Title: Springhill Hospitals, Inc. v. Critopoulos
Citation: N/A
Docket Number: 1090946
State: Alabama
Issuer: Alabama Supreme Court
Date: November 18, 2011

REL: 
11/18/2011 
Notice: T h i s o p i n i o n i s 
s u b j e c t t o f o r m a l r e v i s i o n b e f o r e p u b l i c a t i o n i n 
t h e 
advance 
s h e e t s o f 
Southern Reporter. 
R e a d e r s a r e r e q u e s t e d t o n o t i f y t h e 
Reporter of 
Decisions, 
Alabama A p p e l l a t e C o u r t s , 300 D e x t e r Avenue, Montgomery, Alabama 36104-3741 
((334) 
2 2 9 - 0 6 4 9 ) , o f 
any t y p o g r a p h i c a l o r o t h e r e r r o r s , i n 
o r d e r t h a t c o r r e c t i o n s may be made 
b e f o r e t h e 
o p i n i o n i s 
p r i n t e d i n 
Southern Reporter. 
SUPREME COURT OF ALABAMA 
OCTOBER TERM, 2011-2012 
1090946 
S p r i n g h i l l H o s p i t a l s , Inc., 
e t a l . 
v. 
D i m i t r i o s C r i t o p o u l o s 
Appeal from M o b i l e C i r c u i t Court 
(CV-08-900551) 
WISE, 
J u s t i c e . 
The 
d e f e n d a n t s , 
S p r i n g h i l l 
H o s p i t a l s , 
I n c . , 
d/b/a 
S p r i n g h i l l M e m o r i a l H o s p i t a l 
( " S p r i n g h i l l " ) , Dennis R u s h i n g , 
A s h l e y F l e m i n g , and 
J a n e l O s t r i e c h m e r e r ( h e r e i n a f t e r r e f e r r e d 
1090946 
t o c o l l e c t i v e l y as "the d e f e n d a n t s " ) , 
a p p e a l from a judgment 
i n f a v o r o f t h e p l a i n t i f f , D i m i t r i o s C r i t o p o u l o s . 
F a c t s and P r o c e d u r a l 
H i s t o r y 
On A p r i l 10, 2006, C r i t o p o u l o s was a d m i t t e d t o S p r i n g h i l l 
M e m o r i a l H o s p i t a l t o undergo a h e a r t 
c a t h e t e r i z a t i o n . 
On 
A p r i l 11, 2006, Dr. D i m i t r i s K y r i a z i s p e r f o r m e d a c a r d i a c -
a r t e r y - b y p a s s 
g r a f t 
("CABG") on C r i t o p o u l o s . 
A f t e r t h e 
s u r g e r y , 
C r i t o p o u l o s was a d m i t t e d 
t o t h e 
c a r d i a c - r e c o v e r y 
u n i t . 
C r i t o p o u l o s was i n t h e c a r d i a c - r e c o v e r y 
u n i t 
u n t i l 
A p r i l 16, 2006, when he was t r a n s f e r r e d t o t h e c a r d i a c - s t e p -
down o r c a r d i a c - i n t e r v e n t i o n u n i t . Around 11:50 a.m. on A p r i l 
14, 
2006, 
b e f o r e 
C r i t o p o u l o s was 
t r a n s f e r r e d , R u s h i n g , a 
r e g i s t e r e d nurse who worked i n b o t h t h e c a r d i a c - r e c o v e r y and 
c a r d i a c - i n t e r v e n t i o n 
u n i t s 
p e r f o r m e d 
a 
r e a s s e s s m e n t 
o f 
C r i t o p o u l o s . 
D u r i n g 
t h a t r e a s s e s s m e n t , R u s h i n g n o t i c e d a 
d i s c o l o r a t i o n 
on t h e back 
o f 
C r i t o p o u l o s ' s 
neck. 
He 
s u b s e q u e n t l y moved C r i t o p o u l o s from t h e bed t o a c h a i r . 
A t 
a p p r o x i m a t e l y 1:50 p.m., R u s h i n g was h e l p i n g C r i t o p o u l o s back 
t o bed when he n o t i c e d a b l i s t e r on t h e 
back o f C r i t o p o u l o s ' s 
neck 
and 
a 
s t a g e 
I 
d e c u b i t u s 
o r 
p r e s s u r e 
u l c e r 
on 
2 
1090946 
C r i t o p o u l o s ' s 
c o c c y x . 
On 
A p r i l 19, 2006, C r i t o p o u l o s 
was 
r e l e a s e d from the h o s p i t a l . 
On A p r i l 20, 2006, C r i t o p o u l o s went t o M o b i l e 
I n f i r m a r y , 
a h o s p i t a l i n M o b i l e , 
where he c o m p l a i n e d o f s h o r t n e s s 
o f 
b r e a t h , 
d i f f i c u l t y b r e a t h i n g , a s a c r a l p r e s s u r e u l c e r , and an 
open wound i n the p o s t e r i o r o f h i s neck. 
The p l a s t i c surgeon 
a t the h o s p i t a l d e t e r m i n e d t h a t s u r g e r y was not n e c e s s a r y f o r 
C r i t o p o u l o s ' s wounds a t t h a t time and t h a t the wounds c o u l d be 
t r e a t e d w i t h l o c a l wound c a r e and by a p p l y i n g m e d i c i n e s t o the 
wounds. 
C r i t o p o u l o s 
was 
s u b s e q u e n t l y 
r e l e a s e d 
from 
the 
h o s p i t a l . 
On May 8, 2006, C r i t o p o u l o s was a g a i n a d m i t t e d t o M o b i l e 
I n f i r m a r y because the s a c r a l p r e s s u r e u l c e r had g o t t e n worse. 
The u l c e r was d e b r i d e d by the p l a s t i c surgeon a t t h a t 
t i m e . 
C r i t o p o u l o s was r e l e a s e d from the h o s p i t a l on May 11, 2006. 
C r i t o p o u l o s 
c o n t i n u e d 
t o r e c e i v e 
t r e a t m e n t f o r h i s wounds 
u n t i l l a t e 2009. 
On A p r i l 8, 2008, C r i t o p o u l o s f i l e d a 
m e d i c a l - m a l p r a c t i c e 
a c t i o n a g a i n s t 
S p r i n g h i l l , R u s h i n g , F l e m i n g , 
O s t r i e c h m e r e r , 
3 
1090946 
and 
S c o t t Holcombe.
1 
R u s h i n g , 
F l e m i n g , 
O s t r i e c h m e r e r , 
and 
Holcombe were a l l n u r s e s 
i n the 
c a r d i a c - r e c o v e r y u n i t 
o f 
S p r i n g h i l l who p r o v i d e d c a r e f o r C r i t o p o u l o s . 
On J u l y 10, 2009, Holcombe and the d e f e n d a n t s 
f i l e d 
an 
" O b j e c t i o n s t o Q u a l i f i c a t i o n s o f P l a i n t i f f ' s N u r s i n g E x p e r t , 
Penny J o n e s , R.N.," and a motion t o e x c l u d e her 
t e s t i m o n y . 
The 
t r i a l i n t h i s case s t a r t e d on J a n u a r y 11, 2010. 
A t 
t r i a l , Penny J o n e s , a r e g i s t e r e d nurse who p r a c t i c e d i n wound-
c a r e management, 
t e s t i f i e d 
as C r i t o p o u l o s ' s e x p e r t 
w i t n e s s 
r e g a r d i n g the s t a n d a r d o f c a r e . Jones t e s t i f i e d t h a t R u s h i n g , 
F l e m i n g , Holcombe, and O s t r i e c h m e r e r had b r e a c h e d the s t a n d a r d 
of 
c a r e 
i n 
t h i s 
case 
by 
not 
p e r f o r m i n g 
an 
assessment 
t o 
d e t e r m i n e C r i t o p o u l o s ' s r i s k o f d e v e l o p i n g p r e s s u r e u l c e r s ; by 
not 
t u r n i n g and 
r e p o s i t i o n i n g 
C r i t o p o u l o s e v e r y 
two 
hours 
w h i l e he was 
a p a t i e n t i n the c a r d i a c - r e c o v e r y u n i t ; and 
by 
not d e v e l o p i n g a p l a n o f c a r e f o r the p r e v e n t i o n of p r e s s u r e 
u l c e r s . 
She 
a l s o 
t e s t i f i e d 
t h a t F l e m i n g 
and 
R u s h i n g 
had 
1 C r i t o p o u l o s 
i n i t i a l l y 
i n c l u d e d L o r e t t a Beckham, Mary 
F o o t e , Melody E r n e s t , and B e t t y Brinkman as d e f e n d a n t s . 
On 
J a n u a r y 
28, 
2009, 
the 
p a r t i e s 
e n t e r e d 
a 
" S t i p u l a t i o n 
of 
D i s m i s s a l as t o Defendants L o r e t t a Beckham, Melody E r n e s t , 
B e t t y Brinkman, and Mary F o o t e . " 
On F e b r u a r y 
5, 2009, the 
t r i a l 
c o u r t d i s m i s s e d Beckham, E r n e s t , Brinkman, and 
Foote 
w i t h p r e j u d i c e . 
4 
1090946 
b r e a c h e d the s t a n d a r d o f c a r e by not p r o v i d i n g complete wound 
assessments a f t e r the p r e s s u r e u l c e r d e v e l o p e d . 
A t t r i a l , the 
d e f e n s e moved t o e x c l u d e Jones's t e s t i m o n y on the ground t h a t 
she was not a s i m i l a r l y s i t u a t e d h e a l t h - c a r e p r o v i d e r under 
§ 6-5-548, A l a . Code 1975. 
The 
t r i a l c o u r t d e n i e d the m o t i o n . 
Holcombe and the d e f e n d a n t s f i l e d motions f o r a judgment 
as a m a t t e r o f law a t the c l o s e o f C r i t o p o u l o s ' s c a s e - i n - c h i e f 
and a g a i n a t the c l o s e o f a l l 
the e v i d e n c e , w h i c h the 
t r i a l 
c o u r t d e n i e d . 
On 
J a n u a r y 
19, 
2010, 
the j u r y 
r e t u r n e d a 
v e r d i c t 
i n 
f a v o r 
o f 
C r i t o p o u l o s 
and 
a g a i n s t 
R u s h i n g , 
O s t r i e c h m e r e r , F l e m i n g , and S p r i n g h i l l i n the sum o f $300,000. 
The j u r y a l s o r e t u r n e d a v e r d i c t i n f a v o r o f S c o t t Holcombe 
and a g a i n s t C r i t o p o u l o s . 
On F e b r u a r y 11, 2010, the d e f e n d a n t s 
f i l e d a r e n e w a l o f 
t h e i r motions f o r a judgment as a m a t t e r o f law o r , i n the 
a l t e r n a t i v e , f o r a new 
t r i a l . 
C r i t o p o u l o s f i l e d an o p p o s i t i o n 
to the m o t i o n . 
On F e b r u a r y 26, 2010, the t r i a l c o u r t d e n i e d 
the 
d e f e n d a n t s ' m o t i o n . 
T h i s a p p e a l f o l l o w e d . 
S t a n d a r d o f Review 
"'The 
s t a n d a r d o f 
r e v i e w 
a p p l i c a b l e 
t o 
whether an e x p e r t s h o u l d be p e r m i t t e d t o 
t e s t i f y 
i s w e l l 
s e t t l e d . 
The 
m a t t e r i s 
" l a r g e l y 
d i s c r e t i o n a r y 
w i t h 
the 
t r i a l 
5 
1090946 
c o u r t , and 
t h a t c o u r t ' s judgment w i l l 
not 
be 
d i s t u r b e d 
absent 
an 
abuse 
of 
d i s c r e t i o n . " 
Hannah 
v. 
Gregg, 
B l a n d 
& 
 
B e r r y , 
I n c . , 
840 
So. 
2d 
839, 
850 
( A l a . 
2002). 
We now 
r e f e r t o t h a t s t a n d a r d as a 
t r i a l 
c o u r t ' s " e x c e e d i n g i t s 
d i s c r e t i o n . " 
See, 
e.g., 
V e s t a 
F i r e I n s . Corp. v. Milam  
& Co. 
C o n s t r . , 
I n c . , 
901 
So. 
2d 
84, 
106 
( A l a . 
2004) 
("Our 
r e v i e w 
of 
the 
r e c o r d 
s u p p o r t s 
the 
c o n c l u s i o n 
t h a t 
the 
t r i a l 
c o u r t 
d i d 
not 
exceed 
i t s d i s c r e t i o n i n 
f i n d i n g t h a t Jones was 
p r o p e r l y 
q u a l i f i e d 
as 
an 
e x p e r t 
under 
Rule 
702[, 
A l a . 
R. 
E v i d . , ] 
and 
i n 
c o n s i d e r i n g 
h i s 
t e s t i m o n y . " ) . 
However, the s t a n d a r d 
i t s e l f 
has not changed.' 
"Kyser 
v. 
H a r r i s o n , 
908 
So. 
2d 
914, 
918 
( A l a . 
2 
0 
0 
5 ) . " 
R o b i n s o n v. B a p t i s t H e a l t h 
Sys., 
I n c . , 24 So. 
3d 1119, 
1125 
( A l a . 
C i v . App. 
2009). 
"'"The s t a n d a r d 
o f r e v i e w 
a p p l i c a b l e 
t o 
a 
motion 
f o r 
d i r e c t e d 
v e r d i c t 
or 
judgment n o t w i t h s t a n d i n g 
the v e r d i c t 
[now 
r e f e r r e d 
t o 
as 
a 
p r e v e r d i c t 
and 
a 
p o s t v e r d i c t 
m o t i o n 
f o r 
a judgment 
as 
a 
m a t t e r o f l a w ] i s i d e n t i c a l t o the 
s t a n d a r d 
used by 
the 
t r i a l 
c o u r t 
i n g r a n t i n g 
or 
d e n y i n g the motions i n i t i a l l y . 
Thus, when 
r e v i e w i n g 
the 
t r i a l 
c o u r t ' s 
r u l i n g 
on 
e i t h e r m o t i o n , we d e t e r m i n e whether 
t h e r e 
was 
s u f f i c i e n t 
e v i d e n c e 
t o 
produce 
a 
c o n f l i c t 
w a r r a n t i n g 
j u r y 
c o n s i d e r a t i o n . 
And, 
l i k e the t r i a l c o u r t , we must v i e w any 
e v i d e n c e 
most 
f a v o r a b l y 
t o 
the 
non-movant."' 
6 
1090946 
" G l e n l a k e s 
R e a l t y Co. 
v. Norwood, 721 
So. 
2d 
174, 
177 
( A l a . 1998) 
( q u o t i n g Bussey v. John Deere 
Co., 
531 So. 2d 860, 
863 
( A l a . 
1 9 8 8 ) ) . " 
P a r k e r v. W i l l i a m s , 977 So. 2d 476, 
480 
( A l a . 2007) 
. 
D i s c u s s i o n 
In t h i s case, the d e f e n d a n t s argue t h a t the 
t r i a l 
c o u r t 
e r r o n e o u s l y 
a l l o w e d Penny Jones t o t e s t i f y as 
C r i t o p o u l o s ' s 
s t a n d a r d - o f - c a r e 
e x p e r t because, they argue, she 
was 
not 
a 
s i m i l a r l y s i t u a t e d h e a l t h - c a r e p r o v i d e r as t o the 
i n d i v i d u a l 
d e f e n d a n t s , 
as r e q u i r e d by § 6-5-548, A l a . Code 1975. 
The 
Alabama M e d i c a l L i a b i l i t y A c t , § 6-5-480 e t seq. and § 6-5-540 
e t seq., 
A l a . Code 1975, 
i n c l u d e s the 
f o l l o w i n g p r o v i s i o n s 
r e g a r d i n g m e d i c a l - m a l p r a c t i c e 
c l a i m s : 
"(a) 
In any 
a c t i o n f o r i n j u r y 
or damages 
or 
w r o n g f u l 
d e a t h , 
whether 
i n c o n t r a c t 
or 
i n 
t o r t , 
a g a i n s t 
a h e a l t h c a r e 
p r o v i d e r 
f o r b r e a c h of 
the 
s t a n d a r d 
o f 
c a r e , 
the 
p l a i n t i f f 
s h a l l 
have 
the 
burden o f p r o v i n g by s u b s t a n t i a l e v i d e n c e t h a t 
the 
h e a l t h 
c a r e 
p r o v i d e r 
f a i l e d 
t o 
e x e r c i s e 
such 
r e a s o n a b l e 
c a r e , 
s k i l l , 
and 
d i l i g e n c e 
as 
o t h e r 
s i m i l a r l y s i t u a t e d h e a l t h c a r e p r o v i d e r s i n the same 
g e n e r a l 
l i n e 
of 
p r a c t i c e 
o r d i n a r i l y 
have 
and 
e x e r c i s e i n a l i k e 
case. 
"(b) 
N o t w i t h s t a n d i n g 
any 
p r o v i s i o n 
of 
the 
Alabama R u l e s 
o f E v i d e n c e t o the c o n t r a r y , i f the 
h e a l t h c a r e p r o v i d e r whose b r e a c h o f the s t a n d a r d of 
c a r e i s c l a i m e d t o have c r e a t e d the cause of a c t i o n 
i s not c e r t i f i e d by an a p p r o p r i a t e American b o a r d as 
b e i n g a s p e c i a l i s t , 
i s not t r a i n e d and 
e x p e r i e n c e d 
i n a m e d i c a l 
s p e c i a l t y , or does not h o l d h i m s e l f or 
7 
1090946 
h e r s e l f o u t as a s p e c i a l i s t , a ' s i m i l a r l y 
s i t u a t e d 
h e a l t h c a r e p r o v i d e r ' i s one who meets a l l o f t h e 
f o l l o w i n g 
q u a l i f i c a t i o n s : 
"(1) I s l i c e n s e d by t h e a p p r o p r i a t e 
r e g u l a t o r y b o a r d o r agency o f t h i s o r some 
o t h e r 
s t a t e . 
"(2) I s t r a i n e d and e x p e r i e n c e d i n the 
same d i s c i p l i n e o r s c h o o l o f p r a c t i c e . 
"(3) 
Has 
p r a c t i c e d 
i n t h e 
same 
d i s c i p l i n e o r s c h o o l o f p r a c t i c e d u r i n g t h e 
year p r e c e d i n g t h e date t h a t t h e a l l e g e d 
b r e a c h o f t h e s t a n d a r d o f c a r e o c c u r r e d . 
II 
"(e) The purpose o f t h i s s e c t i o n i s 
t o e s t a b l i s h 
a 
r e l a t i v e 
s t a n d a r d 
o f 
c a r e 
f o r h e a l t h 
c a r e 
p r o v i d e r s . 
A h e a l t h c a r e p r o v i d e r may t e s t i f y as an  
e x p e r t w i t n e s s i n any a c t i o n f o r i n j u r y o r damages  
a g a i n s t 
a n o t h e r 
h e a l t h c a r e 
p r o v i d e r based on a  
b r e a c h o f t h e s t a n d a r d o f c a r e o n l y i f he o r she 
i s 
 
a 
' s i m i l a r l y 
s i t u a t e d 
h e a l t h 
c a r e 
p r o v i d e r ' as  
d e f i n e d above." 
§ 6-5-548, A l a . 
Code 1975 (emphasis added). 
" S t a n d a r d o f 
c a r e " i s d e f i n e d a s : 
"The 
s t a n d a r d 
o f 
c a r e 
i s t h a t 
l e v e l 
o f 
such 
r e a s o n a b l e 
c a r e , 
s k i l l , 
and d i l i g e n c e 
as 
o t h e r 
 
s i m i l a r l y s i t u a t e d h e a l t h c a r e p r o v i d e r s i n 
t h e same  
g e n e r a l 
l i n e 
o f 
p r a c t i c e , 
o r d i n a r i l y 
have and  
e x e r c i s e i n l i k e c a s e s . 
A b r e a c h o f t h e s t a n d a r d o f 
c a r e i s t h e f a i l u r e by a h e a l t h c a r e p r o v i d e r t o 
comply w i t h t h e s t a n d a r d o f c a r e , which 
f a i l u r e 
p r o x i m a t e l y 
causes 
p e r s o n a l 
i n j u r y 
o r 
w r o n g f u l 
d e a t h . 
T h i s d e f i n i t i o n 
a p p l i e s t o a l l a c t i o n s 
f o r 
i n j u r i e s o r damages o r w r o n g f u l 
d e a t h whether i n 
8 
1090946 
c o n t r a c t or t o r t and whether based on i n t e n t i o n a l or 
u n i n t e n t i o n a l c o n d u c t . " 
§ 6-5-542(2), A l a . Code 1975 
(emphasis added). 
I n 
t h i s 
c a s e , O s t r i e c h m e r e r , R u s h i n g , Holcombe, 
and 
F l e m i n g were a l l 
n u r s e s i n the c a r d i a c - r e c o v e r y 
u n i t . 
Each 
was r e s p o n s i b l e f o r the t o t a l c a r e o f C r i t o p o u l o s i m m e d i a t e l y 
f o l l o w i n g h i s CABG. 
Penny Jones t e s t i f i e d t h a t , a t the time o f t r i a l , she was 
l i c e n s e d t o p r a c t i c e n u r s i n g i n N o r t h C a r o l i n a and t h a t she 
has 
been 
l i c e n s e d 
t h e r e 
s i n c e 
1995 
o r 
1996. 
She 
a l s o 
t e s t i f i e d t h a t she was c e r t i f i e d as a wound-care n u r s e by the 
Wound, Ostomy and C o n t i n e n c e Nurses S o c i e t y and t h a t she was 
a l s o 
c e r t i f i e d 
as 
a 
wound 
s p e c i a l i s t 
by 
the 
American 
A s s o c i a t i o n o f Wound Management. 
W i t h r e g a r d t o her t r a i n i n g , Jones t e s t i f i e d t h a t a f t e r 
h i g h s c h o o l she c o m p l e t e d her a s s o c i a t e ' s degree i n n u r s i n g . 
A f t e r she c o m p l e t e d her degree, she s t a r t e d b e d s i d e n u r s i n g . 
Jones t e s t i f i e d t h a t she had worked i n the i n t e n s i v e - c a r e u n i t 
("ICU"); t h a t she had worked a 
l i t t l e b i t i n the 
emergency 
room; t h a t she had worked i n n u r s i n g homes; and t h a t she had 
"worked 
... 
j u s t about everywhere e x c e p t f o r the 
o p e r a t i n g 
room." 
9 
1090946 
Jones 
t e s t i f i e d 
t h a t she l a t e r 
r e t u r n e d t o s c h o o l and 
o b t a i n e d h e r b a c h e l o r ' s degree. 
A f t e r t h a t , she went back t o 
s c h o o l 
and o b t a i n e d 
h e r m a s t e r ' s degree i n 1989. 
Jones 
t e s t i f i e d 
t h a t 
f o r h e r master's 
degree 
she 
f o c u s e d 
on 
c a r d i o p u l m o n a r y s t u d i e s , w h i c h i n c l u d e s the h e a r t and l u n g s , 
but 
t h a t h e r p a r t i c u l a r 
f o c u s was the l u n g s . 
She 
a l s o 
t e s t i f i e d 
t h a t 
she s u b s e q u e n t l y 
worked a t a 
r e s p i r a t o r y 
h o s p i t a l i n 
Los A n g e l e s , C a l i f o r n i a , and t h a t h e r work t h e r e 
i n c l u d e d weaning p a t i e n t s i n the ICU from v e n t i l a t o r s . 
Jones t e s t i f i e d t h a t , i n 
1992, she moved t o 
Durham, N o r t h 
C a r o l i n a , 
and went t o work a t Duke 
U n i v e r s i t y 
H o s p i t a l 
("Duke"). 
She t e s t i f i e d 
t h a t she i s the wound-management 
c l i n i c a l 
nurse 
s p e c i a l i s t 
t h e r e 
and 
t h a t 
she wrote the 
p o l i c i e s and p r o c e d u r e s f o r 
Duke r e g a r d i n g wound management 
and t r e a t i n g p r e s s u r e 
u l c e r s . 
Jones f u r t h e r t e s t i f i e d 
t h a t , 
i n the mid-1990s, she s t a r t e d a " c o n s u l t 
s e r v i c e " a t Duke. 
Jones s t a t e d : 
"There's a c o n s u l t 
s e r v i c e 
t h a t we have a t Duke 
H o s p i t a l , and I run t h a t s e r v i c e , w h i c h means 
t h a t 
p e o p l e -- o t h e r n u r s e s , the p h y s i c i a n s 
w i l l ask us 
t o come and see a p a t i e n t who has a wound, and the 
wound c o u l d be a n y t h i n g 
from a p o s t - s u r g i c a 1 
wound 
t h a t 
h a s n ' t 
h e a l e d , 
a d i a b e t i c 
f o o t 
u l c e r , 
s k i n 
t e a r s , p r e s s u r e u l c e r s , p r e t t y much -- b u r n s , p r e t t y 
much any k i n d o f wound 
t h a t you might t h i n k o f , 
10 
1090946 
w e ' l l see a p a t i e n t and d e t e r m i n e what we 
s h o u l d 
be 
-- what we 
s h o u l d 
do f o r the wound t o h e l p 
i t t o 
h e a l as w e l l as what the p a t i e n t needs t o do t o h e l p 
the wound t o h e a l . " 
(Emphasis added.) 
Jones 
t e s t i f i e d 
t h a t as a 
c l i n i c a l 
s p e c i a l i s t she 
a l s o 
w r i t e s p o l i c i e s f o r Duke. 
She 
a l s o t e s t i f i e d t h a t Duke has 
a 
" S k i n Care Champion Program" t h a t i n v o l v e s b e d s i d e n u r s e s 
who 
have been 
s p e c i a l l y 
t r a i n e d i n the 
p r e v e n t i o n 
o f 
p r e s s u r e 
u l c e r s ; t h a t t h o s e s p e c i a l l y t r a i n e d b e d s i d e n u r s e s then 
go 
back and 
t r a i n 
o t h e r 
n u r s e s on 
t h e i r 
f l o o r s ; and 
t h a t 
she 
s p e n t a l o t o f time i n t h a t program t e a c h i n g the n u r s e s what 
t o do t o p r e v e n t p r e s s u r e 
u l c e r s . 
Jones t e s t i f i e d t h a t 
she 
and her a d m i n i s t r a t o r d e v e l o p e d a program t h a t i s now 
c a l l e d 
the Wound Management I n s t i t u t e . 
She 
a l s o t e s t i f i e d t h a t 
she 
had 
d e v e l o p e d 
a 
s t a n d a r d 
o f 
c a r e 
r e g a r d i n g 
the 
c a r e 
o f 
p a t i e n t s 
w i t h 
c h r o n i c 
s k i n wounds, 
w h i c h 
w o u l d 
i n c l u d e 
p r e s s u r e 
u l c e r s , 
and 
t h a t 
t h a t 
s t a n d a r d 
o f 
care 
i n c l u d e d 
p a t i e n t s 
i n ICUs who 
had 
r e c e n t l y undergone 
c a r d i a c - b y p a s s 
s u r g e r y . 
Jones 
t e s t i f i e d 
t h a t she 
had p r o v i d e d wound-management 
s e r v i c e s t o c a r d i a c p a t i e n t s s i n c e the mid-1990s; t h a t , from 
t h a t time u n t i l the time o f 
t r i a l , 
she had p r o v i d e d hands-on 
11 
1090946 
wound-management care t o c r i t i c a l p a t i e n t s i n 
an ICU s e t t i n g ; 
and t h a t she was p r o v i d i n g such c a r e as r e c e n t l y as the F r i d a y 
b e f o r e 
the 
t r i a l 
s t a r t e d . 
She 
f u r t h e r 
t e s t i f i e d 
t h a t , 
s p e c i f i c t o 
wound c a r e and p r e v e n t i n g p r e s s u r e u l c e r s , she 
had 
t a u g h t d o c t o r s , n u r s e s , and o t h e r h e a l t h - c a r e p r o v i d e r s how t o 
t a k e care o f c a r d i a c p a t i e n t s i n an i n t e n s i v e - c a r e 
s e t t i n g . 
She f u r t h e r t e s t i f i e d 
t h a t , on average 10 t i m e s a week, she 
p r o v i d e d wound-care management t o p a t i e n t s who had r e c e n t l y 
undergone c a r d i a c - b y p a s s 
s u r g e r y and who were i n the 
I C U . 
Jones t e s t i f i e d t h a t as a wound-management s p e c i a l i s t she 
would p e r f o r m some o f the same c l i n i c a l s e r v i c e s as a r e g u l a r 
c a r d i a c - c a r e nurse p e r f o r m e d . She w o u l d check v i t a l s i g n s and 
c o n d u c t 
s k i n a s s e s s m e n t s . 
She w o u l d 
a l s o 
p a r t i c i p a t e i n 
e i t h e r w r i t i n g o r r e v i e w i n g c a r e p l a n s . The F r i d a y b e f o r e the 
t r i a l was the l a s t time she had p r o v i d e d wound-management c a r e 
t o a c a r d i a c p a t i e n t i n an i n t e n s i v e - c a r e s e t t i n g . 
She a l s o 
t e s t i f i e d 
t h a t 
she had t r e a t e d 
o r managed 
p o s t o p e r a t i v e 
c a r d i a c p a t i e n t s t o d e t e c t and p r e v e n t p r e s s u r e 
u l c e r s and 
t h a t she had done so as r e c e n t l y as the week b e f o r e 
t r i a l . 
However, Jones t e s t i f i e d t h a t she has n o t p r a c t i c e d as an 
i n t e n s i v e - c a r e c a r d i a c n u r s e . She a l s o t e s t i f i e d t h a t she 
had 
12 
1090946 
never p r o v i d e d 
d i r e c t , hands-on 
care 
as 
a 
s t a f f n u r s e 
t o 
p a t i e n t s l i k e C r i t o p o u l o s , who 
was 
i n immediate 
p o s t - r e c o v e r y 
i n the c a r d i a c - r e c o v e r y 
u n i t . 
Jones f u r t h e r t e s t i f i e d 
t h a t 
she had never seen a CABG p a t i e n t who 
had j u s t had s u r g e r y 
t o 
implement p r e v e n t i v e m e a s u r e s . 
A d d i t i o n a l l y , she 
t e s t i f i e d 
t h a t she 
had 
n o t , 
as a s t a f f n u r s e , d e t e r m i n e d the 
c a r d i a c 
s t a b i l i t y 
of 
a f r e s h post-CABG p a t i e n t 
f o r the purpose 
of 
p r o v i d i n g hands-on complete c a r e . 
She 
f u r t h e r t e s t i f i e d 
t h a t 
she had not worked i n an ICU s e t t i n g as a b e d s i d e nurse s i n c e 
1992. 
Jones 
t e s t i f i e d 
t h a t 
she 
had 
r e v i e w e d 
C r i t o p o u l o s ' s 
m e d i c a l r e c o r d s , p a r t i c u l a r l y h i s v i t a l s i g n s , d u r i n g h i s time 
i n the c a r d i a c - r e c o v e r y u n i t and t h a t she had d e t e r m i n e d t h a t 
he 
was 
s t a b l e enough t o 
t u r n . 
On 
c r o s s - e x a m i n a t i o n , 
she 
t e s t i f i e d t h a t she had never worked as a s t a f f nurse i n a u n i t 
d e d i c a t e d t o p a t i e n t s coming d i r e c t l y out of c a r d i a c 
s u r g e r y ; 
t h a t , i n her work, she had 
not gone t o the 
c a r d i a c - r e c o v e r y 
u n i t f o r the purpose of p r o v i d i n g hands-on p r e v e n t i v e care f o r 
a p a t i e n t ; t h a t she had o n l y gone t o the c a r d i a c - r e c o v e r y 
u n i t 
as e d u c a t i o n a l s u p p o r t f o r the n u r s e s who worked i n the u n i t ; 
and t h a t , a t Duke, the p r e v e n t i o n of p r e s s u r e 
s o r e s i n c a r d i a c 
13 
1090946 
r e c o v e r y was done by t h e n u r s i n g s t a f f based on p r o t o c o l s she 
had d e v e l o p e d . 
Jones t e s t i f i e d t h a t , e x c l u d i n g wound c a r e , 
she does n o t p r o v i d e 
care t o f r e s h p o s t o p e r a t i v e 
p a t i e n t s as 
a 
s t a f f 
n u r s e . 
A l s o , on c r o s s - e x a m i n a t i o n , 
t h e f o l l o w i n g 
o c c u r r e d : 
"[DEFENSE COUNSEL:] 
R i g h t . 
And you don't 
c o n s i d e r 
y o u r s e l f t o be an e x p e r t on n u r s i n g 
c a r e 
when i t comes t o e v a l u a t i n g t h e c a r d i a c s t a t u s o f a 
post-CABG p a t i e n t i n r e c o v e r y , do you? 
"[JONES:] 
I would be a b l e t o e v a l u a t e 
t h e i r 
b l o o d 
p r e s s u r e , 
t h e i r mean a r t e r i a l p r e s s u r e . 
So 
some p i e c e s 
o f i t , c e r t a i n l y , I can. 
B u t t h e 
o v e r a l l , no. 
"[DEFENSE COUNSEL:] I asked you on page 120 o f 
your d e p o s i t i o n : 'You would n o t c o n s i d e r y o u r s e l f t o 
be an e x p e r t on n u r s i n g when i t comes t o e v a l u a t i n g 
c a r d i a c s t a t u s o f a post-CABG p a t i e n t i n r e c o v e r y ; 
i s t h a t c o r r e c t ? ' 
And what was your answer? 
"[JONES:] 
That i t i s c o r r e c t . 
"[DEFENSE COUNSEL:] An u n q u a l i f i e d c o r r e c t ; 
i s 
t h a t 
r i g h t ? 
"[JONES:] 
C o r r e c t . 
"[DEFENSE COUNSEL:] And you're n o t 
q u a l i f i e d t o 
p r o v i d e 
c o n t i n u o u s hands-on c a r e t o a p a t i e n t i n 
c a r d i a c r e c o v e r y , a r e you? 
"[JONES:] Not w i t h o u t a d d i t i o n a l t r a i n i n g , no. 
"[DEFENSE COUNSEL:] Okay. And you're n o t 
ACLS 
q u a l i f i e d , a r e you? 
14 
1090946 
"[JONES:] 
No. 
"[DEFENSE COUNSEL:] 
What i s ACLS? 
"[JONES:] 
Advanced c a r d i a c 
l i f e 
s u p p o r t , 
I 
b e l i e v e . 
"[DEFENSE COUNSEL:] 
A l l r i g h t . 
And t h a t would 
be 
something 
t h a t any nurse 
w o r k i n g i n c a r d i a c 
r e c o v e r y would have t o 
be? 
"[JONES:] 
I would c e r t a i n l y hope so. 
"[DEFENSE COUNSEL:] 
A l l 
r i g h t . And s o , 
you 
would n o t be a b l e t o p r o v i d e advanced c a r d i a c 
l i f e 
s u p p o r t t o a p a t i e n t i n need i n c a r d i a c 
r e c o v e r y , 
would you? 
"[JONES:] 
C o r r e c t . 
"[DEFENSE COUNSEL:] Now, i n t h i s c a s e , we have 
h e a r d terms such as c a r d i a c o u t p u t , c a r d i a c 
i n d e x , 
o t h e r terms t h a t w i l l be d i s c u s s e d and a p p l i c a b l e t o 
p a t i e n t s coming out o f c a r d i a c s u r g e r y , c o r r e c t ? 
"[JONES:] I'm s o r r y . I haven't h e a r d 
t e s t i m o n y 
about c a r d i a c i n d e x o r o u t p u t . 
"[DEFENSE COUNSEL:] 
A l l r i g h t . 
W e l l , you s a i d 
you r e v i e w e d t h e v i t a l 
s i g n s ? 
"[JONES:] 
I 
d i d . 
"[DEFENSE COUNSEL:] Okay. L e t 
me j u s t -- l e t ' s 
l o o k a t some o f t h e s e . 
And I b e l i e v e t h i s , i n f a c t , 
may be the f i r s t page o r f i r s t s e t o f v i t a l 
s i g n s 
when Mr. C r i t o p o u l o s came out o f s u r g e r y . 
See a t 
the bottom i t ' s A p r i l 1 1 t h , which was t h e day he 
came out o f s u r g e r y , 
c o r r e c t ? 
"[JONES:] 
C o r r e c t . 
15 
1090946 
II 
"[DEFENSE 
COUNSEL:] 
And 
Nurse 
J a n e l 
O s t r i e c h m e r e r 
was h i s 
n u r s e ; i s t h a t 
r i g h t ? 
"[JONES:] Yes. 
"[DEFENSE COUNSEL:] Okay. And J a n e l would have 
e n t e r e d t h e s e e n t r i e s p r e s u m a b l y , c o r r e c t ? 
"[JONES:] 
P r e s u m a b l y , yeah. 
"[DEFENSE COUNSEL:] 
Okay. 
S o , coming out 
o f 
s u r g e r y , Mr. C r i t o p o u l o s had some b l o o d 
p r e s s u r e s 
t a k e n . 
One such p r e s s u r e was an MAP. What i s t h a t ? 
"[JONES:] 
Mean a r t e r i a l 
p r e s s u r e . 
"[DEFENSE COUNSEL:] Do you 
know what t h e n u r s e s 
were l o o k i n g f o r 
i n 
a number w i t h r e g a r d t o t h e MAP 
w i t h Mr. C r i t o p o u l o s ? 
"[JONES:] 
S p e c i f i c t o Mr. C r i t o p o u l o s , no. 
"[DEFENSE COUNSEL:] Okay. Do you 
know how t h a t 
number, MAP h e r e , w h i c h i s 82, would t h a t be an 
a p p r o p r i a t e 
mean 
a r t e r i a l 
p r e s s u r e 
f o r Mr. 
C r i t o p o u l o s coming out of s u r g e r y ? 
"[JONES:] 
I t was my a s s u m p t i o n i t 
was, g i v e n 
t h a t h i s 
b l o o d p r e s s u r e was i n 
the normal range. 
"[DEFENSE COUNSEL:] 
A l l 
r i g h t . 
So, you're 
s a y i n g h i s 
p r e s s u r e was i n 
t h e normal range, 
r i g h t ? 
"[JONES:] 
Yes, i t ' s 126 over -- i s t h a t 60? 
"[DEFENSE COUNSEL:] 
And so, and t h e 
MAP o f 82 
was a p p r o p r i a t e f o r 
him? 
"[JONES:] 
As b e s t I u n d e r s t o o d , y e s . 
16 
1090946 
"[DEFENSE COUNSEL:] 
And what about t h e p u l s e , 
112? 
"[JONES:] 
A l i t t l e h i g h . 
I d i d n ' t a n t i c i p a t e 
t h a t was t o o h i g h coming out o f s u r g e r y . 
"[DEFENSE COUNSEL:] 
A l l r i g h t . 
And l e t ' s l o o k 
a t t h e m e d i c a t e d 
d r i p s . 
What m e d i c a t e d 
d r i p s was 
Mr. C r i t o p o u l o s on a t t h e time? 
"[JONES:] 
He's 
on 
some 
e p i n e p h r i n e , 
n e o s y n e p h r i n e and n i t r o g l y c e r i n . 
"[DEFENSE 
COUNSEL:] 
And 
what 
a r e 
t h o s e 
c a l c u l a t e d t o 
do? 
"[JONES:] 
The f i r s t two, t h e e p i n e p h r i n e and 
n e o s y n e p h r i n e , 
a r e what's c a l l e d v a s o a c t i v e 
drugs, 
w h i c h a r e m e d i c a t i o n s 
t h a t h e l p t o keep t h e b l o o d 
p r e s s u r e i n 
t h e normal range. 
And n i t r o g l y c e r i n i s 
-- t h e b e s t way t o d e s c r i b e i t 
i s 
f o r y o u r h e a r t . 
"[DEFENSE COUNSEL:] 
And t h o s e a r e m e d i c a t i o n s 
t h a t a nurse i n 
c a r d i a c r e c o v e r y would p o s s i b l y have 
t o a d j u s t f r o m time t o time depending on t h e 
changes 
i n b l o o d p r e s s u r e o f t h e p a t i e n t ? 
"[JONES:] Yes. 
"[DEFENSE COUNSEL:] Okay. A r e 
you q u a l i f i e d t o 
make t h o s e 
k i n d o f a d j u s t m e n t s 
i n t h o s e 
k i n d o f 
m e d i c a t i o n s f o r 
a p a t i e n t ? 
"[JONES:] F o r p o s t - s u r g i c a l , no, I wouldn't be 
q u a l i f i e d f o r t h a t . 
"[DEFENSE COUNSEL:] 
Okay. 
A l l 
r i g h t . 
And 
under 
hemodynamic 
m o n i t o r i n g , 
we 
have 
c a r d i a c 
o u t p u t , 4.1 — excuse me, 4.8; i s t h a t c o r r e c t ? 
"[JONES:] Yes. 
17 
1090946 
"[DEFENSE COUNSEL:] A l l 
r i g h t . 
Do you know i f 
t h a t i s an a p p r o p r i a t e number f o r Mr. 
C r i t o p o u l o s 
coming out o f s u r g e r y ? 
"[JONES:] 
I do n o t . 
"[DEFENSE COUNSEL:] 
T h a t ' s not something t h a t 
you m o n i t o r ? 
"[JONES:] 
No. 
"[DEFENSE COUNSEL:] A l l 
r i g h t . 
What about the 
c a r d i a c 
i n d e x o f 2.2, do you know i f t h a t ' s an 
a p p r o p r i a t e number f o r 
Mr. C r i t o p o u l o s coming out o f 
s u r g e r y ? 
"[JONES:] I do n o t . I t ' s 
not something I would 
m o n i t o r . 
"[DEFENSE COUNSEL:] Okay. What about t h e SVR? 
What i s SVR? 
"[JONES:] 
Oh, gosh. 
T h a t ' s making me go back. 
I don't remember enough t o be a b l e t o e x p l a i n i t . 
"[DEFENSE COUNSEL:] 
Okay. How about s y s t e m i c 
v a s c u l a r r e s i s t a n c e ? 
Does t h a t sound 
f a m i l i a r ? 
"[JONES:] 
C o u l d be. 
"[DEFENSE COUNSEL:] Okay. And i t 
i s 1206. 
Do 
you know whether 
t h a t ' s an a p p r o p r i a t e number f o r 
Mr. C r i t o p o u l o s ? 
"[JONES:] 
I do n o t . 
"[DEFENSE COUNSEL:] 
Okay. 
CVP, do you know 
what t h a t i s ? 
"[JONES:] 
Yes. 
"[DEFENSE COUNSEL:] 
What's t h a t ? 
18 
1090946 
"[JONES:] 
C e n t r a l venous p r e s s u r e . 
"[DEFENSE COUNSEL:] 
And i t 
i s 
one. 
"[JONES:] 
Uh-huh. 
"[DEFENSE COUNSEL:] 
Do you know i f 
t h a t ' s an 
a p p r o p r i a t e number f o r 
Mr. C r i t o p o u l o s ? 
"[JONES:] 
Seems a l i t t l e l o w , 
b u t I don't know 
what t h e y were s h o o t i n g f o r , f o r him. 
"[DEFENSE COUNSEL:] 
Okay. S o , a l l 
o f t h e s e 
t h i n g s t h a t we've t a l k e d a b o u t , b l o o d p r e s s u r e s , 
t h e 
c a r d i a c o u t p u t , c a r d i a c i n d e x , SVR, CVP, 
m e d i c a t e d 
d r i p s , a l l 
o f t h o s e t h i n g s have t o be m o n i t o r e d by 
the n u r s e s w o r k i n g i n c a r d i a c r e c o v e r y , c o r r e c t ? 
"[JONES:] Yes. 
"[DEFENSE COUNSEL:] Okay. And t h e y ' r e watched 
v e r y c l o s e l y , a r e n ' t 
t h e y ? 
"[JONES:] 
They a r e . They s h o u l d be. 
"[DEFENSE COUNSEL:] 
Because most o f t h e t i m e , 
the 
n u r s e s 
work one t o one w i t h t h e p a t i e n t o r 
p o s s i b l y one t o t w o ; 
i s t h a t r i g h t ? 
"[JONES:] 
I t ' s v e r y 
t y p i c a l 
r i g h t 
a f t e r 
s u r g e r y , y e s . 
"[DEFENSE COUNSEL:] 
R i g h t . 
Okay. 
B u t t h i s 
k i n d o f m o n i t o r i n g i s 
n o t something t h a t you do? 
"[JONES:] 
Not a l l 
o f i t . 
As I mentioned, I do 
m o n i t o r and l o o k a t b l o o d p r e s s u r e and p u l s e . 
"[DEFENSE COUNSEL:] 
Okay. 
"[JONES:] 
And oxygen s a t u r a t i o n . 
19 
1090946 
"[DEFENSE COUNSEL:] 
B u t t h e o t h e r 
i t e m s we 
d i s c u s s e d , you do n o t ? 
"[JONES:] 
Not t y p i c a l l y , no. 
"[DEFENSE COUNSEL:] 
Now, do you 
t y p i c a l l y 
m o n i t o r p a t i e n t s on a b a l l o o n pump? 
"[JONES:] 
No. 
"[DEFENSE COUNSEL:] 
And as a 
d i r e c t 
c a r e 
p r o v i d e r , you've never had t o weigh t h e competing 
r i s k s 
o f 
r e p o s i t i o n i n g a post-CABG 
p a t i e n t i n 
r e c o v e r y , have you? 
"[JONES:] 
Post-CABG p e r s o n , no. 
"[DEFENSE COUNSEL:] 
A l l r i g h t . 
Now, i f 
tomorrow a t Duke U n i v e r s i t y H o s p i t a l you were 
t o l d 
t o 
r e p o r t 
t o t h e c a r d i a c 
r e c o v e r y 
u n i t o f t h e 
h o s p i t a l and b e g i n c a r i n g f o r p a t i e n t s i n c a r d i a c 
r e c o v e r y on a day-to-day b a s i s , you wouldn't 
f e e l 
c o m f o r t a b l e i n d o i n g t h a t , would you? 
"[JONES:] 
No. 
Not i n p r o v i d i n g a l l o f t h e i r 
c a r e , no. 
"[DEFENSE COUNSEL:] Now, you've i n d i c a t e d t h a t 
sometimes i t 
might n o t be a p p r o p r i a t e 
t o move a 
p a t i e n t i n c a r d i a c r e c o v e r y . 
I t h i n k you a l l u d e d t o 
t h a t e a r l i e r , d i d n ' t you? 
"[JONES:] Yes. 
"[DEFENSE COUNSEL:] 
Okay. 
And I t h i n k you've 
i n d i c a t e d t h a t , i n 
your o p i n i o n , b a s e d on t h e r e v i e w 
of Mr. C r i t o p o u l o s ' s 
v i t a l s i g n s , some o f w h i c h were 
i n c l u d e d on t h e document we j u s t 
l o o k e d a t , t h a t 
you, Nurse J o n e s , would have no p r o b l e m i n t u r n i n g 
Mr. C r i t o p o u l o s , 
c o r r e c t ? 
"[JONES:] 
C o r r e c t . 
20 
1090946 
"[DEFENSE COUNSEL:] 
And t h a t -- on a two-hour 
b a s i s , 
c o r r e c t ? 
"[JONES:] Yes. 
"[DEFENSE COUNSEL:] And t h a t was t h e 
whole time 
t h a t he was i n r e c o v e r y ? 
"[JONES:] Yes. 
"[DEFENSE COUNSEL:] A l l r i g h t . And you came t o 
t h a t c o n c l u s i o n by, as you say, r e v i e w i n g h i s v i t a l 
s i g n s , 
r i g h t ? 
"[JONES:] 
R e v i e w i n g t h e v i t a l s i g n s and some o f 
the c a r e t h a t was p r o v i d e d , y e s . 
"[DEFENSE COUNSEL:] 
R i g h t . 
And you t h i n k i t ' s 
i m p o r t a n t t o r e v i e w t h e v i t a l s i g n s and [be] a b l e t o 
come t o t h a t 
c o n c l u s i o n 
t h a t he c o u l d be 
t u r n e d , 
c o r r e c t ? 
"[JONES:] 
Sure. 
"[DEFENSE COUNSEL:] 
A l l 
r i g h t . 
And you would 
c e r t a i n l y 
e x p e c t 
any 
nurse 
t o 
r e v i e w 
Mr. 
C r i t o p o u l o s ' s 
v i t a l 
s i g n s 
b e f o r e 
u n d e r t a k i n g 
t h e 
t a s k o f t u r n i n g him, c o r r e c t ? 
"[JONES:] Yes. 
"[DEFENSE COUNSEL:] And i t 
would c e r t a i n l y not 
be w i t h i n t h e a p p r o p r i a t e 
s t a n d a r d o f c a r e t o t u r n 
him w i t h o u t e v a l u a t i n g t h o s e v i t a l s i g n s , would i t ? 
"[JONES:] 
C o r r e c t . " 
R e g a r d i n g t h e q u a l i f i c a t i o n s o f an e x p e r t w i t n e s s , 
t h i s C o u r t 
has 
s t a t e d : 
21 
1090946 
" I n M e d l i n 
v. 
Crosby, 
583 
So. 
2d 
1290 
( A l a . 
1991), 
t h i s C o u r t e s t a b l i s h e d a framework under 
§ 
6-5-548[, A l a . Code 1975,] f o r d e t e r m i n i n g whether 
an 
e x p e r t 
w i t n e s s 
i s q u a l i f i e d 
t o 
t e s t i f y 
i n 
a 
m e d i c a l m a l p r a c t i c e c a s e . 
P u r s u a n t 
t o M e d l i n , 
the 
t r i a l 
c o u r t must answer 
the 
f o l l o w i n g 
q u e s t i o n s 
b e f o r e 
d e t e r m i n i n g 
t h a t 
an 
e x p e r t 
w i t n e s s 
i s 
' s i m i l a r l y s i t u a t e d ' as t o the 
d e f e n d a n t : 
" ' ( 1 ) What i s the s t a n d a r d of c a r e a l l e g e d 
t o have b r e a c h e d ? 
(2) I s 
the 
d e f e n d a n t 
" h e a l t h c a r e p r o v i d e r " a s p e c i a l i s t i n the 
d i s c i p l i n e 
o r s c h o o l of p r a c t i c e 
of 
the 
s t a n d a r d 
of 
c a r e 
t h a t 
the 
c o u r t 
has 
p r e v i o u s l y d e t e r m i n e d 
i s a l l e g e d t o have 
been 
b r e a c h e d ? 
(3) Does 
the 
p r o f f e r e d 
e x p e r t 
w i t n e s s 
q u a l i f y 
as 
a 
" s i m i l a r l y 
s i t u a t e d h e a l t h c a r e p r o v i d e r " under 
the 
s u b s e c t i o n d e t e r m i n e d i n the second s t e p t o 
a p p l y ? ' 
"583 
So. 2d a t 1293." 
H e a l t h T r u s t , 
I n c . v. 
C a n t r e l l , 
689 
So. 
2d 
822, 
826 
( A l a . 
1997). 
In t h i s case, the defense p r e s e n t e d e v i d e n c e 
e s t a b l i s h i n g 
the f a c t t h a t C r i t o p o u l o s was i n c r i t i c a l c o n d i t i o n a f t e r the 
CABG s u r g e r y . 
The defense a l s o p r e s e n t e d e v i d e n c e 
i n d i c a t i n g 
t h a t , 
d u r i n g the time he was 
i n r e c o v e r y , 
C r i t o p o u l o s 
had 
i s s u e s w i t h p o s t o p e r a t i v e b l e e d i n g and h i g h p o t a s s i u m 
l e v e l s . 
The defense p r e s e n t e d f u r t h e r t e s t i m o n y t h a t C r i t o p o u l o s was 
on 
a 
v e n t i l a t o r much of 
the 
time 
he 
was 
i n the c a r d i a c -
r e c o v e r y u n i t and as t o h i s r e a c t i o n when he was 
t u r n e d 
o r 
22 
1090946 
r e p o s i t i o n e d . 
The defense a l s o p r e s e n t e d t e s t i m o n y r e g a r d i n g 
the p o t e n t i a l r i s k s o f t u r n i n g o r r e p o s i t i o n i n g C r i t o p o u l o s 
a t 
c e r t a i n t i m e s . 
F i n a l l y , the defense p r e s e n t e d t e s t i m o n y t h a t 
C r i t o p o u l o s was a t r i s k o f d e a t h d u r i n g some o f time he was i n 
the c a r d i a c - r e c o v e r y u n i t and t h a t n u r s e s had t o p r i o r i t i z e 
the d i f f e r e n t r i s k s f o r 
such a c r i t i c a l l y 
i l l 
p a t i e n t . 
The 
f i r s t q u e s t i o n we must answer t o d e t e r m i n e 
whether 
Jones i s s i m i l a r l y s i t u a t e d t o t h e i n d i v i d u a l d e f e n d a n t s i s 
what i s 
t h e s t a n d a r d o f c a r e a l l e g e d t o have been b r e a c h e d i n 
t h i s case. 
I t i s t r u e t h a t t h i s case a d d r e s s e s t h e i s s u e 
whether F l e m i n g , 
R u s h i n g , 
and 
O s t r i e c h m e r e r 
t o o k 
p r o p e r 
measures t o p r e v e n t 
t h e development o f p r e s s u r e 
u l c e r s . 
However, t h e overwhelming i s s u e i s 
whether t h e measures t a k e n 
by t h e n u r s e s i n t h i s case comported w i t h t h e s t a n d a r d o f c a r e 
f o r a post-CABG p a t i e n t l i k e C r i t o p o u l o s . 
In Dempsey v. P h e l p s , 700 So. 2d 1340 ( A l a . 1997), Dr. 
Dempsey, an o r t h o p a e d i c surgeon, p e r f o r m e d s u r g e r y t o c o r r e c t 
a c l u b f o o t on t h e P h e l p s e s ' son. A f t e r t h e s u r g e r y , p o r t i o n s 
of t h e son's f o o t had t o be amputated. On a p p e a l , Dr. Dempsey 
argued t h a t Dr. F r a n k C a t i n e l l a , t h e P h e l p s e s ' e x p e r t w i t n e s s , 
was n o t a " s i m i l a r l y s i t u a t e d h e a l t h c a r e p r o v i d e r " and t h a t 
23 
1090946 
the 
t r i a l 
c o u r t e r r e d when i t a l l o w e d 
C a t i n e l l a t o t e s t i f y 
r e g a r d i n g t h e s t a n d a r d o f c a r e . 
W i t h r e g a r d t o t h e s t a n d a r d 
of c a r e t h a t was a l l e g e d t o have been b r e a c h e d i n t h a t case, 
t h i s C o u r t s t a t e d : 
"As 
t o q u e s t i o n 
( 1 ) , Dempsey 
m a i n t a i n s 
t h a t the 
s t a n d a r d o f c a r e a l l e g e d t o be b r e a c h e d here i s t h a t 
of an o r t h o p e d i c surgeon p r o v i d i n g c a r e f o r 
a c h i l d 
a f t e r 
c l u b f o o t 
s u r g e r y . 
Dempsey 
argues 
t h a t Dr. 
C a t i n e l l a , who i s a b o a r d - c e r t i f i e d c a r d i o v a s c u l a r 
t h o r a c i c surgeon, was n o t q u a l i f i e d t o t e s t i f y as t o 
t h i s s t a n d a r d o f c a r e . 
However, we agree w i t h the 
t r i a l 
c o u r t 
t h a t 
t h i s 
case c o n c e r n e d ' a 
v a s c u l a r 
m a t t e r , n o t an o r t h o p e d i c m a t t e r ' -- i n o t h e r words, 
t h a t t h e P h e l p s e s ' 
c l a i m s 
r e g a r d e d Dr. Dempsey's 
a l l e g e d 
f a i l u r e t o p r o p e r l y t r e a t t h e c h i l d ' s f o o t 
d u r i n g t h e p o s t - s u r g e r y 
phase f o r t h e c i r c u l a t o r y 
and 
v a s c u l a r 
problems 
t h a t 
d e v e l o p e d 
a f t e r t h e 
s u r g e r y and c a s t i n g o f t h e f o o t . 
These problems a r e 
not 
i s o l a t e d t o t h i s t y p e o f s u r g e r y , and t h e y do 
not c o n c e r n t h e o r t h o p e d i c 
s u r g e r y p e r f o r m e d by Dr. 
Dempsey; t h e y c o n c e r n t h e t r e a t m e n t o f t h e i n f e c t i o n 
a f t e r t h e s u r g e r y 
t h a t r e s u l t e d i n the l o s s o f 
h i s 
f o o t . 
The s t a n d a r d o f c a r e a l l e g e d l y b r e a c h e d was 
t h a t o f a h e a l t h c a r e p r o v i d e r 
t r e a t i n g a p a t i e n t 
f o r p o s t - s u r g i c a l v a s c u l a r problems and i n f e c t i o n , 
w h i c h a r e n o t s p e c i f i c t o o r t h o p e d i c 
s u r g e r y . " 
700 So. 2d a t 1344. 
U n l i k e t h e s i t u a t i o n i n P h e l p s , t h e q u e s t i o n whether t h e 
n u r s e s 
i n 
t h i s 
case 
t o o k 
p r o p e r 
measures 
t o 
p r e v e n t 
C r i t o p o u l o s from d e v e l o p i n g 
p r e s s u r e 
u l c e r s i s s p e c i f i c a l l y 
r e l a t e d t o t h e i r d u t i e s i n c a r i n g f o r 
C r i t o p o u l o s as n u r s e s i n 
the c a r d i a c - r e c o v e r y 
u n i t . 
The o v e r r i d i n g q u e s t i o n i n t h i s 
24 
1090946 
c a s e i s whether, 
i n l i g h t o f C r i t o p o u l o s ' s c o n d i t i o n as a 
post-CABG p a t i e n t , the n u r s e s took p r o p e r measures t o p r e v e n t 
t h e development o f p r e s s u r e u l c e r s . 
T h e r e f o r e , the p r o p e r 
s t a n d a r d o f c a r e would be t h a t o f a c a r d i a c - r e c o v e r y nurse 
t r e a t i n g post-CABG p a t i e n t s t o p r e v e n t p r e s s u r e u l c e r s . 
The 
second 
q u e s t i o n we must ask 
i s i s the 
d e f e n d a n t 
h e a l t h - c a r e p r o v i d e r a s p e c i a l i s t i n the s c h o o l o f p r a c t i c e 
the C o u r t has d e t e r m i n e d i s a l l e g e d t o have been 
b r e a c h e d . 
W i t h r e g a r d t o t h i s q u e s t i o n , the d e f e n s e d i d not p r e s e n t any 
e v i d e n c e i n d i c a t i n g t h a t R u s h i n g , F l e m i n g , and O s t r i e c h m e r e r 
were b o a r d - c e r t i f i e d 
s p e c i a l i s t s . 
T h e r e f o r e , we must n e x t 
answer the 
t h i r d 
q u e s t i o n : 
whether Jones 
q u a l i f i e s 
as 
a 
" s i m i l a r l y s i t u a t e d h e a l t h c a r e p r o v i d e r " under § 
6-5-548(b), 
A l a . Code 1975.
2 
S e c t i o n 6-5-548(b), 
p r o v i d e s , p e r t i n e n t p a r t : 
" [ A ] ' s i m i l a r l y 
s i t u a t e d h e a l t h c a r e p r o v i d e r ' i s 
one who meets a l l 
o f the f o l l o w i n g 
q u a l i f i c a t i o n s : 
2 S e c t i o n s 6-5-548(c) and 
( e ) , A l a . Code 1975, 
i n c l u d e 
p r o v i s i o n s 
f o r cases 
i n which 
the 
d e f e n d a n t 
h e a l t h - c a r e 
p r o v i d e r 
i s 
c e r t i f i e d by 
an 
American 
b o a r d 
as 
b e i n g 
a 
s p e c i a l i s t . 
However, none o f t h e p a r t i e s c o n t e n d t h a t the 
i n d i v i d u a l 
d e f e n d a n t s 
i n 
t h i s 
case 
were 
c e r t i f i e d 
as 
s p e c i a l i s t s . 
T h e r e f o r e , t h o s e p r o v i s i o n s o f § 6-5-548, A l a . 
Code 1975, do not a p p l y . 
25 
1090946 
" ( 1 ) I s l i c e n s e d by t h e a p p r o p r i a t e 
r e g u l a t o r y b o a r d o r agency o f t h i s o r some 
o t h e r s t a t e . 
" ( 2 ) I s t r a i n e d and e x p e r i e n c e d i n t h e 
same d i s c i p l i n e o r s c h o o l o f p r a c t i c e . 
"(3) 
Has 
p r a c t i c e d 
i n t h e 
same 
d i s c i p l i n e o r s c h o o l o f p r a c t i c e d u r i n g 
t h e 
y e a r p r e c e d i n g t h e date t h a t t h e a l l e g e d 
b r e a c h o f t h e s t a n d a r d o f c a r e o c c u r r e d . " 
(Emphasis added.) 
F u r t h e r , t h i s C o u r t has h e l d : 
"The M e d i c a l L i a b i l i t y A c t 
does n o t r e q u i r e t h a t 
the d e f e n d a n t 
h e a l t h c a r e p r o v i d e r and t h e e x p e r t 
w i t n e s s 
have 
i d e n t i c a l 
t r a i n i n g , 
e x p e r i e n c e , o r 
t y p e s o f p r a c t i c e , o r even t h e same s p e c i a l t i e s . To 
be ' s i m i l a r l y s i t u a t e d , ' an e x p e r t w i t n e s s must be 
a b l e t o t e s t i f y about t h e s t a n d a r d o f c a r e 
a l l e g e d 
t o 
have been b r e a c h e d 
i n t h e p r o c e d u r e 
t h a t i s 
i n v o l v e d i n t h e c a s e . " 
Rodgers v. Adams, 657 So. 2d 838, 842 ( A l a . 1995). 
I n 
t h i s case, Jones was l i c e n s e d t o p r a c t i c e as a nurse 
i n N o r t h C a r o l i n a . 
T h e r e f o r e , she s a t i s f i e d t h e r e q u i r e m e n t s 
o f § 6 - 5 - 5 4 8 ( b ) ( 1 ) , 
A l a . Code 1975. 
The 
next 
q u e s t i o n i s whether Jones was 
t r a i n e d and 
e x p e r i e n c e d i n t h e same d i s c i p l i n e o r s c h o o l o f p r a c t i c e as 
were R u s h i n g , F l e m i n g , and O s t r i e c h m e r e r . 
I t i s c l e a r t h a t 
Jones was t r a i n e d and e x p e r i e n c e d i n t h e a r e a o f wound-care 
management 
and 
p r e s s u r e - u l c e r 
p r e v e n t i o n . 
C r i t o p o u l o s 
p r e s e n t e d 
e v i d e n c e 
i n d i c a t i n g 
t h a t 
Jones 
was 
g e n e r a l l y 
26 
1090946 
q u a l i f i e d t o t e s t i f y as t o t h e s t a n d a r d o f c a r e f o r p r e s s u r e -
u l c e r p r e v e n t i o n . 
However, h e r t e s t i m o n y c l e a r l y 
i n d i c a t e s 
t h a t she was n o t t r a i n e d and e x p e r i e n c e d w i t h r e g a r d t o t h e 
p r e v e n t i o n 
o f p r e s s u r e 
u l c e r s f o r p a t i e n t s i n a 
c a r d i a c -
r e c o v e r y 
u n i t , 
p a r t i c u l a r l y 
r e g a r d i n g 
t h e c o n c e r n s 
and/or 
r i s k s 
i n v o l v i n g f r e s h post-CABG p a t i e n t s . 
Jones 
t e s t i f i e d 
t h a t she had n e v e r seen an immediate post-CABG p a t i e n t f o r 
p r e v e n t i v e m e a s u r e s ; t h a t she had p r o v i d e d hands-on t r e a t m e n t 
t o f r e s h p o s t o p e r a t i v e p a t i e n t s o n l y f o r wound c a r e ; and t h a t , 
a t Duke, t h e c a r d i a c - r e c o v e r y n u r s e s p r o v i d e d p r e s s u r e - u l c e r -
p r e v e n t i o n 
care f o r p o s t o p e r a t i v e 
p a t i e n t s i n t h e c a r d i a c -
r e c o v e r y 
u n i t . 
A l s o , h e r t e s t i m o n y i n d i c a t e d t h a t she was 
not f a m i l i a r w i t h t h e p r o p e r v a l u e s f o r 
many o f t h e d i f f e r e n t 
s t a t u s components t h a t were m o n i t o r e d by t h e n u r s e s i n 
t h e 
c a r d i a c - r e c o v e r y 
u n i t . 
F i n a l l y , Jones t e s t i f i e d t h a t , as a 
wound-management 
s p e c i a l i s t , she would p e r f o r m some o f the 
same c l i n i c a l 
s e r v i c e s as d i d 
a r e g u l a r c a r d i a c - c a r e 
n u r s e , 
such as c h e c k i n g 
v i t a l s i g n s , c o n d u c t i n g s k i n assessments, and 
p a r t i c i p a t i n g i n w r i t i n g o r r e v i e w i n g 
c a r e p l a n s . 
However, 
she a l s o t e s t i f i e d t h a t , w i t h o u t a d d i t i o n a l t r a i n i n g , she was 
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not q u a l i f i e d t o p r o v i d e c o n t i n u o u s hands-on c a r e t o a p o s t -
CABG p a t i e n t i n 
a c a r d i a c - r e c o v e r y u n i t . 
Under t h e u n i q u e 
f a c t s o f t h i s 
case, 
Jones d i d 
n o t 
q u a l i f y as a " s i m i l a r l y 
s i t u a t e d h e a l t h c a r e p r o v i d e r " as 
d e f i n e d by § 6 - 5 - 5 4 8 ( b ) ( 2 ) , 
A l a . Code 1975. C f . Jordan v.  
B r a n t l e y , 589 So. 2d 680 ( A l a . 1991) ( h o l d i n g t h a t , i n 
a case 
i n v o l v i n g t h e 
m i s i d e n t i f i c a t i o n o f 
b o d i e s by an emergency-room 
n u r s e , 
t h e p l a i n t i f f ' s 
e x p e r t was n o t s i m i l a r l y 
s i t u a t e d 
because she had n o t worked i n a h o s p i t a l d u r i n g t h e t h r e e 
y e a r s b e f o r e t h e date o f t r i a l and had a d m i t t e d t h a t she was 
not an e x p e r t i n 
emergency-room p r o c e d u r e s ) . 
T h i s C o u r t has p r e v i o u s l y h e l d t h a t even i f 
an e x p e r t 
w i t n e s s i s 
n o t 
a s i m i l a r l y s i t u a t e d h e a l t h - c a r e p r o v i d e r , 
t h e 
e x p e r t can o f f e r t e s t i m o n y about t h e s t a n d a r d o f c a r e a l l e g e d 
t o have been b r e a c h e d i f he o r she i s 
h i g h l y q u a l i f i e d . 
See 
 
H e a l t h T r u s t , 
s u p r a ; Dowdy v. L e w i s , 612 So. 2d 1149 ( A l a . 
1992). 
C r i t o p o u l o s has e s t a b l i s h e d t h a t Jones i s h i g h l y 
q u a l i f i e d w i t h r e g a r d t o g e n e r a l wound-care t r e a t m e n t and 
t h e 
p r e v e n t i o n o f p r e s s u r e u l c e r s . 
However, he has 
n o t 
shown t h a t 
Jones was h i g h l y q u a l i f i e d w i t h r e g a r d t o t h e p r e v e n t i o n o f 
p r e s s u r e u l c e r s i n 
post-CABG p a t i e n t s who a r e i n a c a r d i a c -
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1090946 
r e c o v e r y u n i t . 
T h e r e f o r e , t h a t e x c e p t i o n does n o t a p p l y i n 
t h i s case. 
F o r 
t h e s e 
r e a s o n s , 
t h e 
t r i a l 
c o u r t 
exceeded i t s 
d i s c r e t i o n when i t 
d e n i e d t h e d e f e n d a n t s ' motion t o e x c l u d e 
Jones's t e s t i m o n y . 
A l s o , t h e o n l y e v i d e n c e 
i n d i c a t i n g t h a t 
R u s h i n g , F l e m i n g , and O s t r i e c h m e r e r b r e a c h e d t h e s t a n d a r d o f 
n u r s i n g c a r e came from Jones. 
T h e r e f o r e , t h e t r i a l 
c o u r t 
e r r e d when i t 
d i d 
n o t e n t e r a judgment as a m a t t e r o f law 
i n 
f a v o r o f t h e i n d i v i d u a l 
d e f e n d a n t s . 
Because 
S p r i n g h i l l ' s 
l i a b i l i t y 
i s p r e m i s e d on t h e l i a b i l i t y o f t h e 
i n d i v i d u a l 
d e f e n d a n t s , i t 
i s a l s o e n t i t l e d t o a judgment as a m a t t e r o f 
law i n i t s f a v o r . 
A c c o r d i n g l y , we r e v e r s e t h e t r i a l c o u r t ' s 
judgment and remand t h e case f o r 
t h e e n t r y o f a judgment as a 
m a t t e r o f law f o r 
t h e d e f e n d a n t s .
3 
REVERSED AND REMANDED. 
Malone, C.J., 
and S t u a r t , P a r k e r , and Shaw, J J . , c o n c u r . 
3 B a s e d on our d i s p o s i t i o n 
o f t h i s 
case, we p r e t e r m i t 
d i s c u s s i o n o f t h e r e m a i n i n g i s s u e s r a i s e d by t h e d e f e n d a n t s . 
29