Title: Colie E. Crutcher, Jr., M.D. v. Iola Williams
Citation: N/A
Docket Number: 1050893
State: Alabama
Issuer: Alabama Supreme Court
Date: January 9, 2009

Rel 01/09/2009
Notice: This opinion is subject to formal revision before publication in the advance
sheets of Southern Reporter.  Readers are requested to notify the Reporter of Decisions,
Alabama Appellate Courts, 300 Dexter Avenue, Montgomery, Alabama 36104-3741 ((334)
229-0649), of any typographical or other errors, in order that corrections may be made
before the opinion is printed in Southern Reporter.
SUPREME COURT OF ALABAMA
 OCTOBER TERM, 2008-2009
_________________________
1050893
_________________________
Colie E. Crutcher, Jr., M.D.
v.
Iola Williams
Appeal from Sumter  Circuit Court
(CV-00-68)
On Return to Second Remand
COBB, Chief Justice.
Colie E. Crutcher, Jr., M.D., appeals from the October
24, 2005, judgment of the Sumter Circuit Court in favor of
1050893
The trial court's judgment in favor of Iola Williams on
1
her claims against Dr. Crutcher became final upon the trial
court's June 27, 2008, order disposing of a cross-claim
against Dr. Crutcher.
2
Iola Williams on her medical-negligence claims against him.1
We reverse the trial court's judgment and render a judgment
for Dr. Crutcher.
This is the third time this Court has considered this
case.  We described the procedural history of this case in
Crutcher v. Williams, [Ms. 1050893, March 14, 2008] ___ So. 2d
___ (Ala. 2008) ("Crutcher I").  In pertinent part, those
facts are as follows:
"On June 23, 2000, Iola Williams filed a
medical-malpractice 
action 
against 
Colie 
E.
Crutcher, Jr., M.D., and the City of York Healthcare
Authority d/b/a Hill Hospital ('Hill Hospital').
Williams's action arose out of her visit to the Hill
Hospital emergency room in June 1998, during which
she was treated by Dr. Crutcher. Williams alleged
against Dr. Crutcher claims of medical negligence
and the tort of outrage and against Hill Hospital
claims of medical negligence, the tort of outrage,
negligence, and negligent hiring and supervision of
Dr. Crutcher and other Hill Hospital staff.
"....
"On September 26, 2005, the case went to trial.
... Before submitting the case to the jury, the
trial court dismissed all Williams's claims 'except
negligence.'  The trial court instructed the jury on
Williams's medical-negligence claims against Dr.
Crutcher and Hill Hospital. ...
1050893
3
"The jury returned a verdict for Williams
against both Dr. Crutcher and Hill Hospital in the
amount of $145,000. ...
"On October 24, 2005, the trial court entered an
order stating that 'judgment is rendered' in favor
of Williams on her claims against Dr. Crutcher and
Hill Hospital in the amount of $145,000."
___ So. 2d at __.
On November 10, 2005, Dr. Crutcher filed a motion for
judgment as a matter of law, arguing, among other things, that
Williams presented no evidence that any actions of Dr.
Crutcher caused her injuries.  The trial court denied Dr.
Crutcher's postjudgment motion.  On March 7, 2006, Dr.
Crutcher filed a notice of appeal to this Court.  However,
"Dr. Crutcher's appellant's brief was not filed until August
9, 2007, due in large part to the failure of the circuit clerk
to timely file the record on appeal."  Crutcher I, __ So. 2d
at __ n.2.
On March 14, 2008, this Court concluded that the judgment
from which Dr. Crutcher appealed was not a final judgment
because the trial court had not disposed of an indemnity
cross-claim filed by the City of York Healthcare Authority
d/b/a Hill Hospital ("Hill Hospital") against Dr. Crutcher.
See Crutcher I.  Accordingly, we remanded this case to the
1050893
4
trial court with instructions to make its October 24, 2005,
judgment final pursuant to Rule 54(b), Ala. R. Civ. P., or to
adjudicate Hill Hospital's cross-claim against Dr. Crutcher.
Id.  The trial court entered an order in response to our
opinion; however, that order contravened our opinion and
instructions.  Therefore, on May 30, 2008, we again remanded
the case for the trial court to enter another order in
accordance with the opinion and instructions in Crutcher I.
See Crutcher v. Williams, [Ms. 1050893, May 30, 2008] ___ So.
2d ____ (Ala. 2008) ("Crutcher II").
On June 27, 2008, the trial court entered an order
adjudicating the cross-claim in response to our instructions
in Crutcher II.  On October 20, 2008, the clerk of the Sumter
Circuit Court certified the supplemental record on appeal as
complete, and, on October 23, 2008, the record on appeal was
supplemented with the trial court's June 27, 2008, order.  We
now address the merits of the appeal.
Standard of Review
"When reviewing a ruling on a motion for a JML
[judgment as a matter of law], this Court uses the
same standard the trial court used initially in
deciding whether to grant or deny the motion ....
Palm Harbor Homes, Inc. v. Crawford, 689 So. 2d 3
(Ala. 1997).  Regarding questions of fact, the
1050893
5
ultimate question is whether the nonmovant has
presented sufficient evidence to allow the case to
be submitted to the jury for a factual resolution.
Carter v. Henderson, 598 So. 2d 1350 (Ala. 1992).
The 
nonmovant 
must have presented substantial
evidence in order to withstand a motion for a JML.
See § 12-21-12, Ala. Code 1975; West v. Founders
Life Assurance Co. of Fla., 547 So. 2d 870, 871
(Ala. 1989).  A reviewing court must determine
whether the party who bears the burden of proof has
produced substantial evidence creating a factual
dispute requiring resolution by the jury.  Carter,
598 So. 2d at 1353.  In reviewing a ruling on a
motion for a JML, this Court views the evidence in
the light most favorable to the nonmovant and
entertains such reasonable inferences as the jury
would have been free to draw.  Id.  Regarding a
question of law, however, this Court indulges no
presumption of correctness as to the trial court's
ruling.  Ricwil, Inc. v. S.L. Pappas & Co., 599 So.
2d 1126 (Ala. 1992)."
Waddell & Reed, Inc. v. United Investors Life Ins. Co., 875
So. 2d 1143, 1152 (Ala. 2003).
Facts
At the trial in this case, most of the relevant facts
were in dispute.  When the conflicting evidence is viewed in
the light most favorable to Williams and all reasonable
inferences from the evidence are drawn, as they must be, in
her favor, Waddell & Reed, supra, the facts are follows:
In June 1998, Williams, a resident of Livingston,
Alabama, consulted her physician, Dr. Charles Quarles,
1050893
6
regarding severe headaches from which she had been suffering.
Following her visit to Dr. Quarles, Williams underwent an MRI
brain scan around 3:00 p.m. on Friday, June 26, 1998, in
Meridian, Mississippi, approximately 35 miles from her home in
Livingston.  Dr. James A. Kenney signed the MRI report.
According to Dr. Kenney's report, the MRI showed that Williams
was suffering from hydrocephalus.  Dr. Kenney also noted in
his report that a portion of Williams's brain, the cerebellar
tonsils, extended 1.2 centimeters below her foramen magnum, an
opening at the base of the skull through which the spinal cord
enters the skull.  In addition, Dr. Kenney's MRI report
included the following comment:
"The patient's primary physician, Dr. Quarles, was
unavailable and the above results were given to Dr.
Crutcher (the covering physician) ... at the time of
interpretation of the examination.  The patient's
significant other as well as a nurse friend were
given the above findings and instructed to proceed
to an emergency room in order [for Williams] to be
evaluated."
Dr. Kenney contacted Williams at her home that same
afternoon.  After speaking with Dr. Kenney, Williams
telephoned the emergency room of Hill Hospital to notify the
hospital that she was on her way.  Thelma Love, an emergency-
room nurse at Hill Hospital, testified that she received this
1050893
The relationship between Dr. Quarles and Dr. Crutcher is
2
unclear.  Dr Crutcher did have a family practice and was
covering for Dr. Quarles on the day Williams had the MRI.  He
also served as an emergency-room physician at Hill Hospital.
7
call shortly before 5:00 p.m. on Friday, June 26, 1998.  After
taking Williams's call, Nurse Love telephoned Dr. Crutcher,
the emergency-room physician,  and told him that "Iola
2
Williams had a test done in Meridian, and she needs someone to
take the report and transfer her to" the University of Alabama
at Birmingham ("UAB") hospital. At that time, Dr. Crutcher
told Nurse Love to telephone him when Williams arrived at the
hospital.
Approximately 10 minutes after Nurse Love notified Dr.
Crutcher that Williams was on the way, Williams arrived at the
emergency room with her husband, James Cox.  Williams
testified that she asked Nurse Love for help and told her that
her head hurt.  Williams testified that, because of her pain,
she was crying and "balled up" in a chair by the admissions
desk.  Upon Williams's arrival at the emergency room, no
admissions paperwork was completed and Williams's vital signs
were not taken.
Shortly after Williams's arrival, Nurse Love telephoned
Dr. Crutcher to inform him that Williams had arrived.   At
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8
that time, Dr. Crutcher was treating a patient at his family-
practice office across the street from the hospital.  He
continued treating that patient.
At some point while Williams and Cox were waiting for Dr.
Crutcher to arrive at the hospital, Williams telephoned her
friend, Alexis Brown, a nurse, and asked her to come to the
hospital.  When Brown arrived, Cox was speaking by telephone
with Dr. Kenney, who had called the emergency room to speak to
Cox.  Cox handed the telephone receiver to Brown.  Brown made
the following note of the information she received from Dr.
Kenney:
"Iola Williams.  Dr. Kenny [sic], Radiologist[.]
Needs to see a neurologist[.] MRI brain 6/26/98,
Hydrocephalus.  Lat[eral] ventricles are enlarged.
Transit 
ependimal 
[sic] 
edema 
around. 
 
UAB.
Cerebella [sic] tonsils ... sticking down 1.2 cm."
Williams testified that she waited for Dr. Crutcher at the
admissions desk "[m]aybe thirty to forty-five minutes, maybe
longer.  It might have been an hour."
When Dr. Crutcher arrived, Nurse Love showed him Brown's
note from her conversation with Dr. Kenney.  Dr. Crutcher
spoke with Williams, completed a mental assessment of her, and
asked her what type problem she was having.  He found Williams
1050893
9
to be alert and anxious.  Williams asked for pain medicine;
Dr. Crutcher refused to give her pain medication.
Williams gave the following testimony regarding her
conversation with Dr. Crutcher at Hill Hospital:
"Q:
Tell us everything you said to Dr. Crutcher.
"A:
I told Dr. Crutcher my head was hurting so bad
that I felt like it was going to bust open and
that I need some help and that I had called
saying my brain was swollen.  At that time
that's all I know was that my brain was
swollen.
"Q:
What was Dr. Crutcher's response?
"A:
What you want me to do, what you want me to do.
Your brain is swelling, the airway is shutting
down.  What you want me to do.
"Q:
Did you tell him what you wanted him to do?
"A:
Yes, I did.
"Q:
What did you tell him?
"A:
I told him I wanted him to treat me and
transfer me to UAB [hospital].
"Q:
Why did you want him to transfer you to UAB
[hospital]?
"A:
James [Cox] may have said Dr. Kenney.  I don't
know.  But there was some conversation about we
needed to get to UAB [hospital].
"Q:
What was Dr. Crutcher's response to the request
for treatment and to be transferred to UAB
[hospital]?
1050893
10
"A:
He didn't do anything."
Eventually, Williams and Cox left the Hill Hospital
emergency room.  Taking with them Brown's handwritten note
from her conversation with Dr. Kenney, they returned to their
automobile, and Cox drove them to UAB hospital.  On the way,
Williams's pain became greater, she cried, and she began to
have trouble breathing.  Cox testified that, at one point
during the journey, Williams began to make a gurgling noise
"like her breath was not coming through." Williams told Cox
that she could not breathe.  At that point, Cox pulled over
into the emergency lane on the interstate and attempted to
call emergency 911 on his mobile telephone, but he was unable
to give the emergency operator a mile marker or an exit number
by which the operator could pinpoint their location.  Cox
decided he could not take a chance on waiting for emergency
responders to locate them, and he drove on.  Williams
testified that she feared for her life.  When they arrived in
Birmingham, Cox lost his way on the unfamiliar streets, but he
eventually located UAB hospital and took Williams into the
emergency room there.
1050893
11
Dr. Eric Rudolph Ehrensing, an emergency-room doctor at
UAB hospital, examined and treated Williams.  Williams told
him that she had suffered from headaches for about a week and
a half and that she was also having vision problems, trouble
with her balance, and bouts of confusion.  She also told Dr.
Ehrensing that after she had had an MRI earlier that day, Dr.
Kenney told her that she needed to go to the local emergency
room and that she had a cerebellar tonsilar herniation, which,
according to Dr. Ehrensing, "would be a life-threatening
condition."
Dr. Ehrensing had told Cox that he wanted Williams to
undergo an MRI, but when Dr. Ehrensing realized that Williams
had already had an MRI that day, Dr. Ehrensing scheduled a CT
scan instead.  Williams had the CT scan shortly after
midnight.  The results of the CT scan confirmed that Williams
had hydrocephalus.  The radiology report from the CT scan
contained this note: 
"For further evaluation magnetic resonance imaging
is recommended with contrast enhancement."
At 2:10 a.m. on Saturday, June 27, Dr. Ehrensing
consulted with Dr. Mark Hadley, a neurologist at UAB hospital,
about Williams's case and the results of the CT scan.  The CT
1050893
12
scan confirmed that Williams was suffering from hydrocephalus.
The CT scan did not indicate cerebellar tonsilar herniation,
which, according to Dr. Ehrensing, "would have been very
easily seen and definitely described on this C.T. scan."
According to Dr. Ehrensing, the CT scan did not indicate a
life-threatening condition, and Dr. Ehrensing saw no need to
operate immediately.  Dr. Ehrensing made an appointment for
Williams to see Dr. Hadley on Monday, June 29, 1998. 
Dr. Ehrensing advised Williams that she could return to
work and other normal activities.  Williams was then
discharged from UAB hospital early on Saturday, June 27.
Williams received no pain medication and no oxygen while
she was in the emergency room at UAB hospital.  Dr. Ehrensing
did not give Williams pain medication because, he testified,
pain medication would have adversely affected his and other
physicians' ability to evaluate Williams's neurological
condition.
In his deposition, which was admitted as testimony at the
trial in this case, Dr. Ehrensing testified that his treatment
of Williams at the emergency room of UAB hospital would have
been no different had Dr. Crutcher done any, or all, of the
1050893
Dr. Crutcher testified that Williams refused treatment;
3
Williams's testimony, however, was to the contrary.
13
following: completed an emergency-room-screening form for
Williams, made a medical record of Williams's visit, made a
written record of Williams's informed refusal to consent to
treatment,  accepted Williams's MRI report from Dr. Kenney,
3
monitored Williams's vital signs and breathing, administered
oxygen to Williams, telephoned UAB hospital to inform the
medical personnel that Williams was on her way or to give UAB
hospital the results of Williams's MRI report, or transferred
Williams to the UAB hospital emergency room. Dr. Ehrensing
testified that, had Dr. Crutcher administered pain medication
to Williams, it could have adversely affected Dr. Ehrensing's
ability to evaluate Williams and that his treatment of
Williams was not adversely affected by the fact that Dr.
Crutcher had not given Williams pain medication.  Dr.
Ehrensing testified that the fact that Williams was not
transferred to UAB hospital by ambulance did not affect his
treatment of her, but, if she had been, "[i]t may have made
her triage a little faster because ambulances tend to take
priority."  Dr. Ehrensing further testified that, had
personnel at Hill Hospital evaluated the degree to which pain
1050893
14
was affecting Williams's mental status, he would have made use
of that information in treating her but that, in any event, he
would have performed such an evaluation on his own.
Dr. Ehrensing also testified as follows:
"Q.
Would the findings of the M.R.I. report have
been 
important 
to 
you 
in 
assessing 
Miss
Williams when she was in the emergency room
that night?
"A.
Yeah, it would -- yes. I mean, it would be
important to have all the data.  But at the
same time, the only thing that I can see in
front of me is the C.T. scan. So I didn't -- I
didn't have a report nor an M.R.I. to look at.
"Q:
And I believe the C.T. scan report says
recommend an M.R.I. --
"A.
Correct.
"Q.
-- correct?
"A. (Nods head affirmatively.)
"Q.
So had you had the M.R.I., would that have
helped you in assessing Miss Williams that
night?
"A.
Uh-huh. Yes."
Williams spent the weekend at her home in Livingston,
sleeping fitfully and waking at times with excruciating pain
in her head.  Sometimes when she awoke she did not know where
she was; she continued to have bouts of difficulty breathing.
1050893
15
On Monday, June 29, 1998, Cox took Williams to Meridian,
Mississippi, to obtain Williams's MRI films.  He then took her
to Birmingham for her appointment at UAB hospital with Dr.
Hadley.  Dr. Hadley spoke with Williams and looked at the MRI
films she had brought from Meridian, then sent Williams to the
neuro-intensive-care unit, where the pressure on her brain was
monitored for several hours.
On Tuesday, June 30, 1998, Dr. Hadley performed surgery
on Williams.  He installed a ventricular shunt to decrease the
pressure on her brain by draining the excess fluid that had
accumulated in her skull.
In Dr. Hadley's deposition testimony, which was admitted
as evidence at trial, Dr. Hadley gave the following testimony:
"Q.
Had 
[Dr. 
Ehrensing] had -- had the 
UAB
emergency room doctor had this report [the June
26, 1998, MRI report from Meridian] to give you
this report if you were the neuro consult that
he made early Saturday morning, would that have
made a difference with respect to the treatment
of Ms. Williams?
"....
"A.
I don't know. I just don't know what he would
have thought. I don't know -- I didn't know
whether -- I know we had her MR study when I
saw her in my clinic on the 29th. Did she go
home and get it and bring it back, I mean I
don't know.
1050893
16
"Q.
... I will tell you that she brought the films
to your office on Monday....
"A.
I didn't have this [June 26, 1998, MRI result]
apparently when I was consulted either by my
resident or however it was [on Saturday, June
27, 
1998,] 
and 
with 
only 
her 
clinical
examination to base it on by our ER physician
who reported her as awake and alert and
conversant but with some complaints, I agreed
to see her first thing Monday knowing that she
had hydrocephalus. Now, did we have a CT scan?
I'm sure we did. We must have had something or
we wouldn't have known she had hydrocephalus.
"Now, had I -- I do know that when I saw her MR
I didn't say come back and see me in a week.
You know, we made the decision to admit her to
the hospital.  Would it have made a difference?
It might have. I might have just admitted her
on Saturday, pretty impressive, but I was not
asked or was not shown the study to review."
Although Dr. Hadley did not recall his consultation with
Dr. Ehrensing, he testified that he would have had the
following response to the information relayed by Dr.
Ehrensing, 
which 
consisted 
solely 
of 
Dr. 
Ehrensing's
examination and the CT scan, without Williams's MRI results:
"I'm concerned about her.  Does she need to be
admitted? ... I would have asked [Dr. Ehrensing]
some of these other issues about her vital signs
which appear okay on [Dr. Ehrensing's notes], and
with that I would have said, you know, her troubles
alone and the increased tone worry me. Why don't you
make -- I don't know that she needs to be admitted.
...  I would have said if she's not ill and throwing
up and having mental status, then tell her I'm
1050893
17
worried enough about her I want to see her Monday
morning. That's what happened.
"Now, other counsel asked me if I had seen the MR
study what would I have done. I'd [have] admitted
her because that's exactly what I did when I saw her
MR study, so with the information I have given to me
third hand by, you know, an emergency room physician
... I'm worried enough about her to see her the next
possible clinical day, like Monday, but that's all
the information I had.
"Why did I worry?  Because these patients can
deteriorate rapidly.  Did she?  No. So we either got
lucky or we treated her in a timely fashion."
At the trial of this case, Dr. Eldred Mattatha Brunson,
testifying as Williams's medical expert, opined that the
medical care Dr. Crutcher provided Williams when she sought
emergency medical treatment at Hill Hospital on June 26, 1998,
was not consistent with the standard of care ordinarily
exercised in the national medical community by emergency-room
physicians.  According to Dr. Brunson, Dr. Crutcher breached
the standard of care by making "little or no effort to care
for Ms. Williams in a potentially life-threatening situation";
by failing to complete a medical-screening form or an
emergency-room record of Williams's visit; by failing to
explain to Williams that her situation was life-threatening;
by failing to attempt to transfer Williams to UAB hospital in
1050893
18
an emergency medical vehicle; by failing to make arrangements
to make Williams comfortable in the meantime; and by failing
to stabilize her condition.  Dr. Brunson also testified that
the standard of care for a physician treating Williams in the
Hill Hospital emergency room would have required the physician
to consider Williams's headache an emergency and to ensure
that Williams received treatment as quickly as possible.
Dr. Brunson gave the following opinion as to whether any
act or omission on the part of Dr. Crutcher caused Williams
any harm:
"Q:
Can you attach -- Well to a medical degree of
certainty the fact that Ms. Williams was left
in the condition she was in on the day in
question at Hill Hospital and then had to be
transported by private vehicle with her husband
to UAB and the time spent going there or
waiting in the hospital, can you say with any
degree of medical certainty this had an impact
on her medical condition?
"....
"A:
Yes."
When asked about what harm Williams might have sustained
because Dr. Crutcher or Hill Hospital breached the standard of
care, Dr. Brunson responded simply that the injury to Williams
was a "delay in treatment" that could have had a "potential"
1050893
19
for damaging Williams's brain.  Dr. Brunson further testified
that this delay in treatment prolonged Williams's suffering
from pain, headaches, difficulty breathing, and other symptoms
of hydrocephalus.  Dr. Brunson testified that Dr. Crutcher's
failure to communicate to UAB hospital information about
Williams's condition and the MRI results caused a delay in her
treatment once she reached UAB hospital; Dr. Brunson's reason
for this opinion was his understanding that Dr. Hadley
testified by deposition that, had Dr. Hadley seen a copy of
Williams's MRI results when Dr. Ehrensing consulted him early
Saturday morning, June 27, 1998, Dr. Hadley would have
immediately admitted Williams to the neuro-intensive-care
unit.  Dr.  Brunson also testified that Dr. Crutcher met the
standard of care by not administering pain medication to
Williams.  It is undisputed that, if Williams had been
transported to UAB hospital in an emergency vehicle, she would
have been given no medication to ease her pain before she
reached UAB hospital.
At the trial in this case, Williams testified:
"Q:
Has what happened at Hill Hospital in June of
1998 caused you any emotional problems that
still linger?
1050893
20
"....
"A:
Because of the terrible ordeal I went through,
it's something that will stay with me the rest
of my life and something I will fear for the
rest of my life, that I will get sick again and
not be so lucky.  The Lord blessed me, and I
thank him.  I am scared every day I have a
serious medical problem."
Analysis
This is a medical-malpractice action governed by the
Alabama Medical Liability Act, § 6-5-480 et seq. and § 6-5-541
et seq., Ala. Code 1975 ("the AMLA").  See Mock v. Allen, 783
So. 2d 828, 832 (Ala. 2000) ("The AMLA applies '[i]n any
action for injury or damages or wrongful death, whether in
contract or in tort, against a health care provider for breach
of the standard of care.'" (quoting § 6-5-548(a), Ala. Code
1975)).  "To prevail on a medical-malpractice claim, a
plaintiff must prove '"1) the appropriate standard of care, 2)
the doctor's deviation from that standard, and 3) a proximate
causal connection between the doctor's act or omission
constituting the breach and the injury sustained by the
plaintiff."'" Giles v. Brookwood Health Servs., Inc., [Ms.
1060883, June 27, 2008] __ So. 2d __, __  (Ala. 2008) (quoting
Pruitt v. Zeiger, 590 So. 2d 236, 238 (Ala. 1991), quoting in
1050893
21
turn Bradford v. McGee, 534 So. 2d 1076, 1079 (Ala. 1988)).
Although a delay in medical treatment may, in an appropriate
case, constitute a breach of the standard of care as a matter
of law, it does not, in and of itself, constitute an injury.
See McAfee ex rel. McAfee v. Family Med., P.C., 641 So. 2d 265
(Ala. 1994) (holding that, absent proof of actual injury
caused by alleged delay in the diagnosis and treatment of
disease, plaintiffs could not recover on their AMLA claims
against medical-service providers).  Rather, to prevail on a
medical-malpractice claim based on a delay in providing
medical treatment, the plaintiff must prove that a breach of
the standard of care, i.e., the delay in treatment,
proximately and probably caused actual injury to the
plaintiff.  See McAfee, 641 So. 2d at 267 ("In medical
malpractice cases, the plaintiff must prove that the alleged
negligence 'probably caused the injury.'  Parrish v. Russell,
569 So. 2d 328, 330 (Ala. 1990), citing Williams v. Bhoopathi,
474 So. 2d 690, 691 (Ala. 1985). This has been the standard in
Alabama for decades.").
Dr. Crutcher argues that the trial court erred in denying
his motion for a judgment as a matter of law on Williams's
1050893
22
medical-negligence claim against him because, he says, the
evidence at trial did not demonstrate a probability that the
alleged breach of the standard of care by him proximately
caused any injury to Williams.  Williams, however, argues
that, by not treating her or making arrangements for her
transportation to UAB hospital by emergency medical vehicle,
and by not contacting UAB hospital with information on her
condition, Dr. Crutcher negligently caused a delay in
Williams's treatment at UAB hospital.  According to Williams,
had Dr. Crutcher properly transferred her and forwarded her
MRI results to UAB hospital, the neurologist at UAB hospital
would have seen her when she arrived, the pressure on her
brain would have been monitored upon her arrival late Friday
evening, and she would have been treated for hydrocephalus
before Monday, June 29, 1998.  Instead, Williams argues, as a
result of this alleged delay in treatment, she endured
extended pain and suffering from her underlying medical
condition over the weekend of June 27-28, 1998, until she
finally was admitted to the neuro-intensive-care unit on
Monday, June 29, 1998.  Williams further argues that this
1050893
23
delay in treatment has caused her continuing emotional
distress.
Our careful examination of the record reveals no evidence
indicating that, once Williams arrived at UAB hospital,
Williams's treatment, or the outcome of her treatment, was in
any way affected by any action Dr. Crutcher took or failed to
take.  Conjecture by an expert witness that Williams might
have received treatment for her hydrocephalus sooner had Dr.
Crutcher treated Williams for that condition at Hill Hospital
and arranged for her transport to UAB hospital is not
sufficient to establish that she probably would have received
treatment for hydrocephalus sooner.  It is undisputed that
Williams would not have been relieved of her pain before the
ventricular shunt was installed.  Dr. Hadley's testimony that
he would have or might have admitted Williams to the hospital
for monitoring early on Saturday, June 27, 1998, if he had
seen a copy of the MRI report at that time, does not, without
more, indicate a probability that Dr. Hadley would have
performed the surgery to install the ventricular shunt any
earlier than Tuesday, June 30.  See McAfee, 641 So. 2d at 267
("'The proof must go further than merely show that an injury
1050893
24
could have occurred in an alleged way--it must warrant the
reasonable inference and conclusion that it did so occur as
alleged ....'" (quoting McKinnon v. Polk, 219 Ala. 167, 168,
121 So. 539, 540 (1929)).  Because the record does not contain
substantial evidence indicating that Dr. Crutcher proximately
and probably injured Williams by causing a delay in her
medical treatment upon her arrival at UAB hospital, we
conclude that the evidence was not sufficient to warrant a
jury determination on Williams's claim for damages resulting
from delayed treatment at UAB hospital.
In addition to her allegation that Dr. Crutcher's actions
caused a delay in her treatment after she arrived at UAB
hospital, Williams also argues that the evidence of acute fear
and anxiety she suffered in the car on the way to Birmingham
was sufficient to support her claim of emotional distress.
She argues that she presented evidence sufficient to
reasonably support the conclusion that Dr. Crutcher breached
a duty not to place her at risk of foreseeable physical injury
by failing to arrange for emergency transport so that, if
complications, which Williams says were foreseeable, occurred
during transport, medical personnel could address those
1050893
25
complications immediately to avert permanent damage to
Williams's brain or death.  Further, Williams argues that
substantial evidence reasonably supports the conclusion that,
while en route to UAB hospital, she in fact suffered emotional
anguish and distress from complications such as severe pain
and difficulty breathing while no medical personnel were
available.  Specifically, she was afraid that she would die or
suffer physical injury because no medical personnel were
available to monitor or address her symptoms until she arrived
at UAB hospital.  She also alleges that she continues to be
distressed and fearful that she will die or suffer injury if
she suffers another bout of hydrocephalus when medical
personnel are not present to assist her.
Dr. Crutcher argues that Williams's alleged emotional
distress resulting from not being transported to Birmingham by
emergency vehicle is not a sufficient basis for the recovery
of damages.  In response, Williams points out that this Court
has long recognized that mental or emotional harm, such as
fear or anxiety, constitutes a compensable injury when the
plaintiff 
is 
placed 
in 
immediate 
risk 
of 
reasonably
foreseeable physical harm by the negligent conduct of another,
1050893
26
regardless of whether the plaintiff also suffers a physical
injury as a result of that conduct.  AALAR v. Francis, 716 So.
2d 1141, 1145-47 (Ala. 1998); Taylor v. Baptist Med. Ctr.,
Inc., 400 So. 2d 369 (Ala. 1981); see also Flagstar Enters.,
Inc. v.  Davis, 709 So. 2d 1132, 1141 n.5 (Ala. 1997) (noting
that "[d]amages for emotional distress may be awarded in a
negligence case, even in the absence of physical injury," when
the emotional distress results from the breach of a duty not
to place another in danger of physical harm); cf. § 6-5-544,
Ala. Code 1975 ("In any action for injury whether in contract
or in tort against a health care provider based on a breach of
the standard of care, the injured plaintiff ... upon proper
proof may be entitled to recover noneconomic losses to
compensate for pain, suffering, ... and other nonpecuniary
damage.").  
In Taylor, supra, a mother sued her obstetrician,
alleging that the obstetrician had breached the standard of
care and had placed her at risk of physical harm by not
assisting the mother in the labor and delivery of her child.
400 So. 2d at 371. The obstetrician  was notified at 3:00 a.m.
that the mother was in labor, and he told the nurses at the
1050893
27
hospital that he would be "right on over."  Id.  However, the
obstetrician did not arrive at the hospital to assist with the
birth of the child until 11:40 a.m., 10 minutes after the
mother delivered a child who was stillborn or who died within
moments of birth.  The uncontroverted medical testimony
established that, had the obstetrician been present during the
delivery, he could have done nothing to prevent the death of
the child.  The mother made no claim asserting the wrongful
death of her child, and she did not allege that she had been
physically injured in any way by the obstetrician's failure to
attend to the delivery until after the child had been
stillborn.  Rather, the only injury for which the mother
sought compensation was the great pain and physical anguish
she suffered in delivering the child without the assistance of
a physician.  400 So. 2d at 371-72.  The trial court entered
a summary judgment for the obstetrician after finding that the
mother failed to offer any evidence of a compensable injury.
400 So. 2d at 371.  This Court reversed the judgment, holding
that, "to require physical injury caused by culpable tortious
conduct, when mental suffering may be equally recognizable
standing alone, would be an adherence to procrustean
1050893
28
principles which have little or no resemblance to medical
realities."  400 So. 2d at 374. 
However, in a variety of tort cases, this Court has held
that mere fear of a future injury or disease, without more,
does not constitute a compensable mental or emotional injury.
See Houston Health Care Auth. v. Williams, 961 So. 2d 795,
810-12 (Ala. 2006) (holding, in a case arising under the AMLA,
that alleged emotional distress consisting "simply" of fear of
possible future infection from known exposure to fungus in a
contaminated breast implant, without more, did not constitute
a compensable legal injury); Southern Bakeries, Inc. v. Knipp,
852 So. 2d 712, 717-18 (Ala. 2002) (holding, in an action
alleging fraud and failure to warn of the presence of
asbestos, that mere fear that exposure to asbestos could lead
to asbestos-related disease, without more, did not constitute
a compensable injury; this Court noted that the plaintiff
"ha[d] not sought any medical care for his alleged emotional
distress and he did not plan to have any psychiatric or
psychological treatment or any counseling for emotional
distress or mental anguish"); and Pfizer, Inc. v. Farsian, 682
So. 2d 405, 407 (Ala. 1996) (holding, in a product-
1050893
29
liability/personal-injury 
action 
against 
a 
heart-valve
manufacturer, that the plaintiff's alleged emotional distress
consisting merely of the fear that his artificial heart valve,
which was working properly, could one day malfunction, "is
not, without more, a legal injury sufficient to support [the
plaintiff's] claim").  "It is a basic principle of tort law
that in negligence cases, the plaintiff must suffer actual
injury; mere threat of future harm, not yet realized, is not
enough."  Southern Bakeries, 852 So. 2d at 716 n.7 (citing W.
Page Keeton et al., The Law of Torts § 30 at 165 (5th ed.
1984)).
Given every factual inference taken from this record that
can reasonably be drawn in Williams's favor and when the
evidence is viewed in the light most favorable to her, the
evidence in this case of Williams's mental anguish and
emotional distress caused by Dr. Crutcher's alleged failure to
arrange emergency transportation for Williams to UAB hospital
indicates, at most, no more than a fear of future injury.   It
can reasonably be inferred from this record that, while en
route to UAB hospital, without emergency personnel to assist
her, Williams was afraid that she could die or suffer
1050893
30
permanent physical damage from complications.  Further, the
only evidence of continuing emotional distress resulting from
the fact that Williams was not transported to UAB hospital by
an emergency vehicle is evidence indicating that Williams
"will fear for the rest of [her] life, that [she] will get
sick again and not be so lucky."  The evidence is undisputed
that Williams suffered no physical injury due to the lack of
emergency transportation and that emergency medical personnel
would not have administered any medication to reduce
Williams's pain and suffering during transport.  Moreover, as
in Southern Bakeries, supra, Williams makes no allegation that
she has had to seek medical care, psychological treatment, or
counseling for her alleged emotional distress and mental
anguish.  See 852 So. 2d at 717-18.  Thus, at most, the
evidence of Williams's alleged emotional distress indicates
mere fear of future injury that was not and has not been
realized; 
such 
evidence 
cannot reasonably support the
conclusion that Williams suffered a legally compensable mental
or emotional injury as a result of Dr. Crutcher's alleged
failure to arrange emergency medical transportation for her.
"We do not denigrate" Williams's fear of potential injury;
1050893
31
"[w]e simply recognize that under existing precedent, that
fear does not constitute a present legal injury and is not
actionable, when no other present injury can be demonstrated."
Houston Health Care Auth., 961 So. 2d at 811.
Williams also argues that Dr. Hadley's testimony provides
substantial evidence indicating that,  if Dr. Hadley had seen
Williams's MRI results when Dr. Ehrensing consulted him early
on Saturday, June 27, Dr. Hadley would have immediately
admitted Williams to the neuro-intensive-care unit to monitor
the pressure on her brain.  Instead, according to Williams,
because Dr. Crutcher did not provide UAB hospital with a copy
of Williams's MRI report, Dr. Hadley did not see the MRI
results or admit Williams to the neuro-intensive-care unit for
monitoring until Monday, June 29.  Williams argues that she
was, therefore, forced to wait out the weekend, suffering from
hydrocephalus, in her home rather than in the hospital.  As a
result, she says, she suffered great fear and anxiety that she
would die or incur grave injury because medical personnel were
not present to monitor her condition and intervene if
necessary.  It is undisputed that these fears were never
realized.  It is undisputed that, had Williams been in the
1050893
32
hospital for monitoring over the weekend, she would have been
given no pain medication.  Other than the aforementioned
evidence indicating that, over the weekend, Williams simply
experienced fear and distress that she might suffer an injury,
the record contains no evidence indicating that Williams
suffered any physical, mental, or emotional injury because she
spent the weekend at home rather than in the hospital.  As we
have explained, evidence that Williams was afraid that injury
could result, without more, is not evidence of an actual,
legally compensable injury.  See  Southern Bakeries, 852 So.
2d at 716 n.7 (stating that, in negligence cases, absent
actual injury to the plaintiff, mere "threat of future harm,
not yet realized, is not enough" to constitute a compensable
injury).
Williams argues that, under Therrell v. Fonde, 495 So. 2d
1046 (Ala. 1986), she produced sufficient evidence to preclude
a judgment as a matter of law on her claims alleging pain and
suffering as a result of allegedly delayed medical treatment
at UAB hospital and Dr. Crutcher's failure to arrange
emergency medical transportation for her.  In Therrell, a
worker sued his employer's medical-service providers for
1050893
33
allegedly failing to treat him or to arrange emergency medical
transportation for him after his hand was crushed in an
industrial accident.  495 So. 2d at 1047-48.  The worker
alleged that, as a result, he was forced to wait approximately
one or two hours before receiving medical treatment.  495 So.
2d at 1047.  The worker ultimately underwent extensive surgery
on his hand; his left middle finger was amputated, and steel
pins were put in another finger.  At the time he filed his
action, the worker had not regained full use of two of his
fingers.  Id.  In reversing a summary judgment for the
medical-service providers, this Court held:
"Given 
[the 
worker's 
and 
co-employee's]
testimony that [the company nurse] refused to allow
speedier 
transportation and that [the company
doctor] did nothing to prevent this delay and did
not even look at [the worker's] hand, the record in
this case presents sufficient evidence to withstand
a motion for summary judgment. ...  Although the
doctors who treated [the worker's] hand gave
affidavits that the loss was determined by the
initial accident [and there was no other expert
medical testimony], it appears that [the worker]
could show the injury of extended pain and suffering
from 
the 
asserted 
indifferent 
treatment 
and
unnecessary delay.  Because [the worker] has
produced at least a scintilla of evidence of breach
of the standard of care and of injury proximately
resulting therefrom, the trial court erred in
granting summary judgment for these defendants."
495 So. 2d at 1048 (emphasis added).
1050893
34
Thus, in Therrell, we held that the summary judgment was
improper because the worker had presented a "scintilla" of
evidence of an actual injury, which at that time was all that
was required of a nonmovant to overcome a motion for a summary
judgment.  See Drill Parts & Serv. Co. v. Joy Mfg. Co., 619
So. 2d 1280, 1282 (Ala. 1993) (recognizing that, in cases
filed on or before June 11, 1987, the scintilla rule of
evidence provided the applicable standard for determining
whether summary judgment was warranted); § 12-21-12, Ala. Code
1975 (abolishing the scintilla rule in favor of the
substantial-evidence rule).  To defeat a motion for a judgment
as a matter of law, the "nonmovant must have presented
substantial evidence."  Waddell & Reed, Inc., 875 So. 2d at
1152 (emphasis added) (citing § 12-21-12, Ala. Code 1975; West
v. Founders Life Assurance Co. of Florida, 547 So. 2d 870, 871
(Ala. 1989)).  Williams has not come forward with substantial
evidence of actual injury to overcome Dr. Crutcher's motion
for a judgment as a matter of law.  Moreover, Therrell does
not suggest that the "scintilla" of evidence the worker
produced was evidence of a mere possibility of injury or of a
mere fear of injury, without more, as is true of the evidence
1050893
35
upon which Williams relies in this case.  Thus, Therrell does
not support Williams's argument that her case ought to have
been submitted to a jury.
Conclusion
In conclusion, this record does not contain substantial
evidence indicating that any alleged breach of the standard of
care by Dr. Crutcher proximately caused Williams any legally
cognizable injury.  Therefore, Dr. Crutcher was entitled to a
judgment as a matter of law on Williams's medical-negligence
claim.  Accordingly, we reverse the judgment of the trial
court on Williams's medical-negligence claim against Dr.
Crutcher and render judgment in favor of Dr. Crutcher.
REVERSED AND JUDGMENT RENDERED. 
See, Woodall, Smith, and Parker, JJ., concur.