M i norEm er gen cy C l i ni c, s he w as com pl ai ni ng of w or seni ng sym pt om s ofabdom i nal pai n t hat w e r elo c a liz in g t o t h erig h ts id eo ft h ea b d o m e n . A b d o m in a l p a in i n t he ri gh tl ow erqua dr anti s a s ym pt om co m m onl y c aus ed by appen di ci t i s. A t th e t i m e oft hi s second vi si t , Teag an T hi el had be e n t a k i ng ant i bi ot i c sp r e s c r i be d byDr . Sa l a so n Augu s t28, 2 0 0 6 , ye thedi agn os ed herw i t h a ur i nary t r ac ti nf ec t i on on Sept em ber6, 2006 . The ant i bi ot i c t her apys he had be en t ak i ng shoul d have i ncr eased hi s i ndex o fsuspi ci on t hatt he cause ofher abdo m i nal com pl ai nt s w as appendi ci t i s r at herthan t he ur i nar y t r act i nf ect i on. Putsi m pl y, i n l i ght ofherr i ght si ded abd om i n al15

com pl ai nt s, D r . Sal as shoul d have con si der ed t he cause ofTeag an Th i el ’ s abd om i nal com pl ai nt s as appen di ci t i s unt i l pr oven o t her w i se t hr oug h an appropr i at e w or k- up. I n or dert o m ake t he pr oper di agn os i s, t he stand ar d ofca r e r equ i r ed D r . Sal as ’ w or k- up of Teag an T hi el ’ s abdo m i nal pai n t o i ncl ude ( 1) obt ai ni ng hervi t al si gnst o de t er m i ne i ft her e w asa f eve rw hi ch i s f r equ ent l y pr es ent w i t h a p p e n d i c i t i s ; ( 2) o b t a i n i n g a c o m p l e t eb l o o d c o u n t( CBC ) w h ic h isa b lo o d t e s tw h ic h w o u l d h a v ere v e a le d a n ye le v a t io n in h e r w h i te b l o o d ce l l co u n t w h i c h i s c o m m o n l yfou n d i n p a ti e n ts w i t h appen di ci t i s; ( 3) obt ai ni ng a pr egnan cy t estsi nce T eagan T hi el w asofch i l d- bea r i ng a ge and ec t opi c pr egn anc y m ay m i m i c t he si gns and sym pt om s ofappend i ci t i s; and ( 4) obtai ni ng an abd om i nal and pe l vi c CT sc an, a r adi ogr aph i c t es tconduc t ed t o vi su al i z e t he app end i x t o de t er m i ne i fi ti s enl ar ged , di st en de d or t hi ck ene d, f i ndi ngst hati ndi ca t e i nfl am m at i on. Dr . Sal asbr ea che d t he s ta n d a rd o f c a reb yfa i l i n g to o b ta i n a n a d e q u a te h i s to ry , p e rfo rm an app r opr i at e p hys i ca l ex am i nat i on a nd c onduct thew or k- up n e c e s s a ryto d ia g n o s eth e c a u s e o f T e a g a n T h ie l’sc o m p la in ts . In r easonabl e m edi cal p r obab i l i t y, h ad D r . Sal as conducted t he w or ku p d e sc ri b e d ab o v e , h ew o u l d h a v ed i a g n o se d T e a g a n T h i e l w i th app end i ci t i s bef or e h erap pen di x r upt ur ed sp i l l i ng ba ct er i a a nd causi ng t he i nvol vem ent of t he col on t hatnecessi t at ed i t s r em oval on Sep t em be r1 4, 2006 . The C T w oul d ha ve i n a l l l i ke l i hood rev e a l e d ch a n g e s i n d i c a ti v e o f a p p e n d i c i ti s th a t w o u l d h a v el e d to t he cor r ec tdi agn os i s. Thi s opi ni on i s bas ed on hers ym pt om s, t he C T f i ndi ngson Se pt em ber 14, 2006 ofap pen di ci t i s w i t h e xt ens i ve i nf l a m m a t o ryc h a n g e sa n d t h eSe p t e m b e r1 4, 2 00 6 o p e r a t i ve f i ndi ngs ofa r uptur ed, gangr enou s appen d i x t hathad cause ext ens i ve di se as e t o t he adj ac entco l on. 4. Th e st andar d ofcar e f urt herr equi r ed D r . Sal as t o r ef er T e a g a n T h i e l to th eh o sp i tal e m e rge n c yd e p a rt m e n t o r a su rge o n to tr e a t he r ap p e n d i c i ti s o n S e p tem b e r 6 , 2 0 0 6 . H a v i n g fai l e d to cond uctany m eani ngfulw or k- up t o det er m i ne t he cause ofTeag an T h ie l’s a b d o m in a l p a in , D r . S a la sm is -d ia g n o s e d h e ra p p e n d ic it is a n d fa il e d to s e n d T e a g a n T h ie l to th eh o s p ita l o r a s u rg e o n . In r e a s o n a b lem e d ic a l p r o b a b i lit y , D r . S a la s ’ f a ilu r et o a p p r o p r ia t e ly di agn os e Te aga n Thi elan d r efe rhe rt o he al t hca r e p r ovi der s w ho coul d t r eatherappend i ci t i s r esul t ed i n a del ayed di agno si s ofher16

app end i ci t i s. Dur i ng t hi s del aye d pe r i od t he app end i x r upt ur ed, spi l l i ng bacter i a i nt o t he per i t oneal cavi t y. Thi s bact er i a f or m ed an abscess and i nf ect ed t he col on and r esul t ed, i n r easonabl e m edi cal pr obab i l i t y, i n t he gang r enou s col on f oun d dur i ng t he S ept em ber 1 4 , 2 0 0 6 o p e ra ti o n th a t n e c e s s i ta te d th eh e m i c o l e c to m y . To su m m ar i z e, D r . Spangl er se t f ort h at l ea st t w o sp ec i f i c st and ard of ca r e v i ol at i onsby D r . Sal as : ( 1) hef ai l ed t o c onduc tan app r op r i at e a nd t ho r ou gh h i s t ory a nd phy s i c a l ex a m i na t i on ofTea ga n Thi e l on bo t h Augu s t28 a nd Se pt e m be r6 a nd f a i l e d t o pe r f or m di a gn os t i c t e s t i ng on bo t h da t e s , a nd ( 2) he f ai l ed t o r ef erTea gan T hi elt o t he hos pi t alem er gen cy dep art m entort o a s u rg e o n to tre a t h e r a p p e n d i c i ti s . A fte r s e ttin g f o rth th e s es ta n d a rd o f c a re v i o l a ti o n s , D r. S p a n g l e r’sre p o rt s e tsfo rth th ec o n d u c t th a t th es ta n d a rd o f c a re r e qu i r ed i n t het a k i ng o fa m e di c a l h i s t ory a nd p hy s i c a l e xa m i na t i on : ( 1) o b t a in in g T h ie l’s v it a l s ig n s t o d e t e r m in e if T h ie l h a d a f e v e r , w h ic h isf r e q u e n t ly pr esentw i t h appen di ci t i s; ( 2) obt ai ni ng a c om pl et e bl ood count ( C BC ) , w hi ch isa b lo o d t e s tt h a tw o u ld h a v e r e v e a le d a n ye le v a t io n in h e rw h it eb lo o d c e ll cou ntt hati s com m onl y f ou nd i n pa t i ent s w i t h a ppe ndi ci t i s; ( 3) obt ai ni ng a pr egnan cy t est si nce Th i el w as ofchi l d- bear i ng age and an ect opi c pr egnan cy m ay m i m i c t he si gns and sym pt om s ofapp e n d i c i ti s; and ( 4) obt ai ni ng an abd om i nalan d pe l vi c CT sc an, a r adi ogr aph i c t es tco nduc t ed t o vi su al i z e t he a p p e n d i xto d e te rm i n eif i t i se n l a rg e d , d i s te n d e d , o r th i c k e n e d , w h i c h a re f i ndi ngst hati ndi ca t e i nf l am m at i on. The r epo rtthe n se t s f ort h t he t r ea t m ent17

t hats houl d havebeen gi ven t o m ee tt he st and ar d ofca r e— i ncl udi ng r ef er r i ng Thi elt o a hos pi t al ort o a s ur geo n— and opi nest hatD r . Sal asbr ea che d t he sta n d a rd o f ca re a n d w a s n e g l i g e n t w h e n h em i sd i a g n o se d T h i e l w i th gas t r oen t er i t i s and w i t h a u r i nary t r ac ti nf ec t i on w i t houtco ns i der i ng a nd excl udi ng othercauses ofTh i el ’ s abdom i nal sym pt om s. Th us, cont r ary t o D r . Sal as’ s ar gum ent , D r . S pang l er ’ s r eportdoes sp ec i f i c a l l yd e s c r i b ew h a ta “ t h o r o u g h h i s t o rya n d p h y s i c a l e x a m i n a t i o n”
r equ i r ed, doe s sp ec i f i ca l l y de sc r i be how D r . Sal as f ai l ed t o con duc t a t hor ough hi st ory and exa m i nat i on, and doe s sp ec i f i ca l l y i den t i f y w hatdi agn os t i c t es t i ng sh o u l d h a v e b e e n o rde red . F o r th e p u rpo se s of a sta tu to ry ex p e rtre p o rt, st at em ent s concer ni ng t he st andar d ofcar e and br each need onl y i denti f y w hat car e w as expect ed and w as notgi ven w i t h such speci f i ci t y t hati nf er ences need
n o t b ei n d u l g e d to d i s c e rn th e m . See Pal aci os , 4 6 S .W .3 d a t 8 8 0 ; Ben i sh , 281 S .W .3 d a t 1 9 8 ; T

h o m a sv. A lfo rd, 230 S . W . 3d 853, 858 ( Tex. A pp. — H ous t on [1 4 t h D i s t . ] 2 0 0 7 , n o p e t .) . B e c a u s eD r . S p a n g le r ’s re p o rtm e e t st h is
r equ i r em ent , w e h ol d t hatt he t r i alco urtdi d notab use i t s di sc r et i on by d e t e r m in in g t h a tD r . S p a n g le r ’s r e p o rt w a s a d e q u a t e in t h isre g a r d . W eo v e r r u le t hi s port i on of D r . Sal as’ s f i r sti ssue.18

E. D r . Spang l er ’ s ReportA deq uat el y S et s Fort h Caus at i on: The A l l e ged S t andar d ofC are V i ol at i ons by D r . Sal as P ro x i m a te ly C aus ed Thi el ’ s H em i col ec t om y D r . S a la sn e x ta r g u e st h a tD r . S p a n g le r ’s re p o rtf a ilst o a d e q u a t e ly addr ess t he c a u sa ti on el em entofTh i el ’ s heal t h car e l i abi l i t y cl ai m . D r . Sal as contends t hatD r . Sp angl er ’ s causat i on opi ni on i s i nadeq uat e because he f ai l ed t o “pr ovi d[ e] a t i m e f r am e w i th i n w hi ch one w oul d r easonabl y expectan i nf l am ed appen di x t o becom e g angr enou s” and “utt er l y f ai l ed t o est abl i sh w hen T h ie l a c t u a llys t a rt e d s u f f e r in g f r o m a p p e n d ic it is , a s w e ll a s w h e n h e ra p p e n d ix
r uptur ed. ” D r . Sal as ar gues t hatD r . Sp angl e r’ s c ausat i on op i ni on st acks “specul at i on upon s pecul at i on and i nf er ence upo n i nf er ence” concer ni ng w hen T h i e l b e g a n s u ffe ri n g fro m a p p e n d i c i ti s . To es t abl i sh ca us at i on, an ex pertr epo rtm us tpr ovi de i nf or m at i on l i nki ng th ed e fe n d a n t’sp u rp o rte d b r e a c h o f th es ta n d a rd o f c a reto th ep l a i n ti ff’s i n j u ry . SeeT e x . C i v . P ra c . & R e m . C o d eA n n . § 7 4 .3 5 1 (r)(6 ); s e eal s o A r ko ma Basi n Explorati

on Co. v. FMF Ass ocs . 1990

-A , Ltd. , 249 S. W . 3d 380, 390
n. 32 ( Tex . 20 08 ) ( def i ni ng “concl usor y” as “ [ e] xpr essi ng a f act ual i n fere n ce wi t h o u ts t a t i n g t h eu n d e r l yi n g f a c t so n wh i c h t h ei n f e r e n c ei sb a s e d ” ) . An e x p e rtm u st a l so e x p l a i n th e b a sis o f h i s s tate m e n ts to l i n kh i s c o n c l u sion s to th efa c ts . Bowi

e Mem ’ l Hosp. , 7 9 S .W .3 d at 5 2 . T o co n sti tu te a g o o d fai th ef f ortt o e st abl i sh t he ca us alr el at i ons hi p e l em ent , t he exp ertr epo rtne ed not19

m ar shal al l oft he pl ai nt i ff’ s p rooforpr esentevi dence as i ft he pl ai nt i f fw as a c tu a l l ylit i g a ti n g th em e ri ts . See i d. a t 5 2

– 5 3 ; Pal

aci os , 46 S . W . 3d a t878. N o m agi c w or dss uch as“ r ea so nab l e m ed i ca l pr oba bi l i t y”ar e r equ i r ed f or c o m p l i a n c e . Bowi

e Mem ’ l Hosp. , 79 S. W . 3d at53 . The r eport , h ow ever , m ust pr ovi de enou gh i nf or m at i on w i t hi n t he doc um entt o bot h i nf or m t he def end ant oft he sp ec i f i c c onduc tati ss ue and t o al l ow t he t r i alco urtt o c onc l udet hatt he s u i t h a sm e ri t. Id . a t52. A re v ie w o fD r . S p a n g le r ’s re p o rtre f u t e se a c h o fD r . S a la s ’s c la im s c o n c e rn i n g i tsc a u s a ti o n s u fficie n c y . D r. S p a n g l e r’sre p o rt e x p l a i n s ,

A p p e n d i c i ti s s h o u l d b ed ia g n o se d as ea rl yas p o ss i b l eto achi eve t he bestout com e f or t he pat i ent . I fa pat i enti s di agno sed bef or e t he appen di x per f or at es, the appendi x i s t ypi cal l y r em oved v ia a la p a r o s c o p ic s u r g ic a l p r o c e d u r ew h ic h a llo w sf o rm o r era p id h e a lin g a n d m in i m a l s c a r r in g . In c o n t r a s t , ift h ed ia g n o s isis del ayed i n a pat i entunt i l aft ert he appen di x r uptur es, a p at i entm ay dev el op c om pl i ca t i on s su ch asab sc es s, i nf ec t i on ofot heror gan s ori nf ec t i on oft he per i t one alca vi t y t hatr equ i r esm or e e xt ens i ve and di f f i cul ts ur gery. Af t err upt ur e o ft he app end i x, t he l onge rt he d ia g n o s isisd e la y e d , t h em o r ee x t e n s iv et h es p r e a d o fin f e c t io n in t he abdo m en becom es and gr eat erdam age t o abdo m i nal st r uct ur es occur s. I n t hi s case, t he di agno si s of Teag an Th i el ’ s appen di ci t i s w as del ayed du e t o D r . S a l as’ f ai l ur e t o obtai n t he appr opr i at e cl i ni cal h i s to ryo r c o m p l e te a n a d e q u a te p h y s i c a l e x a m i n a ti o n a n d p e rfo rm t he appr opr i at e di agno st i c t est i ng t o det er m i n e t he cause ofher a b d o m in a l c o m p la in t s . B e c a u s eo ft h isd e la y , h e ra p p e n d i c it is pr ogr essed unt i l t he ap p e n di x becam e gangr enou s and r uptur ed t her ebys pi l l i ng ba ct er i a i nt o he rper i t one alca vi t y. As a r es ul tof t he perf or at i on, Tea gan Thi el ’ s col on be ca m e i nf ec t ed and20

gang r enou s w hi ch r equi r ed t hata port i on of t hi s t w ent y- t w o year o l d ’sc o l o n n e e d e d to b es u rg i c a l l yre m o v e d (h e m i c o l e c to m y ). I ti s m y opi ni on, b ased o n r easonabl e m edi cal pr obab i l i t y, as expl ai ned i n det ai l above, t hat D r . S al as f ai l ed t o t i m e l ydi agno se Teag an Thi el ’ s app end i ci t i s. I ti s f urt herm y op i ni on, ba se d on rea so na bl e m ed i ca l prob ab i l i t y, t ha tt hi s ca us ed T ea ga n T hi el ’s di agno si s ofappend i ci t i s t o be del ayed. D ue t o t hi s del ay, Teag an Th i el ’ s appendi x r uptur ed and her col on becam e g angr enou s. H er i ncr easi ng sym pt om at ol ogy i s consi st entw i t h appen di ci t i s at di f f er ents t age s and s upport s t he con cl us i on t hatt he del ay i n t he d ia g n o s isc a u s e d , in re a s o n a b lem e d ic a l p r o b a b ilit y , t h ea p p e n d ix t o r uptur e. I ni t i al l y, appen di ci t i s t ypi cal l y pr esent s w i t h abdo m i nal pai n l ocat ed ar oun d t he um bi l i cal area. A s t he appen di x becom es m or e di st ended , t he over l yi ng par i et al per i t oneu m becom es i r r i t at ed causi ng t he pai n t o m i gr at e an d becom e l ocal i zed t o t he r i ght l ow er q u a d ra n t. W h e n T e a g a n T h i e l i n i ti a l l y p re s e n te d to th e G ra n b u ry M i no rE m e r ge nc y Cl i ni c a nd w a ss e e n by Dr . Sa l a so n Augu s t28, 2 0 06 , she w as not yet com pl ai ni ng of pai n t hat w as l ocal i zed to t he r i ght l ow erq uadr ant . Thi s i s i ndi cat i ve ofan ear l y appen di ci t i s. Th e second t i m e Teag an Th i el w as seen by D r . S al as on Sep t em ber 6, 2006 , t he pai n w as l oca l i z i ng t o t he r i ghts i de w hi ch i s i ndi ca t i ve ofan acu te a p pend i ci t i s w i t h i r r i t at ed par i et al per i t oneu m m ost c o m m o n lya s s o c ia t e d w it h in c r e a s e d s w e llin g o ft h ea p p e n d ix w i t houtpe r f or at i on. Thus , i fD r . S al ashad ac t ed w i t hi n t he st and ar d ofca r e a nd t i m el y di agn os ed Teag an Thi el , he rap pend i x w oul d notha ve r upt ur ed, he rco l on w oul d notha ve bec om e g ang r eno usan d s he w oul d notha ve had t o e ndur e t he ext ens i ve su r gery s he unde r w ent on Sep t em ber14, 2006 t hat i ncl ude d r em ova l of partofhe rco l on. W i th o u t re s ta ti n g e v e rys e n te n c ei n th ec a u s a ti o n p o rti o n o fD r. Spangl er ’ s r epo rts etf ort h a bove , a r evi ew oft he abo ve par agr aph s d e m o n s t r a t e sin f o r m a t io n s u f f ic ie n te n o u g h t o in f o r m D r . S a la so ft h es p e c if ic c o n d u c t t h a t T h ie l h a sc a lle d in t o q u e s t io n a n d h o w t h a tc o n d u c tp u r p o rt e d ly21

in ju r e d T h ie l, p r o v id in g a b a s isf o rt h e t r ia l c o u rt t o c o n c lu d et h a tT h ie l’s c la im s a g a i n s t D r. S a l a sh a v em e ri t. See, e. g. , i d. (s e tt in g f o rt h w h e n a re p o rtis s u fficie n t o n c a u s a ti o n ). D r. S p a n g l e r li n k sD r. S a l a s ’sb re a c h e so f th es ta n d a rd ofca r e ( “h avi ng f ai l ed to conduc tan y m ea ni ngf ul w or k- up t o de t er m i ne t he cause ofT eagan T hi el ’ s abdom i nal pai n, D r . Sal as m i s- di agno sed her a p p e n d i c i ti s a n d fai l e d to s e n d T e a g a n T h i e l to the h o sp i tal o r a su rge o n ”) to T h i e l ’s i n j u ry (“[i ]n rea so n a b le m e d i c a l p rob a b i l i ty, D r. S a l a s’ fai l u re to app r opr i at el y di agn os e Te aga n Thi elan d r ef erhe rt o he al t hca r e p r ovi der s w ho coul d t r eatherappend i ci t i s r esul t ed i n a del ayed di agno si s ofherappend i ci t i s. D ur i ng t hi s del ayed p eri od t he app end i x r upt ur ed, s pi l l i ng ba ct er i a i nt o t he per i t one alca vi t y. Thi s bac t er i a f or m ed an abs ce ssan d i nf ec t ed t he col on a nd
r es ul t ed, i n r ea so nab l e m edi ca l pr oba bi l i t y, i n t he gan gr eno usco l on f ound dur i n g t h eSe p t e m b e r1 4, 2 00 6 o p e r a t i o n t h a tn e c e s s i t a t e d t he h e m i c o l e c to m y ” ). C o n c e rn i n g D r. S a l a s ’sa rg u m e n t th a t D r. S p a n g l e r fa i l e d to “ p ro v i d [e ] a ti m e fr a m e w i th i n w h i c h o n e w o u l d rea so n a b l y e x p e c t a n i n fl a m e d ap p e n d i xto becom e gangr enou s” or“utt er l y f ai l ed t o est abl i sh w hen T hi el act ual l y st art ed suf f er i ng f r om append i ci t i s, as w el l as w hen herappend i x r uptur ed, ” D r . Sal as poi nt s us t o no case l aw orst at ut or y pr ovi si ons t hatw oul d r equi r e D r . Sp angl er t o opi ne i n a ch apt er7 4 e xpe rtr epo rtw hen Thi els t art ed su f f er i ng f r om22

a p p e n d i c i ti so r w h e n h e r a p p e n d i xru p tu re d . N o n e th e l e s s , D r. S p a n g l e r’sre p o rt speci f i cal l y expl ai ns how append i ci t i s pr ogr essesand st at es t hatw hen D r . Sal as i n i ti a l l y sa w T h i e l , h e r sy m p to m s ( g e n e ral a b d o m i n a l p a i n ) w e re c o n sisten t w i th ear l y appen di ci t i s; t hatw hen he saw herappr oxi m at el y ni ne days l ater, her sy m p to m s (ab d o m i n a l p a i n l o c a li z in g to th eri g h t si d e ) w e re c o n sisten t w i th a c u te a p p e n d i c i ti s ; a n d th a t i f D r. S a l a sh a d a c te d w i th i n th es ta n d a rd o f c a re and t i m el y di agn os ed Thi el , he ra pp en di x w oul d notha ve r upt ur ed, an d s he
w oul d notha ve had t o e ndur e t he ext ens i ve su r gery s he unde r w enton Sept em ber14, 2006 t hati ncl ude d r em ova l ofpa rtofhe rco l on. I ti s eno ugh th a t D r. S p a n g l e r o p i n e d th a t D r. S a l a s ’s b re a c h e so f th es ta n d a rd o f c a re del ayed t he di agno si s of T hi el ’ s app endi ci t i s so t hatTh i el ’ s appendi x r uptur ed a fter D r. S a l a s’s S e p tem b e r 6 , 2 0 0 6 e x a m i n a ti o n a n d c a u se d T h i e l ’s co l o n to b e c o m eg a n g re n o u s . See T e x . C i v . P ra c . & R e m . C o d e A n n . § 7 4 .3 5 1 (r)(6 ); s e eal s o, e .g ., Si

m o n s o nv. Kepp a rd, 225 S . W . 3d 868, 875– 76 ( Tex. A pp. — D al l as 20 07 , no pet . ) ( causat i on op i ni on t hatf ai l ur e t o t i m el y di agno se c e r e b e lla rin f a r c t io n o rh e m o r r h a g ev ia a C Ts c a n o rn e u r o lo g ic a l c o n s u lt p ro x i m a te l yc a u s e d p a ti e n t’sd e a th w a sa d e q u a te ). D r. S a l a sa l s o c l a i m sth a t D r. S p a n g l e r’sc a u s a ti o n o p i n i o n sa re con cl us ory. But , ass etf ort h a bove , D r . Spang l er ’ s ca us at i on op i ni ons s p e c i fic a llya n d e x te n s i v e l ys e t fo rth a l l o f th efa c tso n w h i c h th e ya re23

bas ed— t hati s, T hi el ’ s sy m pt om s on A ugus t2 8, he rco nt i nui ng a nd w or se ni ng sy m pt om s on Sep t em ber6, an d herul t i m at e r upt ur ed appe ndi x a nd ga ngr eno us c o l o n . T h u s , D r. S p a n g l e r’sc a u s a ti o n o p i n i o n sa ren o t c o n c l u s o ry . Se e, e .g ., A r kom a Basi

n Expl orati on Co. , 2 9 4S .W .3 d a t 3 9 0 n .3 2 ; Mo s ely , 249 S. W . 3d a t 7 8 0

– 8 1 ( h o l d i n g e x p e rt’sc a u s a ti o n o p i n i o n w a sn o t m e rec o n j e c tu re b e c a u s ei t w a ss u p p o rte d w i th fa c ts ); Si m ons on , 2 2 5 S .W .3 d a t 8 7 6 (sa m e ). Fort hes a m er e a s o n st h a tDr . Sp a n g l e r ’ sc a u s a t i o n o p i n i o n sa r e not c o n c l u s o ry , th e ya l s o d o n o t s ta c ki n fe re n c e u p o n i n fe re n c ea sa l l e g e d b yD r. S al as. An i nf e r e nc ei sa d e du c t i on o ff a c tt ha tm a y bed r a w n f r om a no t her fa c t. SeeBl ac k’ s La w D i ct i ona ry 700 ( 5t h e d. 1 979 ) . D i r ec tev i den ce , on t he ot herhand, i s “evi dence w hi ch, i f bel i eved, pr oves t he f act w i t hou ti nf er ence or pr e s um pt i on. ” Bro wnv. E. Mi ss . E le c . Po wer A ss 'n , 989 F. 2d 858, 861 ( 5th C i r. 19 93 ) . D r . Sp angl er ’ s causat i on op i ni ons const i t ut e di r ectevi dence th a t D r. S a l a s ’sb re a c h e so f th es ta n d a rd o f c a rec a u s e d T h i e l ’si n j u ri e s . D r. S pang l erexpr essl y expl ai ned t hat b a s e d o n re a s o n a b lem e d ic a l p r o b a b ilit y , a se x p la in e d in d e t a il a b o v e, . . . D r . S al as fai l ed t o ti m el y d i ag no se T ea ga n T hi el’s appen di ci t i s. I ti s f urt herm y opi ni on, b ased o n r easonabl e m edi cal pr obabi l i t y, t hatt hi s ca us ed Teag an Thi el ’ s di agn os i s of a p p e n d i c i ti sto b ed e l a y e d . D u eto th i sd e l a y , T e a g a n T h i e l ’s appen di x r uptur ed and her col on becam e gangr enou s.24

N o i n fe re n c e i s re q u i re d . D r. S p a n g l e r e x p re s s l y s ta te s th a t D r. S a la s ’s br eaches oft he st andar d ofcare caused Th i el ’ s i nj ur i es. Li kew i se, D r . Sp angl er e x p r e s s lyo p in e st h a tT h ie l w a ss u f f e r in g f r o m a p p e n d ic it isw h e n s h ein it ia lly pr e s e nt e d t o Dr . Sa l a s on Augu s t 28 ( “ e a r l y a pp e nd i c i t i s ” ) ; t ha t w hen Thi el p res e n ted t o D r. S a l a s o n S e p tem b e r 6 , sh ew a s s u fferi n g fr o m ac u te app end i ci t i s buthe rap pen di x ha d notye tr upt ur ed ( “p ai n w asl oca l i z i ng t o t he
r i ght si de w hi ch i s i ndi cat i ve of an acut e appen di ci t i s . . . w i t h i n cr eased sw el l i ng oft he app end i x without perf orati on ”) ( em phasi s added) ; and t hat , as a r esul tofD r . Sal as’ s f ai l ur e t o t i m el y di agno se Thi el ’ s a p p e n d i ci t i s, her app end i x s ubs equ ent l y r upt ur ed ( “i fD r . Sal asha d a ct ed w i t hi n t he st and ar d of ca r e a nd t i m el y di agn os ed Teag an Thi el , he ra pp endi x w oul d notha ve r upt ur ed” ) . No i nf er enc esar e r equ i r ed t o s upportD r . Spang l er ’ s ca us at i on opi ni ons. V i e w i n g th ei n fo rm a ti o n s e t fo rth w i th i n th e fo u r c o rn e rs o f D r. S p a n g l e r’s
r epo rt , w e h ol d t hatt he t r i alco urtdi d notabus e i t s di sc r et i on byde t er m i ni ng th a t D r. S p a n g l e r’ s re p o rtp rov i d e s a fai r su m m a ry o f h i s e x p e rto p i n i o n s a s to t he “a ppl i ca bl e s t and ar dsofca r e, t he m ann eri n w hi ch t he ca r e r end er ed by t he physi ci an orheal t h car e pr ovi derf ai l ed t o m eett he st andar ds, and t he causal re l a ti o n s h i p b e tw e e n t h a tf a i l u rea n d th ei n j u ry , h a rm , o r d a m a g e sc l a i m e d .” T e x . C i v . P ra c . & R e m . C o d eA n n . § 7 4 .3 5 1 (r)(6 ); see Pal aci os , 46 S. W . 3d at25

8 7 8 ; W alter s v. Hudoba , N o. 0 2- 08- 001 96- C V , 2 009 W L 16 107 9, at*6 ( Tex. A p p .— F o rt W o rt h J a n . 2 2 , 2 0 0 9 , n o p e t .) (m e m . o p .) . T h u s , t h et r ia l c o u rtd id not abuse i t s di scr et i on bydet er m i ni n g thatD r . Sp angl er ’ s r eportconst i t ut es a n obj e c t i vegood fa i t h e f f ortt o s a t i s f y t het w o pu r po s e so fs e c t i on 74. 351. See Pal aci os , 4 6 S .W .3 d a t 8 7 9 ; see al soTex. Ci v. Pr ac . &Rem . Code Ann. § 74. 351( l), (r )(6 ); CH CA Ma i nl and, L. P. v. W

heeler, No . 0 9

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- 0 0 6 3 4
- CV , 2 0 0 8 WL9 6 0 7 9 8 , a t* 5 ( T e x . A p p . — B e a u mo n tAp r . 1 0 , 2 0 0 8 , n o p e t . ) ( me m. o p .) ( h o l d i n g tha t do c to r’s e x p e rtrep o rtrep res e n ted a g o o d fai th effo rtto com pl y w i t h t he d e f i ni t i on of an expertr eportw hen i texpr essed opi ni on t hat i fnotf orm edi ca l ce nt er ’ s br ea ch oft he st and ar d ofcar e, w i t h t he sy m pt om s t he pat i entpr esent ed at t he em er gency r oom , t he pat i entw oul d have been seen and ev al uat ed by q ual i f i ed m edi ca l pe r so nne l an d “ w oul d ha ve bee n s par ed t he gen er al i z ed i nt r ape r i t one als eps i s t hatne ce ss i t at ed m or e e xt ens i ve su r gery a nd an ext end ed hos pi t al i z at i on” ) . Accor di ngl y, w e over r ul e t he r em ai nde rof A ppel l ant s’ f i r sti ssue. IV . T RIALC OURTF AI LE D TOA WARDA TT OR NEY ’SF EE S TOC LINIC I n A ppel l ant s’ second i ssue, t he C l i ni c argues t hatthe t r i al courtabused i t s di scr et i on w hen i tr ef used t o aw ar d t he C l i ni c att or ney’ s f ees aft er di sm i ssi ng, w i t h pr ej udi ce, t he heal t h car e l i abi l i t y cl ai m s Thi el al l eged agai nst th eC l i n i c . I n th eC l i n i c ’sm o ti o n to d i s m i s s , ito b je c t e d to D r. S p a n g l e r’s2 ... L i k e w i s e , i n h e r a p p e l l a te b ri e f, T h i e lp ra y st h a t th i sc o u rt “ w i l l a ffir m

th ej u d g m e n t o f th etri a l c o u rt.” 26 q u a l i fi c a ti o n s a n d the su b sta n c eo f his o p i n i o n s, m o v e d for d i sm i ss a l w i th pr ej udi ce oft he cl ai m s Thi el br oug htagai nstt he C l i ni c, and r equest ed a tto rn e y ’sfe e s . T h etri a l c o u rt th e re a fte r s i g n e d a n o rd e r s u s ta i n i n g th eC l i n i c ’s o bj e c ti o n s , g ra n ti n g th e C l i n i c ’s m o ti o n to d i s m i s s w i th p rej u d i c ea l l h e a l th c a re l i a bi l i t y c l a i m sa l l e ge d byTh i e l a ga i ns tt heCl i ni c , a nd a w a r di ng t heCl i ni c “ $0” i n a tto rn e y ’sfe e s . T h i e l d i d n o t p e rfe c t a n a p p e a l c h a l l e n g i n g th e tri a l c o u rt’s di sm i s s a l w i t h pr ej ud i c eo fh e rh e a l t h c a r el i a bi l i t y c l a i m sa ga i ns tt heCl i ni c; th u s , th ep ro p ri e tyo ft h e t r i a l c o u rt’so rd e r d i s m i s s i n g w i th p rej u d i c eT h i e l ’s cl ai m s agai nstt he C l i ni c i s notbef or e us. 2 S ee T e x . R . A pp. P. 25 . 1( c) ( r e qu i r i ng a ny pa rt y w ho s e e k s t o a l t e r t he t r i a l c ou rt ’ s j ud gm e ntorot her a p p e a l a b l eo rd e r to fi l ea n o ti c e o f a p p e a l ). W h e n a h e a l th ca re l i a b i l i ty c l a i m i s d i sm i ss e d w i th p rej u d i c ep u rsu a n t t o T e x a sC iv il P r a c t ic ea n d R e m e d ie sC o d es e c t io n 7 4 .3 5 1 (b ), t h et r ia l c o u rtis
r equ i r ed t o a w ar d a tt or ney ’ s f ee s. Tex . Ci v. Pr ac . &Rem . Code Ann. § 7 4 .3 5 1 (b ) (p ro v i d i n g th a t tri a l c o u rt s h a l l a w a rd re a s o n a b l ea tto rn e y ’sfe e s ). St at ut espr ovi di ng t hata part y “ sh al l ” be aw ar ded att or ne y’s fees ar e n ot d i s c re ti o n a ry . Bocque tv. Her r i ng , 9 7 2 S .W .2 d 1 9 , 2 0 (T e x . 1 9 9 8 ); A bi lene Di agn os ti c Cl i ni c v. D owni

ng , 233 S . W . 3 d 5 32, 535 ( Tex. A pp. — Eas t l and27

200 7, pe t . de ni ed) . W e t her ef or e hol d t hatt he t r i alco urtab us ed i t s di sc r et i on b ya w a rd i n g n o a tto rn e y ’sfe e s . SeeTex. Ci v. Pr ac. &Rem . Code Ann. § 7 4 .3 5 1 (b ); a c c o rd Da vi sv. Webb , 2 46 S. W . 3d 768, 774 ( Tex. A p p .— H o u s to n [1 4 th D i s t.] 2 0 0 8 , n o p e t.). W e sust ai n A ppel l ant s’ second i ssue. V . C ONC L USI ON H avi ng ov er r ul ed A ppel l ant s’ f i r sti ssue, w e af f i r m t he port i on oft he t r i al court ’ s N ovem ber 17 , 20 08 or der denyi ng D r . S al as’ s m ot i on t o d i sm i ss. B e c a u s eT h i e l d o e sn o t c h a l l e n g eth ep o rti o n o f th eo rd e r g ra n ti n g th eC l i n i c ’s
m ot i on t o di sm i ss , w e aff i r m t hatport i on of t he or der . H avi ng sust ai ned A ppel l ant s’ second i ssue, w e re v e rse t he port i on of t he t r i al court ’ s or der a w a rd i n g n o a tto rn e y ’sfe e sto th eC l i n i c a n d re m a n d th ei s s u eo f a tto rn e y ’s fe e sto th etri a l c o u rt.

SU E W A LKER J U S T I C E PA N EL: GA RD N ER, W A LKER, an d M C C O Y, JJ. DEL I VERE D: Aug us t27, 2009