Court Opinion

ID: 6114169
Source: CourtListenerOpinion
Date Created: 2022-02-01 00:01:44.322128+00
Date Added: 2024-06-11T08:13:21.005932
License: Public Domain

Filed 1/31/22
                CERTIFIED FOR PUBLICATION

IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

                SECOND APPELLATE DISTRICT

                        DIVISION EIGHT

RONALD ZANNINI et al.,                  B302404

       Plaintiffs and Appellants,       (Los Angeles County
                                        Super. Ct. No. BC614661)
       v.

MARK A. LIKER, M.D.,
       Defendant and Respondent.

     APPEAL from a judgment of the Superior Court of Los
Angeles County, Frank J. Johnson, Judge. Affirmed.

      Gordon Edelstein Krepack Grant Felton & Goldstein, Roger
L. Gordon; Law Office of Joshua M. Merliss and Joshua M.
Merliss for Plaintiffs and Appellants.

      Cole Pedroza, Kenneth R. Pedroza, Matthew S. Levinson;
Packer, O’Leary & Corson, Robert B. Packer and Paul M. Corson
for Defendant and Respondent.

                    _________________________
                       INTRODUCTION

      In early 2015, appellant and plaintiff Ronald Zannini began
to experience weakness in his left arm. Mr. Zannini consulted a
neurologist, who referred him to respondent neurosurgeon Mark
A. Liker, M.D. Dr. Liker diagnosed cervical myelopathy (cervical
spinal cord dysfunction) and recommended surgery to relieve
pressure on Mr. Zannini’s cervical spine. Dr. Liker performed the
surgery on March 25, 2015. Eleven days later, Mr. Zannini
experienced paralysis of his arms and legs. He was taken by
ambulance to the emergency room and diagnosed with a cervical
epidural hematoma – a blood clot. He underwent emergency
surgery six hours after arriving at the emergency room. Despite
the surgery, he ended up partially quadriplegic, able, after years
of physical and occupational therapy, only to breathe on his own
and move his left hand to operate his wheelchair.
      Mr. Zannini believed his partial quadriplegia was due to a
delay in the diagnosis and treatment of the epidural hematoma.
He attributed the delay to medical malpractice. He and his
spouse, Bonnie Zannini, filed a complaint against Dr. Liker and
others involved in his treatment in the emergency room.
Plaintiffs’ theory was that the emergency surgery should have
taken place sooner than six hours after Mr. Zannini’s arrival at
the emergency room because time was of the essence in removing
the blood clot. At trial, he attributed the delay solely to Dr.
Liker, who consulted with the emergency room and on-call
physicians, but did not perform the emergency surgery. After a
multi-day trial, the jury rendered a verdict in favor of Dr. Liker
and against the Zanninis.
      The Zanninis appeal the judgment against them. We
affirm.

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      FACTUAL AND PROCEDURAL BACKGROUND

A.     March 25, 2015 Surgery
       In early 2015, Ronald Zannini (Mr. Zannini) was a retired
musician and general contractor in his mid-70s living with his
spouse Bonnie Zannini (Mrs. Zannini) in Valencia, California. He
began to notice weakness in his left arm and could not lift weight
with it. He consulted a neurologist who examined him and
ordered magnetic resonance imaging (MRI) of his spine. After
reviewing the images, the neurologist referred Mr. Zannini to a
neurosurgeon, respondent Mark Liker, M.D. Dr. Liker examined
Mr. Zannini on February 2 and 9, 2015 and reviewed the MRI.
He diagnosed cervical myelopathy or spine dysfunction, and
recommended cervical spine surgery to correct degeneration of
the spine, which had occurred with age.
       Mr. Zannini underwent the surgery on March 25, 2015.
The surgery was uneventful and two days later, Mr. Zannini was
discharged from the hospital. The surgery involved placing
hardware in Mr. Zannini’s neck to stabilize it. Dr. Liker
instructed Mr. Zannini to wear a cervical collar at all times
except when bathing or sleeping. Mr. Zannini followed the
instructions religiously. Nevertheless, once at home, Mr. Zannini
noticed that now both of his arms were weak and he was
experiencing severe neck pain. So, on March 28, 2015, he went to
the emergency room where he met with Dr. Liker who ordered an
MRI of the cervical area. The imaging showed no abnormalities –
no movement of the hardware that had been placed in Mr.
Zannini’s spine, no blood clot, no fluid, nothing that would be the
likely source of Mr. Zannini’s continued weakness and pain. Dr.
Liker prescribed a steroid and advised Mr. Zannini to take
medication for the pain. Mr. Zannini complied. Dr. Liker told

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him the use of his arms would probably come back. Mr. Zannini
settled in for the healing process to begin.
      On March 30, 2015, Mr. Zannini was still experiencing
excruciating pain and both arms were bothering him. He had a
previously scheduled appointment with Dr. Liker that day. Dr.
Liker told him the steroid was to calm down nerves in the painful
area. Between March 30 and April 5, 2015, Mr. Zannini
remained mostly bedridden in pain.

B.    April 5, 2015 Paralysis and Emergency Room Treatment
      In the afternoon of April 5, 2015, Easter Sunday, Mr.
Zannini took a shower with the assistance of his wife. As
instructed, he did not wear the cervical collar in the shower. He
got out of the shower and went into his bedroom, where he sat on
the bed and began to apply lotion to his legs. All of a sudden, Mr.
Zannini felt a warmth flow through his body and then he could
not move his legs or arms. His wife noticed a ripple travel
through his body. Mr. Zannini was paralyzed. “I can’t feel my
body.” Mrs. Zannini called 911 and the paramedics came within
10 minutes of the call. They took Mr. Zannini by ambulance to
the emergency room at Henry Mayo Medical Center in Newhall,
where his initial surgery had been performed 11 days earlier. He
arrived in the emergency room at 5:25 p.m.
      Dr. Elaine Lee, the emergency room physician, was notified
that an acutely paralyzed patient was en route via ambulance.
Upon arrival, Mr. Zannini was seriously compromised. He was
acutely paralyzed with no motor strength and had no sensation
from the nipple line down. He had no anal reflex. He had a
priapism(an involuntary erection), a slow heartbeat, and low
blood pressure. Dr. Lee knew time is of the essence in every
patient who is paralyzed. At 5:26 p.m. she called a Code Trauma,

                                4
which activated the trauma team and gave priority to Mr.
Zannini for radiology studies. At 5:39 p.m., she paged Dr. Liker
and Dr. Martin Mortazavi, the on-call neurosurgeon. Because
Dr. Mortazavi and Dr. Liker were members of the same
neurosurgical medical practice and Dr. Liker coincidentally
happened to be at the hospital seeing other patients, Dr. Liker
told Dr. Mortazavi he would handle the page and immediately
went to the emergency room.
       Dr. Liker consulted with Dr. Lee, who, as the emergency
room physician, was responsible for managing Mr. Zannini’s care.
On the recommendation of Dr. Ranbir Singh, the trauma
surgeon, Dr. Lee immediately ordered CT scans of the head, neck,
chest, and abdomen for the purpose of diagnosing the cause of the
paralysis. Dr. Liker also recommended adding a CT angiogram
to determine whether any blood vessels to and of the brain were
blocked. At 5:45 p.m. Mr. Zannini was taken to the CT scanning
suite which was adjacent to the emergency room. Dr. Liker and
Dr. Lee went into the CT scanning suite to review the scans,
which were available at 6:00 p.m. Dr. Liker spoke as well with
the radiologist. The CT scans, which best display metal
hardware and bone mass in a patient’s body, were to rule out
migration of hardware or movement of the bones. The CT scans
showed nothing amiss.
      The process by which physicians arrive at a diagnosis for
symptoms is called differential diagnosis. That is, possible
diagnoses are considered and methodically ruled out to narrow
the range of possible causes. The standard is to rule out the
worst-case scenario first. A useful differential diagnosis
considers the conditions that are most likely and the conditions
most amenable to treatment. Dr. Liker was pondering a stroke of

                               5
the brain or spinal cord or a bleed as the top causes of the
paralysis. He knew whatever the cause, it was going to be a
“very, very rare event.” He knew that the prognosis for recovery
from a hematoma compressing the spinal code depends on the
type of hematoma and the duration of time and the acuity of the
event. Once the problem is identified, it becomes a surgical
emergency because if the hematoma is not removed, the problem
could get potentially worse. Based on Mr. Zannini’s condition
upon arrival at the emergency room, Dr. Liker believed the
damage was “already done”; he did not foresee any meaningful
recovery with surgery. But that expectation did not preclude
surgery, if a hematoma was diagnosed. Dr. Singh examined Mr.
Zannini, reviewed the CT scans, and ruled out trauma as the
cause of the paralysis. His consultation as to trauma ended at
that point.
      A Code Neuro was then called which enabled a consultation
with the on-call neurologist, Dr. Schultz, who did not think the
brain was involved. Dr. Liker wanted to discuss whether a stroke
was causing the paralysis. Based on Dr. Schultz’s telephone
consultation, however, the Code Neuro was cancelled. Dr.
Schultz recommended an MRI of the thoracic and cervical spine.
Dr. Liker recommended an MRI of the cervical spine as well. The
MRI is the gold standard for showing soft tissues of the spinal
canal and whether there is hemorrhaging, infection, swelling, or
anything pressing on the soft tissues of the spinal cord. It is used
to diagnose tumors, blood clots and hematomas. Dr. Lee ordered
the MRI scans at 6:11 p.m. The plan was to determine if there
was pathology that could be corrected by surgery.
      The MRI scanner was located in a separate building which
required medical staff to transport Mr. Zannini out of the

                                 6
emergency room, across a street. and into another building about
300 yards away. The MRI team had to be summoned to the
hospital. The MRI technician arrived at 6:50 p.m.
       In the meantime, Mr. Zannini was in the emergency room
experiencing, in addition to his paralysis, difficulty breathing,
severely low heartbeat, and low blood pressure. He had one-on-
one nursing care. Dr. Lee prescribed Levophed, a medication to
stabilize blood pressure. The medication was infused into Mr.
Zannini and very gradually began to take effect. However, the
MRI technicians could not take Mr. Zannini to the MRI suite and
put him into the scanner unless he was medically stable; to
remain stable, Mr. Zannini needed the Levophed infusion during
the MRI. The Levophed pump had to be MRI compatible. The
hospital did not have a compatible pump readily available. By
the time hospital staff located a compatible pump and Mr.
Zannini was stabilized, it was 7:40 p.m. when he was finally
transported to the MRI scanner.
       While Dr. Lee was trying to stabilize Mr. Zannini’s blood
pressure and staff looked for a compatible pump, Dr. Liker called
Dr. Mortazavi at 6:00 pm. to brief him on what was happening.
Dr. Liker told Mr. Mortazavi to be ready for the results of the
MRI. He stated that his differential diagnoses included a spinal
cord stroke or a bleed compressing the spinal cord causing
paralysis.
       Dr. Liker also spoke to Mrs. Zannini from about 6:40 p.m.
to 7:00 p.m. He told her that the doctors were trying to arrive at
a diagnosis for Mr. Zannini’s paralysis. He himself was confused
by the symptoms and said he thought Mr. Zannini had had some
sort of stroke. He told Mrs. Zannini that this was a very serious
event and he did not know how it was going to play out. He

                                7
explained the MRI would help rule out possible incorrect
diagnoses and arrive at a correct one. He also told Mrs. Zannini
that if surgery were needed that night, he would not be the one to
perform it as he was scheduled to board an out of town flight that
night at 11:45 p.m. (She testified that he had previously told her
at one of Mr. Zannini’s visits that he was going out of town.) He
told Mrs. Zannini that his associate Dr. Mortazavi would do any
necessary surgery. As Dr. Mortazavi was the on-call
neurosurgeon, hospital protocol dictated that he had to arrive at
the hospital within 30 minutes of being called in to operate.
       Dr. Liker left the hospital at around 7:17 p.m. to catch his
flight. The MRI was a series of scans of the thoracic and cervical
areas of Mr. Zannini’s spine. The first images began to emerge
from the scanner around 8:10 p.m. The first images showed a
blood clot. Neuroradiologist Dr. Goldman read the complete set
of scans and reported his results to Dr. Lee in the emergency
room at 9:38 p.m. He also called Dr. Mortazavi with the results.
He did not call Dr. Liker. The MRI showed a blood clot was
pressing on Mr. Zannini’s cervical spine and was the likely cause
of the paralysis. Formation of such a blood clot, a cervical
epidural hematoma, 11 days of the initial surgery was, as Dr.
Liker knew, a “very, very rare occurrence.” At 9:39 p.m., once
notified of the result of the scans, Dr. Mortazavi agreed to go
immediately to the hospital to perform emergency surgery.
       Although Dr. Liker had left the hospital at 7:17 p.m., he
remained in contact by text with Dr. Mortazavi and Dr. Parham
Yashar, another medical associate who was a vascular
neurosurgeon. When Dr. Mortazavi was notified of the
neuroradiologist’s findings at 9:38 p.m., he made the decision to
do the emergency surgery on Mr. Zannini. He relayed his

                                8
decision to Dr. Liker. He, Dr. Liker, and Dr. Yashar reviewed the
MRI scans on their phones. Dr. Mortazavi called the operating
room and the emergency room and told the staff to prep Mr.
Zannini for surgery and to be prepared to start surgery at 10:00
p.m. when he arrived. Dr. Mortazavi received a response from
the hospital that the operating room was not going to be available
for Mr. Zannini’s emergency surgery until 11:00 p.m. because
there was another operation in progress that would not be
finished until then. Mr. Mortazavi asked staff to bring in a
second operating room team; he was told that would take even
longer.
       Both Dr. Liker and Dr. Mortazavi separately called the
hospital to no avail to try to expedite the surgery. Dr. Liker
called Mrs. Zannini to tell her that Dr. Mortazavi had decided on
surgery. Dr. Mortazavi called the hospital and told staff to have
Mr. Zannini in the operating room ready to proceed when he
arrived.
       Now that he knew he could not start surgery until 11:00
p.m., Dr. Mortazavi drove a little more slowly and arrived at the
hospital at around 10:50 p.m. He was dismayed to find that Mr.
Zannini was still in the emergency room, not yet in the operating
room as he had requested. He yelled at the staff. Eventually Mr.
Zannini was taken to the operating room where Dr. Mortazavi
commenced surgery at 11:35 p.m. and removed the blood clot.
       Before beginning the surgery, Dr. Mortazavi told Mrs.
Zannini that he thought the chances of Mr. Zannini recovering
his lost motor function were low. He said the goal of the surgery
was to save Mr. Zannini’s life because of the location of the
bleeding, his problems breathing, and his low blood pressure.

                                9
The surgery started six hours after Mr. Zannini’s arrival at the
emergency room.

C.     Dr. Liker’s Testimony
       Dr. Liker testified that even if he had not left at 7:17 p.m.,
he would have not commenced the surgery before getting the
results of the complete MRI series, which were not available until
9:30 p.m. The hematoma was a “very, very rare occurrence” in
his experience. He would have been looking for some sort of
anomaly that would have caused the bleed. Sometimes
hematomas extend under the bones and the bone needs to be
removed as well as the hematoma. He needed the complete MRI
series to get that information.
       The suddenness of the injury is one of the most important
indictors of the eventual status of the patient and the ability of
the patient to recover.
       Dr. Liker testified that it was such a “very, very rare event”
that he did not know anything that he could have done
differently that would have changed the outcome. He was
surprised by the diagnosis coming two weeks after the surgery,
especially because the intervening MRI made it much less likely
that the epidural hematoma could be the cause of the problem.
He had never read about a post-surgical bleed 11 days after
surgery nor had he ever heard other doctors talk about such a
thing. He does 500 surgeries a year and had never seen this. It
was extremely rare.
       His examination of Mr. Zannini in the emergency room was
equivocal in that some tests were consistent with damage to the
spinal cord and some were not. He acknowledged some fibers in
the cord may have survived, but given the complexity of the
situation, he concluded Mr. Zannini was in spinal shock, the

                                 10
spinal cord was significantly damaged, the cord would not repair
itself, and recovery would likely involve only a minimal change.
Because of the rare nature of the event, he needed to determine if
there was a blood vessel or an abnormal triangle of blood vessels
causing the bleed. He believed it would have been below the
standard of care to start surgery without having reviewed and
interpreted the complete MRI series.

D.    Post-Operative Prognosis
      The removal of the blood clot did not reverse Mr. Zannini’s
paralysis. He remains partially paralyzed from the chest down.
After years of in-patient rehabilitative therapy and several
hospitalizations for complications arising from the quadriplegia,
Mr. Zannini can breathe on his own and move fingers of his left
hand to operate a wheelchair. He lives at home with his spouse
and requires 24-hour healthcare.

E.     The Complaint and Trial
       On March 22, 2016, the Zanninis filed a complaint in the
Los Angeles Superior Court against Dr. Liker, Dr. Lee, Dr. Singh,
Dr. Mortazavi, California Neurological Institute Inc., Santa
Clarita Emergency Medical Group, Inc., Henry Mayo Newhall
Community Medical Center, and Dr. Liker’s medical practice,
Neurosurgical Associates of Los Angeles, Inc. The complaint
alleged medical malpractice as the cause of Mr. Zannini’s partial
quadriplegia. Specifically, the complaint alleged “defendants
failed to timely diagnose and treat a spinal subdural hematoma
resulting in plaintiff Ronald Zannini becoming quadriplegic.” Mr.
Zannini sued for general and special damages. Mrs. Zannini
sued for loss of consortium.

                               11
       Judgments dismissing all defendants except Dr. Liker were
eventually entered by the trial court as a result of motions for
dismissal, nonsuit, or summary judgment. On July 16, 2019,
trial commenced as to Dr. Liker only. Plaintiffs’ theory was that
Dr. Liker was negligent when he left the hospital at 7:17 p.m. to
catch his flight instead of staying at the hospital, reviewing the
MRI as it began to emerge from the scanner at 8:10 p.m., and
commencing surgery shortly after 8:10 p.m. when the operating
room was still available. Plaintiffs argued that when Dr. Liker
left the hospital, he caused the surgery to be delayed until 11:30
p.m., too late to reverse Mr. Zannini’s paralysis. The jury
returned a verdict in favor of Dr. Liker and against the Zanninis.

F.     Expert Testimony
       Both sides presented expert testimony to the jury. All the
experts agreed that there was no malpractice surrounding the
initial cervical spine surgery performed by Dr. Liker on March
25, 2015. They agreed time was of the essence in determining
the cause of Mr. Zannini’s paralysis in order to obtain the best
treatment result. Plaintiffs’ experts also agreed they could not
say whether Mr. Zannini’s prognosis would have been
appreciably different had the surgery occurred earlier in the
evening. No expert could quantify the degree to which the
patient would have been better off in the absence of the alleged
delay in getting to the operating room. And all the experts
agreed that no other individual that night, physician or staff
member, committed professional malpractice of any kind. The
sole issue at trial was whether Dr. Liker’s decision to leave at
7:17 p.m. constituted medical negligence because it unduly
delayed the emergency surgery.

                                12
       Plaintiffs’ experts were Dr. Christopher Taylor and Dr.
Barry Pressman. Dr. Pressman, a neuroradiologist at Cedar
Sinai Medical Center, reviewed the MRIs from March 28, 2015
and April 5, 2015 and opined that something happened between
those dates to create pressure on the spinal cord, which looked
“pancaked” from the pressure. He said that he had seen worse
but the compression was “pretty significant” on April 5. From the
images taken March 28, he saw no evidence of spinal cord
compression.
       Dr. Pressman specifically noted that he was not giving an
opinion about what Dr. Liker should or should not have done in
the case. He testified he could neither quantify the degree of
recovery statistically nor “put any numbers” on the prognosis. He
testified that blood pressure which cannot be supported in the
absence of intravenous Levophed due to spinal shock is a poor
prognostic sign, meaning there is a high likelihood of more
damage to the cord. He opined that generally the less time the
problem is present, the more likely there is some degree of
recovery. The records he reviewed noted the patient moved his
toes on April 5, 2015. The more function that is present, the
better the prognosis.
       Plaintiffs’ other expert was neurosurgeon Dr. Christopher
Taylor. He also reviewed the medical records and imaging and
agreed with Dr. Liker’s initial finding that Mr. Zannini’s
dysfunction was due to age and degeneration as opposed to
trauma or tumor. Dr. Taylor opined it was “completely
appropriate” for Dr. Liker to order an MRI of the neck on April 5,
2015 as it is better to “have a road map before you open the
patient up.” He opined it was important to get the pressure off
the spine as soon as reasonably possible because this was a

                               13
neurological medical emergency where every minute counted.
The concern has to do with whether there is a chance of recovery
in the situation, which is related to the severity of the
compression and how quickly the pressure on the spinal cord can
be relieved. Dr. Taylor agreed with Dr. Pressman that Dr.
Liker’s observation that Mr. Zannini could move his toes was a
sign it was not a complete spinal cord injury.
       Dr. Taylor opined that by 6:30 p.m., Dr. Liker knew or
should have known this was most likely an acute surgical
emergency and an MRI would be necessary to confirm that
surgical treatment would be indicated. In his opinion, Dr. Liker
should have stayed with Mr. Zannini and made sure that
someone capable of performing the surgery was immediately
available when the study was done and interpreted. Dr. Taylor
concluded that Dr. Liker did not meet the standard of care
because he did not ensure that the surgery was done “earlier.”
Had it been done earlier, “Mr. Zannini’s condition more likely
than not would be significantly better than it is today.” He
estimated that Dr. Liker should have been able to diagnose the
condition by 7:40 p.m. that evening, allowing for time to complete
the MRI after the order was placed at 6:30 p.m. He
acknowledged that his timeline did not take into account delays
associated with the blood pressure problem, the incompatibility of
the pump, and a kink in the infusion line during the MRI itself.
Nor did he fault anyone for not reporting the results of the MRI
until 9:30 p.m. He noted that he believed Dr. Liker acted within
the standard of care in treating Mr. Zannini up to April 5, 2015.

                               14
       Dr. Taylor noted he has never read about an 11-day post-
operative bleed creating an epidural hematoma. Most of these
incidents occur within the first 12 to 24 hours after the surgery or
even sooner, when the patient is still generally in the hospital
when the symptoms appear. He had no criticism of anyone else
who cared for Mr. Zannini on April 5, 2015 except Dr. Liker. He
agreed with Dr. Pressman that the imaging showed that when
Mr. Zannini arrived at the emergency room, the spinal cord had
pancaked and he was already in spinal shock, a poor prognostic
sign for eventual recovery. He opined Mr. Zannini’s symptoms of
no bladder control, no anal reflex, no motor function in any
extremity, and an involuntary erection were “suggestive” of a
spinal cord that had been “severely insulted with a low
probability of neurological recovery even if surgery was done
immediately.” Like Dr. Pressman, Dr. Taylor could not quantity
how much better Mr. Zannini would have been with earlier
surgery. He could not say Mr. Zannini would not have needed
the same post-operative care with earlier intervention.
       Dr. Taylor opined Dr. Liker “was involved in [Mr.
Zannini’s] care up to a point” in that he had “examined him at
least twice” by 6:30 p.m. Dr. Taylor testified a reasonably
prudent neurosurgeon would have 1) viewed the initial MRI
images at 8:10 p.m. which clearly showed a hematoma, 2) ruled
out alternate causes other than the epidural hematoma at 8:10
p.m., and 3) immediately secured an operating room. Dr. Taylor
concluded that because Dr. Liker did not do this, he did not meet
the standard of care. Dr. Taylor testified it would have been
better to do the surgery at 8:30 p.m. rather than 11:30 p.m.

                                15
       Presenting a different opinion of the standard of care was
Dr. Liker’s expert neurosurgeon Dr. Howard Tung. Dr. Tung
agreed with the other experts that Dr. Liker complied with the
standard of care in recommending and performing the initial
spine surgery on March 25, 2015 and in providing post-operative
care. He opined the standard of care in California requires
confirmation by MRI of the diagnosis of epidural hematoma
affecting the spinal cord before taking a patient to the operating
room for evacuation of an epidural hematoma. The entire study
must be completed because the surgeon would want to see the
full extent of the problem, which is not apparent from the initial
images that emerge. The neurosurgeon would want to see the
entire spine visualized. He also testified that if a neurosurgeon is
called in to consult because a spinal cord compression is in the
differential diagnosis, the neurosurgeon does not take over the
overall care of the patient in the emergency room. Dr. Tung
testified that it would be unusual for a reasonable and prudent
neurosurgeon to accompany a patient to the MRI and it is not
called for by the standard of care.
       Most hematomas ever reported in any study usually form
within 24 to 48 hours of surgery. Mr. Zannini was already past
that window which meant the physicians were “talking about
something very, very remote.” That there was an intervening
normal MRI on March 28, 2015 also affected the differential
diagnosis on April 5, 2015. This made the patient’s presentation
on April 5 acute, unusual and “very, very rare. It’s more rare
than getting struck by lightning.” Dr. Tung asked, “If you
already know you’ve ruled out . . . 99.99 percent of all epidurals
that are going to occur with an M.R.I. three days out, now why

                                16
would I be thinking about the .0001 percent? [¶] . . . [¶] Now you
have to think about other things . . . that can occur.”
       Dr. Tung noted there was no evidence Mr. Zannini’s
condition improved from the time he arrived at the emergency
room until the time he was taken to the operating room. He
opined that the most important determination in the prognosis is
the patient’s presenting neurological status or function. He
scored 0 out of 5 on movement which was not a good prognosis.
None of the examiners found sensation and their evaluations
were all essentially consistent with one another, that is, Mr.
Zannini was a complete or near complete quadriplegic.
       Dr. Tung concluded, within a reasonable medical
probability, that if the surgery had commenced at 7:30 p.m., the
outcome would not have been different. He opined Dr. Liker
complied with the standard of care by telling the family that he
was departing the hospital and advising them that Mr. Zannini
would be in the care of another neurosurgeon who was fully
aware of his status and ready to do timely surgery if it was
indicated. There is no standard that dictates that a
neurosurgeon has to stay on the premises of a hospital to wait
and see if surgery is indicated. It did not become a surgical
emergency until 9:30 p.m. when the MRI results were
communicated to Dr. Mortazavi and Dr. Lee. After the results
were communicated, an operating room was secured without
delay.

G.    The Verdict
      In its deliberations, the jury considered a special verdict
form prepared by the parties and approved by the court. The
special verdict form included a list of questions to be answered by
the jury in the order in which they were presented. After each

                                17
question, the special verdict form instructed the jury how and
whether to proceed to the next question. The first question on
the special verdict form asked the jury whether Dr. Liker was
medically negligent in his care and treatment of Mr. Zannini. If
the answer was “no,” the jury was instructed to stop, answer no
further questions, and have the presiding juror sign and date the
form. If the answer was “yes,” the jury was instructed to proceed
to the next question. There were four questions in all. The jury
answered the first question “no,” finding Dr. Liker not negligent.
As instructed, it then did not answer any of the other questions,
which pertained to causation and damages.
      The trial court entered judgment in favor of Dr. Liker and
against the Zanninis on September 4, 2019. The judgment was
amended on November 18, 2019, to add a cost award in favor of
Dr. Liker. This timely appeal followed.

                          DISCUSSION

      At the outset, it is important to note plaintiffs do not argue
on appeal that the evidence was insufficient to support the
verdict. Instead, they challenge the trial court’s decisions to give
and refuse certain instructions to the jury.

A.      Standard of Review
       “A party is entitled upon request to correct,
nonargumentative instructions on every theory of the case
advanced by him which is supported by substantial evidence. The
trial court may not force the litigant to rely on abstract
generalities, but must instruct in specific terms that relate the
party’s theory to the particular case.” (Soule v. General Motors
Corp. (1994) 8 Cal.4th 548, 572 (Soule).) A proposed instruction

                                 18
that is irrelevant, confusing, incomplete, or misleading need not
be given. (Solgaard v. Guy F. Atkinson Co. (1971) 6 Cal.3d 361,
370.) A court may refuse an instruction when the legal point is
adequately covered by other instructions given. (Arato v. Avedon
(1993) 5 Cal.4th 1172, 1189, fn. 11.)
       Instructional error must be prejudicial. This means it must
be reasonably probable that the complaining party would have
obtained a more favorable result in the absence of the error.
(Soule, supra, 8 Cal.4th at pp. 570, 573–574; Rutherford v.
Owens-Illinois, Inc. (1997) 16 Cal.4th 953, 983.) The reviewing
court should consider not only the nature of the error, including
its natural and probable effect on a party’s ability to place his full
case before the jury but the likelihood of actual prejudice as
reflected in the individual trial record, taking into account (1) the
state of the evidence, (2) the effect of other instructions, (3) the
effect of counsel’s arguments, and (4) any indications by the jury
itself that it was misled. (Soule, at pp. 580–581.)
       The propriety of giving a jury instruction is reviewed de
novo. (People v. Posey (2004) 32 Cal.4th 193, 218.)

B.    The Trial Court Did Not Err in Declining to Instruct the
      Jury with CACI 509 (Abandonment of Patient) as the
      Instruction Was Not Supported by Substantial Evidence
      Plaintiffs asked the court to instruct the jury with CACI
509 (Abandonment of Patient). That instruction, as proposed by
plaintiffs read: “Ronald Zannini claims Mark A. Liker, M.D., was
negligent because he did not give Ronald Zannini enough notice
before withdrawing from the case. To succeed, Ronald Zannini
must prove both of the following: [¶] 1. That Mark A. Liker,
M.D. withdrew from Ronald Zannini’s care and treatment; and
[¶] 2. That Mark A. Liker, M.D. did not provide sufficient notice

                                 19
for Ronald Zannini to obtain another medical practitioner. [¶]
However, Mark A. Liker, M.D., was not negligent if he proves
that Ronald Zannini consented to the withdrawal or declined
further medical care.”
       In settling the instructions, the trial court observed that
the evidence did not support the notion that Dr. Liker failed to
give sufficient notice that he was not going to be available to do
the surgery. Both parties immediately agreed the court was
correct and the case was not about Dr. Liker giving insufficient
notice. The court then stated: “I think we could give [CACI] 509,
but we need to add some language that recognizes that good faith
efforts to obtain alternative medical assistance are to be
credited.” The court stated: “We need to instruct a jury on
everything that they conceivably might find to be the facts. I’m
not saying anybody should or should not find one way or the
other on Instruction 509, and neither am I saying they should
find one way or the other on the proposed modification that I just
mentioned. But both have some support in the facts. . . . [¶] But
I think the court’s obligation at this point is to instruct the jury
on any plausible interpretation of the facts that might occur
during their deliberations. And, you know, perhaps they’ll
conclude there was abandonment. [¶] Perhaps they’ll conclude
that the efforts that were made to secure additional medical
treatment were sufficient, and I just think it needs to be
acknowledged. I’ll just tell you flat out, I’m not giving this
instruction unless it is modified because it’s too draconian, and it
leaves the jury almost no choice but to vote in a particular way,
and I don’t think that’s correct.” When plaintiffs’ counsel
suggested that the term “secure the presence” meant that Dr.
Liker had to remain at the hospital until Dr. Mortazavi

                                20
physically arrived (“To secure the presence is the whole key. The
body has to be there. You can’t do a handoff on a promise.”), the
court disagreed. “Securing the presence does not mean that in
this case Dr. Liker would have to go find Dr. Mortazavi, drive
him to the hospital, plant him in the operating room, and then,
okay, now, I can leave. It doesn’t mean that. What it does mean
is going to be up to the jury. [¶] Secure the presence could mean
it takes reasonable steps to obtain an alternative medical
treatment or it could mean . . . they had to wait until he actually
shows up. That’s fine. You can argue that. But there’s nothing
in that case [Hongsathavij v. Queen of Angels etc. Medical Center
(1998) 62 Cal.App.4th 1123 (Hongsathavij)] that says Dr. A has
to wait until Dr. B is physically at his side. There’s nothing in
the case that says that.” The court asked both counsel to come up
with an instruction that recognized all inferences that could be
drawn from the evidence either way without referring to issues of
notice.
       Dr. Liker presented a modification to be added to CACI
509. The modification read: “Efforts by Dr. Liker to secure a
substitute physician can be considered when determining
whether Dr. Liker was medically negligent or acting reasonably
under the circumstances.” Plaintiffs opposed Dr. Liker’s
proposed language because Dr. Liker “walked away and did not
secure the presence of a person of similar capabilities as himself
to be there in a timely manner.” The court reiterated that the
law did not require that Dr. Liker remain at the hospital until his
replacement physically arrived. Plaintiffs submitted Special
Instruction No. 1, which was still focused on inadequate notice.
Citing Hongsathavij, Special Instruction No. 1 read: “A physician
cannot just walk away from a patient after accepting the patient

                                21
for treatment. . . . In the absence of the patient’s consent, the
physician must notify the patient he is withdrawing and allow
ample opportunity to secure the presence of another physician.”
Again stating that the case was not about notice, the trial court
refused to give Special Instruction No. 1 and adhered to its prior
refusal to give CACI 509 as initially proposed. The court adopted
Dr. Liker’s argument that according to plaintiffs’ standard of care
expert, Dr. Taylor, Dr. Liker was medically negligent for leaving
the hospital before Dr. Mortazavi was physically present. “If the
jury believes that, that may be medical negligence.” Dr. Liker
argued that the abandonment instruction did not apply; instead
the instruction on medical negligence and the standard of care
covered the argument plaintiffs wanted to make to the jury.
       Plaintiffs now argue that the court erred when it did not
give CACI 509. We disagree. CACI 509 is based on the general
proposition that “a physician who abandons a patient may do so
‘only . . . after due notice, and an ample opportunity afforded to
secure the presence of other medical attendance.’ ” (Payton v.
Weaver (1982) 131 Cal.App.3d 38, 45. Indeed, a “physician
cannot just walk away from a patient after accepting the patient
for treatment. . . . In the absence of the patient’s consent, the
physician must notify the patient he is withdrawing and allow
ample opportunity to secure the presence of another physician.”
(Hongsathavij, supra, 62 Cal.App.4th at p. 1138.)
       Hongsathavij is the quintessential case of abandonment of
patient. There, Dr. Hongsathavij, the on-call doctor for labor and
delivery, accepted for treatment an emergency room high-risk
patient in premature labor and admitted her to the hospital as
his patient. Upon learning later that the patient was not one for
whom Los Angeles County would pay his fees, Dr. Hongsathavij

                                22
refused to issue any orders for her care or treatment. He told the
nursing director on duty that he did not want to take care of the
patient and his insurance would not allow him to do so. Nursing
staff had to call another physician to the hospital to treat the
patient. (Hongsathavij, supra, 62 Cal.App.4th at p. 1131–1132.)
The court of appeal repeated “well-accepted principles,” to wit,
that a “physician cannot just walk away from a patient after
accepting the patient for treatment”; a “physician cannot
withdraw treatment from a patient without due notice and an
ample opportunity afforded to secure the presence of another
medical attendant”; and in “the absence of the patient’s consent,
the physician must notify the patient he is withdrawing and
allow ample opportunity to secure the presence of another
physician.” (Id. at p. 1138; Payton v. Weaver, supra,
131 Cal.App.3d at p. 45 [no abandonment where physician gave
sufficient notice to patient that he would no longer treat her and
provided patient with names and telephone numbers of alternate
dialysis providers].) Given the evidence that Dr. Hongsathavij
admitted the patient as his own, refused to provide care, and did
not give notice to the patient that he would not treat her, the
court there found “patient abandonment.” (Hongsathavij, at
p. 1139.)
       Here, the undisputed facts are that Dr. Liker consulted
with Dr. Lee, the emergency room physician managing Mr.
Zannini’s care; Dr. Liker did not take over the patient’s care; Dr.
Liker reminded Mrs. Zannini he would not be available to do
emergency surgery if it was needed, but his associate and on-call
physician Dr. Mortazavi would be available; Dr. Liker made Dr.
Mortazavi aware of the patient’s circumstances, pending tests,
and possible diagnoses; and Dr. Liker remained available to

                                23
discuss with Dr. Mortazavi possible diagnoses and treatment
after Dr. Mortazavi received the MRI results. When Dr. Liker
left the premises, there was a plan in place for his treatment by
Dr. Lee and Dr. Mortazavi. There was no evidence of
abandonment of patient as contemplated by CACI 509. The trial
court was correct in declining to give the instruction. 1
       Plaintiffs argue that the standard of care required Dr.
Liker to remain physically at the hospital until the next
neurosurgeon physically arrived to take his place. The trial court
did not disagree; it simply ruled abandonment did not occur as a
matter of law just because Dr. Liker physically left the hospital
before Dr. Mortazavi physically arrived.
       We agree. Abandonment as a theory warrants CACI 509
only where there is evidence that the physician has accepted
responsibility for the patient and then has withdrawn without
giving enough notice to ensure timely continuity of treatment.
The facts at trial did not support the notion that Dr. Liker took
over Mr. Zannini’s treatment and then withdrew without
sufficient notice. No witness testified that Dr. Liker was in
charge of Mr. Zannini’s care in the emergency room. Dr. Lee
testified she was managing the case. Dr. Mortazavi testified the

1     In addition to arguing that Dr. Liker had actually assumed
responsibility for Mr. Zannini’s care and then abandoned him,
plaintiffs argued alternatively that because Dr. Liker had a pre-
existing relationship with the patient, the standard of care
required him to assume responsibility for Mr. Zannini’s care and
to remain at the hospital until another physician physically
arrived to take over. The jury found no negligence and the
evidence in support of the jury’s verdict is not challenged on
appeal.

                               24
emergency room physician is in charge until a diagnosis is made
that requires surgery. Even plaintiffs’ expert would only say that
Dr. Liker “was involved in his care up to a point.” The
instruction was not warranted.
       We also disagree with plaintiffs’ contention that the court
should have given CACI 509 because their theory of the case was
not adequately covered by CACI 502 (Standard of Care for
Medical Specialists). CACI 502 reads: “A neurosurgeon is
negligent if he or she fails to use the level of skill, knowledge, and
care in diagnosis and treatment that other reasonably careful
neurosurgeons would use in similar circumstances. This level of
skill, knowledge, and care is sometimes referred to as ‘the
standard of care.’ [¶] You must determine the level of skill,
knowledge, and care that other reasonably careful neurosurgeons
would use in similar circumstances based only on the testimony
of the expert witnesses, including Mark A. Liker, M.D., who have
testified in this case.”
       First, plaintiffs requested CACI 502 as set out above
without suggesting it be modified to be more specific as to Dr.
Liker’s early departure. Second, plaintiffs’ theory was Dr. Liker
never should have left the hospital under the dire circumstances
before another neurosurgeon physically arrived to take over the
patient’s care. This iteration of the standard of care was
supported by Dr. Taylor’s expert testimony: “In my opinion he
should have stayed with Mr. Zannini and made sure that he got
the appropriate study, the M.R.I. or he should have made sure
that someone capable of getting that study done, interpreting it
and performing the surgery was immediately available.” With
this expert testimony, CACI 502 adequately permitted the jury, if
it had been so inclined, to find medical negligence based upon Dr.

                                 25
Liker’s early departure. If the jury believed Dr. Liker was
negligent to hand off the patient’s care to Dr. Mortazavi as he
did, the jury could have so found. Plaintiffs’ theory of the case
was adequately supported by the instructions as given.

C.    CACI 411 (Reliance on the Good Conduct of Others) Did Not
      Prejudice Plaintiffs
      Plaintiffs contend that CACI 411 (Reliance on the Good
Conduct of Others) should not have been read to the jury. CACI
411 reads: “Every person has a right to expect that every other
person will use reasonable care, unless he or she knows, or
should know, that the other person will not use reasonable care.”
Plaintiffs’ counsel initially stated they objected to the instruction
and then told the court, “I’m not sure there’s evidence of that.
But I can see their point.” The court then stated it would give the
instruction and plaintiffs said nothing more.
      Plaintiffs fail to show how they were prejudiced by the
instruction. Nor do they cite any legal authority for their
proposition that the instruction was prejudicially given in error.
There was no evidence of misconduct or professional negligence
by other personnel at the hospital that night upon which the
delay in treatment could be blamed. Indeed, no party even
argued about the good or bad conduct of parties other than Dr.
Liker. No party argued that the conduct of third parties
influenced Dr. Liker’s decision to leave at 7:17 p.m. Plaintiffs’
position was that Dr. Liker alone was responsible for the delays
in Mr. Zannini’s treatment and the good conduct of others did not
mitigate the delays caused by his premature departure from the
hospital. The defense likewise argued Dr. Liker’s decision to
depart when he did was consistent with the standard of care and
did not cause a delay in treatment, given the inability to

                                 26
responsibly diagnose the need for surgical intervention without
Dr. Goldman’s report interpreting the complete series of scans.
The instruction did nothing to call attention to the conduct of
third parties in such a way as to undermine plaintiffs’ argument
or to support the defense position. We find no error and no
prejudice.

D.     The Trial Court’s Refusal to Give CACI 430 (Causation:
       Substantial Factor) and CACI 431 (Causation: Multiple
       Causes) and its Decision to Give Defense Special Instruction
       No. 2 Are Moot in Light of the Jury’s Finding of No
       Negligence
       Plaintiffs also contend that the trial court erred when it
declined to give two CACI instructions on causation. The court
declined to give CACI 430, which reads: “A substantial factor in
causing harm is a factor that a reasonable person would consider
to have contributed to the harm. It must be more than a remote
or trivial factor. It does not have to be the only cause of the
harm. [¶] Conduct is not a substantial factor in causing harm if
the same harm would have occurred without that conduct.”
CACI 431 reads: “A person’s negligence may combine with
another factor to cause harm. If you find that Mark A. Liker,
M.D.’s negligence was a substantial factor in causing Ronald
Zannini’s harm, then Mark A. Liker, M.D., is responsible for the
harm. Mark A. Liker, M.D., cannot avoid responsibility just
because some other person, condition, or event was also a
substantial factor in causing Ronald Zannini’s harm.”
       Instead of giving these causation instructions, the trial
court gave Defense Special Instruction No. 2: “You must decide
whether the alleged negligent conduct of the defendants was a
substantial factor that contributed to the injury complained of by

                                27
plaintiff. [¶] 1. To be ‘substantial,’ a ‘factor’ (alleged negligent
conduct of defendant) must be something that actively
contributes to the production of harm; [¶] 2. ‘Substantial’ means
that the ‘factor’ is more than remote, trivial or merely possible in
contributing to the harm; [¶] 3. A ’factor’ is not ’substantial’ if the
harm complained of by plaintiff would have occurred without the
conduct of the defendant. [¶] In making this determination, you
must rely upon the testimony of the expert witnesses who
expressed opinions as to whether there was a reasonable medical
probability that the conduct of the defendants contributed to the
injury complained of by Plaintiff.”
      We conclude these contentions are moot. Because the jury
never found negligence, it did not answer the questions on the
issue of causation. “Reversal is in order only if the error was a
factor in the verdict it did reach.” (Wilkinson v. Southern Pac.
Co. (1964) 224 Cal.App.2d 478, 490; see Spriesterbach v. Holland
(2013) 215 Cal.App.4th 255, 273.) Determining the propriety of
the instructions on causation will have no effect on the jury’s
finding that Dr. Liker was not negligent. There is no point in
analyzing the challenged instructions and we decline to do so.

E.    Plaintiffs’ Challenge to CACI 506 (Alternative Methods of
      Care) Is Waived
      The trial court gave CACI 506 (Alternative Methods of
Care) which reads: “A neurosurgeon is not necessarily negligent
just because he or she chooses one medically accepted method of
treatment or diagnosis and it turns out that another medically
accepted method would have been a better choice.” Plaintiffs
contend there was no evidence of any “alternative method of
treatment or diagnosis.”

                                  28
       This contention is waived. Plaintiffs cite no legal authority
in support of their argument and make no argument whatsoever
as to the prejudicial effect of giving the instruction. We decline to
make their argument for them. (United Grand Corp. v. Malibu
Hillbillies, LLC (2019) 36 Cal.App.5th 142, 146.)

F.      The Trial Court Did Not Err in Refusing to Give BAJI 6.15
        Which Defined “Emergency.”
        Plaintiffs asked the court to instruct the jury with BAJI
6.15, which defines emergency as: “[A]n unforeseen combination
[of] circumstances creating a condition which . . . requires
immediate care, treatment or surgery in order to protect a
person’s life or health.” The court declined to do so, noting that
the instruction was just a definition which did not add anything
to the case.
        We agree. There was no witness at trial who disputed that
Mr. Zannini was in a situation which “require[d] immediate care,
treatment or surgery in order to protect a person’s life or health.”
This is a non-issue, perhaps implicitly acknowledged by plaintiffs
who cite no points and authorities in support of their argument
and fail to argue or establish prejudice.

                                 29
                         DISPOSITION

     The judgment is affirmed. Costs are awarded to
respondent Mark A. Liker, M.D.

      CERTIFIED FOR PUBLICATION

                                     STRATTON, J.

We concur:

             GRIMES, Acting P. J.

             HARUTUNIAN, J. *

*     Judge of the San Diego Superior Court, assigned by the
Chief Justice pursuant to article VI, section 6 of the California
Constitution.

                                30