Opinion ID: 1559793
Heading Depth: 3
Heading Rank: 1

Heading: Whether Vaughn's experts were able to establish the necessary element of proximate cause.

Text: ¶ 12. The trial court, in its Order Granting Defendant's Motion for Summary Judgment, found that the evidence before the court showed Vaughn's infection did not proximately result from any acts or omissions of Baptist. Moreover, the trial court found that Vaughn had presented no proof from a medical expert, as required by law, that Baptist proximately caused any infection. As a result it granted summary judgment, and the trial court struck Vaughn's expert, Crystal Keller, R.N., finding that nurses could not properly offer expert testimony as to medical causation. ¶ 13. Baptist argues that the trial court was correct in this finding, inasmuch as Vaughn's designated expert was not qualified to diagnose an infection and, according to Vaughn's treating physician at Baptist, no infection was present in the leg wounds during her first hospitalization from October 24, 2005, through November 2, 2005. Baptist contends that, because Nurse Keller is not qualified to make a medical diagnosis, she is not qualified to render an opinion as to medical causation. According to Baptist, because no genuine issue of material fact exists with regard to the requisite element of proximate cause, it was entitled to summary judgment as a matter of law. ¶ 14. Vaughn argues that as a nurse, Keller was trained to recognize the signs and symptoms of infection and that Keller never opined as to anything above and beyond a nurse's area of practice. Keller maintained that Vaughn had signs and symptoms of infection during her first hospitalization at Baptist and that a breach in the standard of nursing care caused Vaughn's staph infection. Alternatively, Vaughn contends that, even if there was no infection during the initial hospitalization, the negligent care Vaughn received during subsequent hospitalizations contributed to the progression of the infection. ¶ 15. Our law is clear as to what is required to make out a prima facie case of medical negligence. This Court recently stated: In order to establish a prima facie case of medical negligence, [a plaintiff] must prove that (1) the defendant had a duty to conform to a specific standard of conduct for the protection of others against an unreasonable risk of injury; (2) the defendant failed to conform to that required standard; (3) the defendant's breach of duty was a proximate cause of the plaintiff's injury, and (4) the plaintiff was injured as a result. McDonald v. Memorial Hosp. at Gulfport, 8 So.3d 175, 180 (Miss.2009) (quoting Delta Reg'l Med. Ctr. v. Venton, 964 So.2d 500, 504 (Miss.2007)). The general rule in Mississippi is that medical negligence may be established only by expert medical testimony, with an exception for instances where a layman can observe and understand the negligence as a matter of common sense and practical experience. Coleman v. Rice, 706 So.2d 696, 698 (Miss. 1997) (quoting Erby v. N. Miss. Med. Ctr., 654 So.2d 495, 500 (Miss.1995)). See also Estate of Northrop v. Hutto, 9 So.3d 381, 384 (Miss.2009). ¶ 16. The experts Vaughn designated were Crystal Keller, R.N., Dr. Victor Kessler, Dr. Bashrat Houssein, and Dr. Pierce D. Dotherow, II. Drs. Houssein and Dotherow were expected to testify regarding their assessment and treatment of Vaughn, but not to testify as to any acts of negligence on behalf of the Baptist staff. Dr. Victor Kessler, one of Vaughn's treating physicians at Baptist, was expected to testify that Vaughn had suffered gastrointestinal complications as a result of the antibiotics used to treat Vaughn's staph infection and other infections while a patient at Baptist Hospital. Thus, Nurse Keller was the only witness designated to testify as to standard of care, breach of standard of care, the causal nexus between the alleged negligent acts of the Baptist nursing staff, and the resulting staph infection incurred by Vaughn. ¶ 17. As to the element of proximate cause, Nurse Keller's affidavit read as follows: The deviations in the Nursing Standard of Care by the nursing staff at Baptist Hospital led to the development of signs and symptoms of infection in her bilateral leg wounds during her October 24-November 2, 2005 admission to Baptist Hospital. In addition, the deviations in the Nursing Standard of Care by the nursing staff at Baptist Hospital resulted in the further development of and progression of infection in her bilateral leg wounds during the initial admission and subsequent admissions to Baptist Hospital. ¶ 18. Both parties cite Richardson v. Methodist Hospital of Hattiesburg, Inc., 807 So.2d 1244 (Miss.2002), in support of their arguments. In Richardson, the same expert witness, Crystal Keller, R.N., opined that Methodist Hospital staff's deviation from the requisite standard of nursing care led to the patient's pain and suffering and subsequent death. Id. at 1245. Testimony by Keller that the deviation in the standard of nursing care was the proximate cause of the patient's death was found by this Court to be outside the realm of Nurse Keller's qualifications. Id. at 1248. The reasoning behind this holding was that the cause of a stroke is a complex medical issue that was outside the scope of the education and experience of Nurse Keller; therefore, she lacked the qualifications to establish a causal nexus between the deviations in nursing care and cause of death. Id. at 1248. However, this Court found that Keller could offer an expert opinion as to whether the negligent acts on behalf of the nursing staff proximately caused the plaintiff's pain and suffering. Id. at 1247-48. [1] ¶ 19. Baptist cites Richardson in support of its premise that a nurse is not qualified to testify as to whether the deviation in the standard of nursing care caused Vaughn's staph infection, nor is Keller qualified to diagnose a staph infection. Baptist points to Nurse Keller's opinion that Vaughn was suffering from infection of her surgical leg wounds during Vaughn's initial hospitalization from October 24, 2005, until November 2, 2005  a diagnosis that contradicted the opinions of Vaughn's treating physician, Dr. McMullan, and Baptist's infectious disease expert, Dr. Rathel L. Nolan, III. ¶ 20. There is no dispute between the parties that a staph infection developed in the surgical wounds. There is a dispute, however, as to when the infection developed, more specifically, whether it developed during Vaughn's initial hospitalization. While Richardson explicitly held that a nurse cannot testify as to cause of death, we agree with Baptist that Richardson should be interpreted as having made impermissible any testimony from a nursing expert on diagnostic impressions, because nurses are not qualified to make medical diagnoses or attest to the causes of illnesses. Richardson, 807 So.2d at 1247-48. We now explicitly hold that nurses cannot testify as to medical causation. ¶ 21. Since medical diagnosis is outside a nurse's scope of practice, logically it would follow that a nurse should not be permitted to testify as to his/her diagnostic impressions or as to the cause of a particular infectious disease or illness. This is in keeping with the majority rule that nursing experts cannot opine as to medical causation and are unable to establish the necessary element of proximate cause. See Richberger v. West Clinic, P.C., 152 S.W.3d 505, 511 (Tenn.Ct.App. 2004) (registered nurse is prohibited from making a medical diagnosis [pursuant to T.C.A. § 63-7-103(b),] and is therefore not competent to offer opinions on medical causation in a medical malpractice action.); [2] Elswick v. Nichols, 144 F.Supp.2d 758, 767 (E.D.Ky.2001) (nursing expert cannot testify as to how plaintiff received infection because it was outside [her] area of expertise); Colwell v. Holy Family Hosp., 104 Wash.App. 606, 15 P.3d 210, 213-14 (2001) (holding that while nursing expert possesse[d] the education and skill to testify to the standard of care of the decedent's treating nurses, a medical doctor must still generally connect [decedent's] death to the alleged nursing deficiencies. Accordingly, the trial court did not abuse its discretion in finding [a nurse] incompetent to testify to medical causation.); Long v. Methodist Hosp. of Indiana, Inc., 699 N.E.2d 1164, 1169 (Ind. Ct.App.1998) ([W]e now hold that nurses are not qualified to offer expert testimony as to the medical cause of injuries.); Phillips v. Alamed Co., Inc., 588 So.2d 463, 465 (Ala.1991) ([W]e cannot say that the trial judge abused his discretion by requiring the testimony of a physician and, implicitly, holding that a registered nurse was not competent to testify as an expert on the issue of proximate cause.). ¶ 22. Vaughn cites Sacks v. Necaise, 991 So.2d 615 (Miss.Ct.App.2007) [3] for the premise that, under current Mississippi law, nurses can offer opinions on proximate cause. The decedent in Sacks was being treated for lung cancer with a highly toxic drug named Taxol. Id. at 618. The treatment was administered via intravenous therapy by a nurse. The second treatment resulted in pain, swelling, and discoloration to the arm that was being infused  the subsequent damage to the arm was a third-degree chemical burn. Id. at 623. The plaintiff's theory was that the nursing staff had breached the standard of care by continuing to administer the drug over the course of three hours, despite having been alerted to the adverse reaction, i.e., swelling. Id. at 620. The defense's theory of the case was that the damage to the patient's arm was a result of a hypersensitivity to the drug, not negligent care. Id. at 621. The trial court allowed the nursing expert to dispute the theory of the defense expert, a physician, by testifying that the medical literature stated that tissue damage can be caused by the leaking of Taxol from the vein into the surrounding tissue, and that patients should be monitored continuously during administration. Id. at 623. The Court of Appeals rejected the defendants' argument on appeal that this testimony was outside the scope of nursing practice. Id. ¶ 23. Sacks is easily distinguished from our case today inasmuch as the nursing expert in Sacks offered testimony on the validity of the defense's hypersensitive-reaction theory  an opinion based on the witness's review of the prevailing medical literature, not on the expert's own diagnostic impression. Id. at 623. Moreover, the Court of Appeals noted in Sacks that the expert nurse was not designated to testify as to the causation of the plaintiff's injury, but she was called to testify as to whether the intravenous administration of the drug was done correctly. Id. at 622. The plaintiff's attorney, in a motion hearing, made clear that any theory of causation would be left to the testimony of Dr. Sacks  not the expert nurse. Id. Therefore, we do not find the substance of the testimony by Nurse Keller in today's case to be analogous to that of the nursing expert in Sacks, and we do not find that the Sacks holding can be read to allow nurses to testify as to medical causation. ¶ 24. Accordingly, because Vaughn failed to establish the requisite element of proximate cause, Baptist was entitled to summary judgment as a matter of law.