Opinion ID: 2496476
Heading Depth: 2
Heading Rank: 1

Heading: The Trial Court's Judgment on Bailey's Claim of Medical Negligence

Text: At the outset, we note that Miller does not dispute that Bailey presented substantial evidence of medical negligence in relation to the stomach-wrap surgery Dr. Miller performed on September 26, 2000. Rather, Miller contends solely that Bailey failed to present substantial evidence that any act or omission by Dr. Miller during the thoracotomy performed on October 1, 2000, caused injuries to Bailey. 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.' Pruitt [ v. Zeiger ], 590 So.2d [236,] 238 [(Ala. 1991)] (quoting Bradford v. McGee, 534 So.2d 1076, 1079 (Ala.1988)). Giles v. Brookwood Health Servs., Inc., 5 So.3d 533, 549 (Ala.2008). A plaintiff in a medical-malpractice action must ... present expert testimony establishing a causal connection between the defendant's act or omission constituting the alleged breach and the injury suffered by the plaintiff. Pruitt v. Zeiger, 590 So.2d 236, 238 (Ala.1991). See also Bradley v. Miller, 878 So.2d 262, 266 (Ala.2003); University of Alabama Health Servs. Found., P.C. v. Bush, 638 So.2d 794, 802 (Ala.1994); and Bradford v. McGee, 534 So.2d 1076, 1079 (Ala.1988). To prove causation in a medical-malpractice case, the plaintiff must demonstrate `that the alleged negligence probably caused, rather than only possibly caused, the plaintiff's injury.' Bradley, 878 So.2d at 266 (quoting University of Alabama Health Servs., 638 So.2d at 802). Sorrell v. King, 946 So.2d 854, 862 (Ala. 2006). At trial, Bailey argued that Dr. Miller erred in attempting to repair the perforation in her stomach during the thoracotomy he performed on October 1, 2000, by using sutures because the tissue surrounding the perforation was inflamed and thus, she says, too weak to hold together with sutures. Bailey contended the result was that, instead of healing, the perforation became larger and acidic fluid from Bailey's stomach continued to leak into her chest cavity until Dr. Laws remedied the problem through his course of treatment at Carraway. Miller contends that Bailey failed to demonstrate that Dr. Miller's actions during the thoracotomy probably caused injuries in addition to those she sustained as a result of the stomach-wrap surgery. Specifically, she argues that the expert testimony elicited by Bailey at trial was insufficient to establish that Bailey sustained injuries as a result of Dr. Miller's suturing of the perforation in Bailey's stomach. Bailey's primary expert witness on the issue of Dr. Miller's breach of the standard of care during the thoracotomy was Dr. Joseph Colella. In pertinent part, Doctor Colella testified with regard to this second surgery as follows: Q. [Bailey's counsel:] Do you have an opinion ... as to how Dr. Miller's approach to this repair violated the standard of care? A. I do. Q. What is that opinion, please, sir? Explain to us. A. I think he tried to close a hole in an inflammatory area with inflammatory tissue. Q. What's wrong with that? A. It's just not going to hold the stitches. Those tissues are not in their normal state. They are not of the appropriate viability. Or they are not of the appropriate life-sustaining character that they have under normal circumstances to be able to place the stitch, tie the stitch, and not have that stitch either pull through or slowly but surely pull through or keep the tissues together and make them stick to each other. Q. Well, how else are you going to close it if you're in the cavity and the chest cavity is bathed in these gastric juices and everything is inflamed and angry, how are you going to close sutureI mean, close the hole in the stomach? A. Somehow find healthy tissue to close it. Q. And what does the term `dissection' mean? A. It means exposed or cut around or get to healthy tissue surgically. Or get to exposed, identify, deliver into Q. In this context and in this operation, if you were going to dissect something, what would you dissect? A. Well, I would dissect this area or mobilize it such that I could find healthy tissue to put over the hole. Q. Is there any indication in this note at all that this doctor did any dissection of the inflamed material to get down to the healthy tissue? A. There isn't. Q. Could any board certified surgeon have reasonably expected that these two sutures, covering it with the mediastinal wall that had been bathed in gastric juices would hold? A. Not the way it was done here. If it's not healthy tissue, it's not going to hold. Q. Well, if there's no healthy tissue in the chest cavity, what do you do to repair the hole? A. You can choose not to repair it and just drain it and get appropriate drainage. If that wasn't the chosen option or the other option is to completely undo the wrap, bring it to a position in the body, whether that be in the abdomen or the chest, most likely the abdomen where you have healthy tissue to work with. Replacing sutures in inflamed area where the tissue is angry and not prepared to hold those sutures basically guarantees ongoing trouble. Q. From looking at the records, that's what she had, was ongoing trouble, isn't it? A. It is. .... Q. We talked about [the October 1 surgery] earlier; I'm not going to go back through all that. [Dr. Miller's] choice was to try to stitch it up or, as you said, an alternative way would be to leave it alone and do nothing? A. With adequate drainage. Q. With adequate drainage. You said really the way you looked back on this, the way you added it up was that the tissue really was like wet paper towels and wasn't going to hold anything, true? A. That's consistent with my experience, yes, sir. .... Q. Here's my point: It really wouldn't make any sense for a surgeon to try to sew into something that looked and felt like wet paper towels, would it? A. Would not. Q. It just doesn't make any sense? A. That's correct. Bailey also questioned Dr. Lowerywho had assisted Dr. Miller in the stomach-wrap surgery and who served as an expert for Millerabout the attempt to repair Bailey's stomach perforation with sutures. In pertinent part, Dr. Lowery testified as follows: Q. Now, let's talk for a minute to the thoracotomy on [October 1]. You have reviewed the medical records because you, I guess, may be called as an expert also; is that correct? A. That's correct. Q. And that repair that Miller did on the 1st, it was leaking seven to ten days later, wasn't it? A. When the fluid reaccumulated in the chest on the 8th or 9th, yes, sir. Q. It was leaking seven to ten days later? A. Correct. Q. Now, did the tissueBack up. He stitched together two stitches where the hole in the stomach was, didn't he? A. Yes, sir. Q. Now, if the tissue where those stitches go in was inflamed, you would agree that it's probable that if that stitch doesn't hold, the hole gets bigger? A. No, sir. I disagree with that. Q. Do you remember being asked that in your deposition? A. No, sir, I don't. .... Q. Look at line 10. Where you [were] asked, `What was the point of stitching the perforation?' Is that the question? A. Yes, sir. Q. Did you answer: `In hopes of helping it heal. I think it was acceptable to do that. I think it would have been acceptable not to have done that.' Was that your answer? A. Yes, sir. Q. Then we ask this question: `Assume for me that that one millimeter perforation was inflamed. If you applied a stitch to that perforation, would that have a probability of making the hole larger if the stitch doesn't hold?' You were asked that question, and you answereddid you not answer under oath: `If the tissue where the actual stitch goes in is inflamed, then yes, I would agree.' A. Yes, sir. That's what I answered. Q. And that's true today, isn't it? A. Yes, sir. .... Q. If there's a lot of inflammation and if that tissue is inflamed that he stitched over, if the tissue where the actual stitch goes in is inflamed, then yes, you would agree that when it breaks, the hole gets larger? A. Yes, but to stitch it through inflamed tissue would also not be correct. Q. It would be an absolute gross violation of the standard of care, wouldn't it? A. Dr. Miller did not do that. .... Q. If Dr. Miller closed with the two stitches on that opening in an inflamed area, that would be a gross breach of the standard of care, wouldn't it? A. I apologize for not just saying yes or no. If the stitches went through nonhealthy tissue, yes, sir. Q. It would be a gross breach of the standard of care? A. It would beYes, sir. .... Q. But it would be easier to fix that leak, wouldn't it, if you had good healthy tissue? A. Good healthy tissue is always better than unhealthy tissue, yes, sir. Q. And if you fix the leak with good, healthy tissue, there's no reason to think it's going to reopen, is there? A. You would anticipate it remaining closed, yes, sir. Q. In this case, that repair didn't remain closed, did it? A. No, sir. .... Q. Now, you state that Dr. Miller wouldn't have done this because in your opinion he's a very highly qualified surgeon. Isn't that the reason that you give as to why he wouldn't have stitched together inflamed tissue? A. One of the reasons, yes, sir. Q. Well, if he had left the hole alone and not done anything, the hole wouldn't have gotten any larger, would it? A. No, sir, would not have expected the hole to get any larger. Q. But if he did in fact stitch the hole together in inflamed areas and it came undone, then it's probable that the hole got larger, isn't it? A. In the theoretical situation that you have just described, the possibilities of it getting larger are there, yes, sir. Q. So if that in fact did happen, what Dr. Miller did was make the situation worse, didn't it? A. No, sir. I don't think it would have made the situation worse, because I don't think the original hole would have sealed. Q. Well, isn't a larger hole worse than a smaller hole? A. There's no indication there was a larger hole. Q. I know. But if we get back to that tissue being inflamed and it was stitched together and it was stitched together and it came undone, it's probable that the hole was larger, isn't it? A. Sounds like we're talking about a different case now, because it's a theoretical situation that didn't exist. But in your theoretical situation, yes, sir. Miller contends that Dr. Colella's testimony that Bailey encountered ongoing trouble as a result of Dr. Miller's attempt to repair the perforation in Bailey's stomach was too generalized to establish that Dr. Miller caused Bailey additional injury. She also observes that in Dr. Lowery's testimony concerning the hole getting larger Dr. Lowery actually stated that he did not believe that the perforation became larger. Moreover, Miller argues, Dr. Lowery's testimony did not establish that, even if the perforation was larger, it caused more problems for Bailey than she otherwise would have had. In short, Miller contends that, at best, the expert testimony from Dr. Colella and Dr. Lowery simply established that Bailey continued to have the same problems she had developed following the stomach-wrap surgery or that she experienced a general worsening of her condition that, Miller contends, is not compensable. Miller's arguments do not correlate with the inferences the jury could draw from the evidence presented at trial. First, Bailey presented substantial evidence through the testimony of Dr. Colella and Dr. Lowery that, if Dr. Miller sutured the perforation with inflamed tissue, he breached the standard of care. She also presented substantial evidence that the tissue Dr. Miller sutured was inflamed. It was undisputed that there was a lot of inflammation in the chest cavity when Dr. Miller performed the thoracotomy: the pleura (the chest cavity surrounding the lungs), the mediastinum (the portion of the chest cavity containing the heart), the chest wall, and the lungs were all inflamed. Indeed, the day before the October 1, 2000, surgery, a pint of fluid had been drained from Bailey's chest. Because the medical records indicated the entire area was inflamed by gastric juices, Dr. Colella surmised that Dr. Miller sutured the stomach perforation together using inflamed tissue, and both he and Dr. Lowery testified that inflamed tissue would not hold together with sutures. Dr. Lowery also testified that, if healthy tissue had been used to support the sutures, [y]ou would anticipate [the perforation] remaining closed. The evidence indicated that Bailey's condition improved for approximately a week following the October 1, 2000, surgery, but then it began to worsen and fluid once again started draining from her chest. Thus, the evidence supported Dr. Colella's theory that Dr. Miller sutured inflamed tissue in closing the perforation, which held for a brief period but then gave way, resulting in new leakage from Bailey's stomach to her chest cavity. Dr. Colella testified that sutures placed in inflamed tissue will not hold, and Dr. Lowery confirmed that testimony. Dr. Colella further testified that the fact that the sutures would not hold basically guarantee[d] ongoing trouble for Bailey. Following the October 1, 2000, thoracotomy, Bailey spent over two months in the hospital because additional stomach acid was leaking into her chest cavity and it constantly had to be drained from her body. Bailey testified that, as a result, she suffered from debilitating pain and a persistent cough during her treatment. In addition, Dr. Laws noted that Bailey suffered from bouts of nausea during the two occasions over her two months of treatment at Carraway that she was discharged, a condition that Dr. Laws eventually traced to her body having become addicted to the pain medication being administered during her hospital stays. Dr. Laws also discovered that a further problem had developeda fistula between Bailey's stomach and her right lung as a result of the damage being inflicted by the stomach fluid. The jury reasonably could have found that all of these conditions constituted injuries Bailey suffered as a direct result of Dr. Miller's negligence in the attempted repair of Bailey's stomach perforation during the October 1, 2000, thoracotomy. This Court has stated: [A] theory of causation is not mere conjecture, when it is deducible as a reasonable inference from `known facts or conditions,' Alabama Power Co. v. Robinson, 447 So.2d 148, 153-54 (Ala. 1983). `[I]f there is evidence which points to any one theory of causation, indicating a logical sequence of cause and effect, then there is a judicial basis for such a determination, notwithstanding the existence of other plausible theories with or without support in the evidence.' Griffin Lumber Co. v. Harper, 247 Ala. 616, 621, 25 So.2d 505, 509 (1946) (quoting Southern Ry. v. Dickson, 211 Ala. 481, 486, 100 So. 665, 669 (1924)). Dixon v. Board of Water & Sewer Comm'rs of Mobile, 865 So.2d 1161, 1166 (Ala.2003). Dr. Colella's theory of causation, which was supported by general statements from Dr. Lowery's testimony, was deducible as a reasonable inference from the known facts and conditions of Bailey's situation. Given that in reviewing Miller's motion for a judgment as a matter of law we are to view the evidence in the light most favorable to Bailey and to entertain such reasonable inferences as the jury would have been free to draw, we conclude that the trial court did not err in finding that Bailey presented substantial evidence that Dr. Miller's actions during the October 1, 2000, thoracotomy caused injuries to Bailey.