Court Opinion

ID: 9914866
Source: CourtListenerOpinion
Date Created: 2024-01-03 16:03:23.346649+00
Date Added: 2024-06-11T13:14:48.842960
License: Public Domain

DISTRICT COURT OF APPEAL OF THE STATE OF FLORIDA
                                FOURTH DISTRICT

             JENNIFER M. CARRASQUILLO, M.D.,
  CAROLINA GLADYS VALDES, M.D., and HOLY CROSS HOSPITAL,
          INC. d/b/a HOLY CROSS MEDICAL GROUP,
                  Appellants/Cross-Appellees,

                                        v.

 LAWRENCE PETER METZLER, JR., as Personal Representative of the
             ESTATE OF WENDY M. METZLER,
                 Appellee/Cross-Appellant.

                    Nos. 4D2022-2019 and 4D2022-2078

                               [January 3, 2024]

   Appeal from the Circuit Court for the Seventeenth Judicial Circuit,
Broward County; Carlos A. Rodriguez, Judge; L.T. Case No. CACE19-
022758.

   John Goran, Stewart G. Milch, and R. Ryan Rivas of Hall Booth Smith,
P.C., Miami, and Austin Atkinson of Hall Booth Smith, P.C., Atlanta,
Georgia, for appellants/cross-appellees.

    Philip D. Parrish of Philip D. Parrish, P.A., Miami, and Sean F.
Thompson, Scott S. Liberman, Ivan F. Cabrera, and Brent M. Reitman of
Liebman Cabrera Thompson & Reitman, PLLC, Fort Lauderdale,
for appellee/cross-appellant.

DAMOORGIAN, J.

    This appeal and cross-appeal arise from a medical malpractice action
filed by Lawrence Peter Metzler (“Plaintiff”), as personal representative of
the Estate of Wendy Metzler, against Dr. Jennifer Carrasquillo, Dr.
Carolina Valdes (collectively the “Defendant Doctors”), and Holy Cross
Hospital, Inc. (“Holy Cross”) 1 in connection with the death of his wife,
Wendy Metzler. The lawsuit alleged the Defendant Doctors were negligent
in failing to timely refer Mrs. Metzler for a chest CT scan, a delay which
deprived Mrs. Metzler of a chance to have life-saving surgery. The case
proceeded to a jury trial and resulted in a complete defense verdict.

1 Holy Cross was sued on a theory of vicarious liability.
Following the verdict, Plaintiff moved for judgment notwithstanding the
verdict (“JNOV”) as to both of the Defendant Doctors. The trial court
ultimately granted the motion as to Dr. Carrasquillo but denied the motion
as to Dr. Valdes. The trial court thereafter unilaterally determined Plaintiff
suffered $1.125 million in damages and entered final judgment against Dr.
Carrasquillo and Holy Cross in that amount.

    On direct appeal, Dr. Carrasquillo and Holy Cross argue the trial court
reversibly erred by: (1) granting the motion for JNOV as to Dr. Carrasquillo
because sufficient evidence was presented at trial to support the jury’s
verdict; (2) striking the Defendant Doctors’ standard of care expert; and
(3) determining the amount of damages after granting the JNOV.

   On cross-appeal, Plaintiff argues the trial court reversibly erred by:
(1) denying the motion for JNOV as to Dr. Valdes; and (2) admitting
evidence concerning the denial or delay of authorization of medical
insurance coverage for an MRI study.

   For the reasons discussed in this opinion, we reverse the order granting
JNOV and the final judgment against Dr. Carrasquillo and Holy Cross and
remand for entry of a final judgment consistent with the jury’s verdict. We
also affirm on all issues raised in the cross-appeal without further
comment.

   The evidence at trial established the following chronology of events
leading to Mrs. Metzler’s death. In March 2017, Mrs. Metzler was referred
to Dr. Valdes, a neurologist, for a neurological workup after complaining
of chronic back pain believed to have been potentially caused by a prior
motor vehicle accident. Dr. Valdes recommended that Mrs. Metzler have
a thoracic and lumbar MRI to diagnose the source of her pain. After a
period of delay unattributed to Dr. Valdes, the MRI was performed on May
23, 2017. 2 At issue in this case is what transpired between May 24, 2017,
and June 1, 2017.

     On May 24, a neuroradiologist reviewed the MRI and noticed a “lesion
. . . sitting . . . between the spine and the aorta.” However, it was difficult
to see the lesion clearly on the MRI. This lack of clarity in the MRI caused
the neuroradiologist to reach out to a radiologist for a second opinion. The
radiologist mentioned that, given the patient’s history of a prior motor
vehicle accident, a “chronic intramural hematoma [wa]s a possibility.” The

2 Mrs. Metzler’s health insurance carrier denied authorization for the MRI and

instead authorized six weeks of physical therapy first. Dr. Valdes attempted to
obtain insurance approval through a peer-to-peer review, which was denied.

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neuroradiologist and radiologist exchanged several e-mails about possible
diagnoses and agreed that a chest CT scan should be the next diagnostic
step. The neuroradiologist’s report (“MRI report”) mentioned that it was
difficult to localize the origin of the lesion on this type of exam and included
three possible differential diagnoses: (1) a neoplastic process, (2) an
unusual inflammatory/granulomatous lesion, or (3) possibly a chronic
aortic intramural hematoma given the history of a prior motor vehicle
accident. Significantly, there was no mention of a “critical finding” in the
MRI report requiring the chest CT scan to be “urgent.”

    The neuroradiologist faxed her report to Dr. Valdes’ office and then
called the office as well. It is undisputed that the patient care coordinator
who answered the phone did not tell anyone about the phone call or
otherwise make a notation of the phone call in Mrs. Metzler’s patient file.
Unbeknownst to the neuroradiologist, Dr. Valdes was on vacation. On
May 26, neurologist Dr. Carrasquillo, who was covering for Dr. Valdes,
reviewed the report.          Within minutes of reviewing the report,
Dr. Carrasquillo directed her assistant to get the chest CT scan approved.
Dr. Carrasquillo did not request that the chest CT scan be performed
immediately because the MRI report did not mention a “critical finding.”
Dr. Carrasquillo also called Mrs. Metzler and left a message advising her
of the need for a chest CT scan. The patient file was then tasked back to
Dr. Valdes.

   On May 30, Dr. Valdes returned from vacation but did not see the MRI
report or get a message that the neuroradiologist had called her. On May
31, Dr. Valdes reviewed the report, ordered a chest CT scan, and spoke to
both Mrs. Metzler and her primary care physician. On June 1, Mrs.
Metzler was brought to the emergency room where a chest CT scan was
performed. The chest CT scan revealed a penetrating aortic ulcer. The
ulcer ruptured twenty minutes after the chest CT scan was performed and
Mrs. Metzler passed away at the hospital.

   At trial, Plaintiff introduced the testimony of three relevant expert
witnesses. The first expert to testify was Dr. Flanigan, a vascular surgeon.
Dr. Flanigan testified as to causation, opining that had Mrs. Metzler’s
aortic condition been diagnosed sooner, the ulcer could have been repaired
and she would not have died. On cross-examination, Dr. Flanigan
acknowledged that the aortic condition present in this case is uncommon
and would not be an immediate consideration when a patient is
complaining of back pain.

   Next, Plaintiff introduced the testimony of Dr. Gaensler, a radiology
expert. This expert testified that both the neuroradiologist and radiologist

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breached the standard of care by not recognizing the urgency of the
situation when they reviewed the MRI and by not immediately ordering an
expedited chest CT scan. This failure, in turn, led to a “failure to
communicate the gravity of the situation” to the Defendant Doctors.
Specifically, Dr. Gaensler testified that listing the intramural hematoma
as the third possible diagnosis in the MRI report made the situation seem
less severe than it was and failed to communicate the urgency of Mrs.
Metzler’s condition. Dr. Gaensler also agreed that “the urgency on [the
MRI] report was not palpable in terms of ordering a CT scan.”

    Finally, Plaintiff introduced the testimony of Dr. Gold, a neurologist.
This expert opined that the failure to appreciate the urgency of the need
for a chest CT scan fell below the standard of care. Specifically, Dr. Gold
opined that because the MRI report listed an intramural hematoma as a
possible diagnosis, the report indicated a medical emergency and the
Defendant Doctors’ failure to order an urgent chest CT scan was therefore
a departure from the standard of care. On cross-examination, Dr. Gold
acknowledged that the MRI report described the hematoma as “chronic”
as opposed to acute and that the words “urgent” and/or “stat” did not
appear in the report. Moreover, Dr. Gold also acknowledged that once Dr.
Carrasquillo was made aware that the MRI report was in the office, it took
her only twenty-one minutes to review the report and start the process to
get the chest CT scan approved.

    The Defendant Doctors testified in their own defense. Consistent with
Plaintiff’s neurology expert, the Defendant Doctors both testified that there
was nothing in the MRI report indicating Mrs. Metzler’s condition was
critical and/or that a chest CT scan was urgently needed. In relevant part,
Dr. Carrasquillo testified the report did not come stamped with a critical
finding and, to her knowledge, was not coupled with a direct phone call,
two things which typically occur when there is a critical finding.
Dr. Carrasquillo also testified that her specialty is the brain and spine and
she therefore deferred to the radiologists who reviewed the MRI. Had the
report been stamped critical or urgent, Dr. Carrasquillo testified she would
have ordered the chest CT scan as an urgent scan. Dr. Valdes similarly
testified that nothing in the MRI report suggested a medical emergency.
Rather, the report recited only that the lesion was possibly a chronic aortic
intramural hematoma given the history of a prior motor vehicle accident,
indicating a long-standing problem. Overall, the Defendant Doctors both
testified that their respective actions and treatment of Mrs. Metzler were
reasonable given the information provided to them in the MRI report.

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    Before closing arguments, Plaintiff moved for a directed verdict. The
trial court reserved ruling. The case was presented to the jury and after
two hours of deliberation, the jury returned a complete defense verdict.

   Following the verdict, Plaintiff moved for JNOV on the ground that the
Defendant Doctors presented no expert witness to refute Dr. Gold’s
testimony that their failure to appreciate the urgency of the need for the
chest CT scan fell below the standard of care. The trial court ultimately
granted the motion for JNOV as to Dr. Carrasquillo but denied the motion
as to Dr. Valdes. In granting the motion as to Dr. Carrasquillo, the trial
court reasoned Dr. Carrasquillo “shuffled” responsibility for Mrs. Metzler’s
care and that no reasonable jury “would return that verdict. There’s no
basis for that in law.” The trial court thereafter unilaterally determined
Plaintiff suffered damages in the amount of $1.125 million and entered
judgment in that amount against Dr. Carrasquillo and Holy Cross. This
appeal and cross-appeal follows.

    “In reviewing an order granting a judgment notwithstanding the verdict
(‘JNOV’), an appellate court must view the evidence in a light most
favorable to the non-moving party, resolve all conflicts in the evidence in
favor of the non-movant, and construe every reasonable conclusion which
may be drawn from the evidence in favor of the non-movant.” Hancock v.
Schorr, 941 So. 2d 409, 412 (Fla. 4th DCA 2006). “A JNOV is appropriate
only in situations where there is no evidence upon which a jury could rely
in finding for the non-movant.” Id.

   In the present case, our review of the evidence adduced at trial leads
us to the inescapable conclusion that the evidence was conflicting on the
issue of whether the Defendant Doctors breached their standard of care.
As reflected in the facts, the crux of Plaintiff’s claim against the Defendant
Doctors was that they failed to recognize the urgency for a chest CT scan.
To that end, Plaintiff primarily relied on the expert testimony of Dr. Gold
who opined that because the MRI report listed an intramural hematoma
as a possible diagnosis, the Defendant Doctors should have recognized the
report indicated a medical emergency.               However, Dr. Gold also
acknowledged during cross-examination that the MRI report described the
hematoma as “chronic” as opposed to acute and that the words “urgent”
and/or “stat” did not appear in the report. Moreover, Plaintiff’s own
radiology expert testified that listing the intramural hematoma as the third
possible diagnosis in the MRI report made the situation seem less severe
than it was, which in turn led to a “failure to communicate the gravity of
the situation” to the Defendant Doctors. The radiology expert further
agreed that “the urgency on [the MRI] report was not palpable in terms of
ordering a CT scan.”          Finally, Plaintiff’s vascular surgeon expert

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acknowledged that the aortic condition present in this case is uncommon
and would not be an immediate consideration when a patient is
complaining of back pain. In other words, there were discrepancies within
the testimony of Plaintiff’s own expert witnesses as to whether the MRI
report conveyed a medical emergency. These discrepancies were further
accentuated by the testimony of the Defendant Doctors who both testified
that nothing in the MRI report indicated Mrs. Metzler’s condition was
critical and/or that a chest CT scan was urgently needed.

    Simply put, the experts’ testimony, together with the Defendant
Doctors’ individual denials, created conflicts in the evidence which only
the jury, and not the trial court, could resolve. Accordingly, by granting
the motion for JNOV as to Dr. Carrasquillo, the trial court committed
reversible error by failing to resolve the conflicts in the evidence in favor of
the non-moving party. See Aurbach v. Gallina, 721 So. 2d 756, 758 (Fla.
4th DCA 1998) (“[A] trial judge may not sit as a seventh juror, thereby
substituting his or her resolution of the factual issues for that of the jury.”
(citation and internal quotation marks omitted)); Johnson v. Swerdzewski,
935 So. 2d 57, 62 (Fla. 1st DCA 2006) (“By granting the extreme sanction
of dismissal of the cause after the jury had returned a verdict for appellant,
the court essentially assumed the role of a seventh juror by making a
credibility determination contrary to that reached by the jury . . . .”).

    Plaintiff nonetheless argues that pursuant to section 766.102, Florida
Statutes (2022), in order to avoid entry of JNOV against them, the
Defendant Doctors were required to present independent expert testimony
on the standard of care issue. Specifically, Plaintiff argues the Defendant
Doctors were required to present expert testimony to oppose Dr. Gold’s
testimony that the failure to timely refer Mrs. Metzler for a chest CT scan
fell below the prevailing professional standard of care. In support of his
argument, Plaintiff points to the language in section 766.102(5)(a), Florida
Statutes (2022), stating: “If the health care provider against whom or on
whose behalf the testimony is offered is a specialist, the expert witness
must . . . .” (emphasis added). Based on the italicized language, Plaintiff
maintains the statute “requires expert testimony to support or oppose an
allegation of the breach of standard of care.”

   We reject Plaintiff’s reading of section 766.102(5), Florida Statutes.
Section 766.102(5) governs the qualifications an expert witness needs to
testify on the standard of care. Although those qualifications certainly
apply to experts testifying on behalf of a defendant health care provider,
nothing in section 766.102(5) requires a defendant health care provider to
present independent expert testimony to oppose an allegation of the
breach of standard of care. Such a requirement would improperly shift

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the burden of proof and contravene the language in the statute providing
that “the claimant shall have the burden of proving by the greater weight
of evidence that the alleged actions of the health care provider represented
a breach of the prevailing professional standard of care for that health care
provider.” § 766.102(1), Fla. Stat. (2022); see also Saunders v. Dickens,
151 So. 3d 434, 441 (Fla. 2014) (“[I]n a medical malpractice action, the
burden is on the plaintiff to establish that the care provided by the
physician was not that of a reasonably prudent physician.” (emphasis
added)). Once Plaintiff presented expert testimony on the standard of care
issue, the jury was free to reject the testimony of the expert witnesses and
accept only the denials of the Defendant Doctors to return a defense
verdict. See Haas v. Zaccaria, 659 So. 2d 1130, 1133 (Fla. 4th DCA 1995)
(“[S]urely the defendants’ own individual denials of personal negligence
would have permitted the jury to find that neither was negligent. The jury
would have been free to reject the testimony of plaintiff’s expert witnesses
and accept only the denials of the defendants to return a verdict of not
guilty for both defendants.”).           Indeed, even Plaintiff’s attorney
acknowledged during closing arguments that standard jury instruction
601.2(b) permitted the jury to either accept or reject the expert witness
testimony. See Fla. Std. Jury Instr. (Civ.) 601.2(b).

   Although moot in light of our holding, we are compelled to clarify that
even if we were to affirm the final judgment granting JNOV as to
Dr. Carrasquillo, under no circumstances could the trial judge unilaterally
determine and award damages. Where the jury has considered the
evidence and awarded zero damages, it is not the trial judge’s role to
reweigh the evidence and substitute his or her own judgment in
determining damages. See Melgen v. Suarez, 951 So. 2d 916, 918 (Fla. 3d
DCA 2007) (“As the trial judge cannot reweigh the evidence and substitute
her own judgment for that of the jury, we conclude that the trial court
erred in effectively overruling the jury’s determination of [plaintiff’s]
entitlement to zero damages.”). Notably, even Plaintiff concedes the trial
court erred in awarding damages.

   Affirmed in part, reversed in part, and remanded with instructions.

MAY and FORST, JJ., concur.

                            *        *         *

   Not final until disposition of timely filed motion for rehearing.

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