Court Opinion

ID: 4639475
Source: CourtListenerOpinion
Date Created: 2020-12-04 07:14:43.603441+00
Date Added: 2024-06-11T07:58:56.949273
License: Public Domain

In The

                               Court of Appeals

                    Ninth District of Texas at Beaumont

                              ________________

                              NO. 09-20-00108-CV
                              ________________

            CHRISTUS HEALTH SOUTHEAST TEXAS D/B/A
           CHRISTUS HOSPITAL – ST. ELIZABETH, Appellant

                                        V.

MYRANDA CARNAHAN AND ALEX YATES, INDIVIDUALLY, AND AS
            NEXT FRIEND OF M.Y., Appellees
________________________________________________________________________

                   On Appeal from the 172nd District Court
                          Jefferson County, Texas
                         Trial Cause No. E-204,242
________________________________________________________________________

                          MEMORANDUM OPINION

      We decide in this interlocutory appeal whether the trial court abused its

discretion by denying Christus Health Southeast d/b/a Christus Hospital – St.

Elizabeth’s (“Christus”) motion to dismiss the health care liability claims of

Myranda Carnahan and Alex Yates (“the Claimants”). In two issues encompassing

various sub-issues, Christus contends that the Claimants’ expert report and expert’s

accompanying CV fail to meet the Texas Medical Liability Act’s (hereinafter “the

                                         1
Act”) requirements. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(l) (requiring a

court to grant a motion challenging the adequacy of an expert’s report if it does not

constitute an objective good faith attempt to comply with the Act’s definition of an

expert report). Specifically, Christus challenges the expert’s qualifications and the

sufficiency of the expert’s opinions. The hospital argues that the expert’s report is

so deficient it constitutes “no report at all[.]” For the following reasons, we overrule

Christus’s issues and affirm the trial court’s order denying the motion to dismiss.

                                   I. Background1

      Carnahan and Yates sued the hospital, asserting a vicarious liability theory

based on the negligent care and treatment by its nurses during Carnahan’s

hospitalizations while pregnant.2 Within 120 days of the hospital filing its answer,

the Claimants served the hospital with James Wheeler, MD’s expert report and

accompanying CV as required by the Act. See id. § 74.351(a).

      1
        The expert report at issue in this appeal provides the background facts. The
medical records are not part of the appellate record, and we rely on the report’s
factual statements for the limited purpose of this appeal. See Bowie Mem’l Hosp. v.
Wright, 79 S.W.3d 48, 52–53 (Tex. 2002).
      2
        In their first amended petition, the Claimants also named Jurswin Pieternelle,
MD, as a defendant; however, the attending doctor is not a party to this appeal.
                                           2
              II. Contents of Curriculum Vitae and Expert Report

A. Qualifications

      Dr. Wheeler’s CV notes that he has been a board-certified obstetrician3 and

gynecologist 4 since 1989, with his most recent recertification occurring in 2019. His

medical employment history from 1995 to the present lists his private practice as a

“Reproductive endocrinologist,5 Obstetrician/Gynecologist” and parenthetically

notes “Occasional Ob/Gyn Locum tenens placement[.]” 6 His current hospital

appointments indicate that since 2006, he has served as a courtesy staff member with

admitting and consulting privileges at Woman’s Hospital of Texas, having been

renewed most recently in 2018. Prior to that, between 1988 and 1994, he had an

      3
         An obstetrician is a physician specializing in obstetrics. See https://merriam-
webster.com/dictionary/obstetrician last accessed 11/9/2020. “Obstetrics” is defined
as “a branch of medical science that deals with pregnancy, childbirth, and the
postpartum period[.]” https://merriam-webster.com/dictionary/obstetrics (last
accessed 11/19/2020).
       4
         A gynecologist is a physician specializing in gynecology. See
https://merriam-webster.com/dictionary/gynecologist (last accessed 11/9/2020).
“Gynecology” is defined as a “branch of medicine that deals with the diseases and
routine physical care of the reproductive system of women[.]”https://merriam-
webster.com/dictionary/gynecology (last accessed 11/19/2020).
       5
         The American College of Obstetricians and Gynecologists’ website explains
that some ob-gyns have extra training in a focused area of women’s health care, and
specifically notes that “reproductive endocrinology” is “focused on the hormones of
the reproductive system and helping women who have problems getting pregnant[.]”
https://acog.org/womens-health/about-acog (last visited 11/19/2020).
       6
         “Locum tenens” is defined as “one filling an office for a time or temporarily
taking the place of another[.]” https://merriam-webster.com/dictionary/
locum%20tenens (last accessed 11/19/2020).
                                           3
academic practice at Baylor College of Medicine, where he worked from 1988 until

1996 as a reproductive endocrinologist and obstetrician/gynecologist and as a

clinical assistant professor and assistant professor in the Departments of

Obstetrics/Gynecology and Community Medicine.

      Dr. Wheeler’s CV also reveals he is a licensed attorney. From 2016 through

2018, he served as a professor of medicine, law, and nursing for Brighton

College/The Paralegal Institute, where he taught courses such as “Legal Research –

Legal Nurse Consultant Diploma Program[.]” Dr. Wheeler’s expert report states that

he has earned a Legal Nurse Consulting diploma, and from 2016 to 2018, he “taught

undergraduates, nurses, medical students and doctors in various courses pertaining

to consulting in medical and nursing issues within legal cases.” Dr. Wheeler asserts

the following in his report,

      I have worked side-by-side with nurses at various educational levels,
      nurse-midwi[v]es, and physician assistants. I have taught these
      professionals a variety of subjects in Ob/Gyn, including topics in
      Obstetrics. I have worked as a nurse, moonlighting in medical school,
      in Surgical, Medical and Cardiac ICUs. I have edited and helped with
      the publication of documents for the Nurses Association of the
      American College of Obstetricians and Gynecologists (“NAACOG”). I
      have reviewed hospital policies pertaining to nursing care, including
      policies and procedures within Labor & Delivery units.

B. Review of Carnahan’s and M.Y.’s Medical Records

      Dr. Wheeler outlines the medical records reviewed in this case, including,

among others, Carnahan’s records from the hospital. Of significance, Dr. Wheeler

                                         4
notes Carnahan’s “medical comorbidities.” He mentions Carnahan’s BMI of 41.3

kg/m2, classifying her obesity as “extreme,” and she suffered from hypothyroidism,

treated by levothyroxine. She also had a recent “positive history of E. coli UTI.”

      Dr. Wheeler’s report explains that on May 30, 2017, Carnahan presented to

Christus at 26 3/7 weeks’ gestation with complaints of “pelvic pressure” and lower

abdominal pain that began the previous day, which she described as “crampy.” A

vaginal exam was ordered “per unit standard” and noted by a nurse, but the exam

was “deferred.” Dr. Wheeler explains in the report that the notation “per unit

standard” means the “exam [w]as part of the routine evaluation of a woman in

possible preterm labor; other units have this as a standing order from each

Obstetrician.” Dr. Wheeler mentions that fetal heart rate monitoring was ordered as

were urinalysis, urine culture, and vaginal nitrazine pH test to assess rupture of

amniotic fluid. The urinalysis and urine culture suggested a bacterial infection but

was considered contaminated. Dr. Wheeler notes that a Complete Blood Count

(“CBC”) was also ordered, but Carnahan was discharged on May 30, 2017, before

the results were received.7 Carnahan was discharged on the evening of May 30,

2017, on antibiotics with instructions about contractions.

      7
        More specifically, the report notes the results were not returned to the chart
until June 1, 2017.
                                          5
      On June 1, 2017, Carnahan returned to Christus where at 04:58 a nurse

responded to an emergency call light in Carnahan’s room. The nurse then observed

Carnahan sitting on the toilet with the baby hanging out of her vagina. Nurses

retrieved the baby, wrapped her in towels, and a nurse stimulated the baby. Nurses

then “rushed [the infant] to the NICU,”8 arriving at 05:05.

      In his expert report, Dr. Wheeler mentions a history and physical plus delivery

note that Carnahan presented

      complaining of pelvic pressure and Urinary Tract Infection (“UTI”)
      symptoms continuing. Was seen in triage 5/30/17 with complaints of
      UTI. The physical exam noted “placenta and cord at the introitus with
      clamp and foul smell”. Under assessment, “No contractions reported.
      Admitted for intravenous antibiotics – Rocephin 1 g at 01:20 . . . patient
      resting and when got up to use bathroom, sat down to seat, felt gush of
      fluids and baby coming out. Called RN. RN found patient on toilet with
      baby between legs, face-up above water – grasped baby and called for
      help. Cord clamped and cut infant rushed to NICU. 2#, 14 ½ inches
      long – suspect chorioamnionitis.”

Dr. Wheeler noted that “[p]lacental pathology demonstrated severe acute

chorioamnionitis and moderate acute funisitis of the umbilical cord” and bacterial

cultures were positive for “two anaerobic species . . . known to be associated with

chorioamnionitis, and preterm labor.”

      8
       NICU is the acronym for neonatal intensive care unit. See https://merriam-
webster.com/dictionary/NICU (last accessed 11/19/2020).
                                          6
      Dr. Wheeler writes that M.Y. had “Apgar scores of 2, 2 and 4 at 1, 5, and 10

minutes of life.”9 Dr. Wheeler included in his review the records from Texas

Children’s Hospital for minor M.Y. (DOB 06/01/2017). Dr. Wheeler explains that

recorded problems associated with M.Y.’s prematurity “included intraventricular

hemorrhage, retinopathy of prematurity, bronchopulmonary dysplasia, feeding

difficulties, apnea, anemia, and diaper dermatitis.” He further notes Early Childhood

Intervention documents M.Y.’s ongoing developmental delay.

C. Opinions on Standards of Care and Causation

      Citing multiple sources, Dr. Wheeler’s report explains that “[p]reterm birth is

the leading cause of neonatal mortality in the U.S.,” and the “[d]iagnosis of preterm

labor is aided by detecting maternal risk factors.” The report also notes that risk

factors for preterm birth and labor “have been published for decades in Ob/Gyn

textbooks and include complications like . . . infection including urinary tract

infection (“UTI”), and . . . obesity.” (Emphasis original.) Dr. Wheeler states, “Ob

nurses have been taught[] that [e]very attempt should be made to detect preterm labor

early in its evolution.” (Internal quotations omitted.)

      9
         Apgar refers to “an index used to evaluate the condition of a newborn infant
based on a rating of 0, 1, or 2 for each of the five characteristics of color, heart rate,
response to stimulation of the sole of the foot, muscle tone, and respiration with 10
being a perfect score.” https://merriam-webster.com/dictionary/Apgar%20score
(last accessed 11/19/2020).
                                            7
      Dr. Wheeler outlines the applicable standards of care for the Christus nurses

as “those standards of reasonably well-trained and well-experienced labor and

delivery nurses caring for patients the same as, or similar to, Ms. Carnahan[,]” which

include: (1) the proper assessment of risk factors of preterm labor; (2) recognition of

subtle symptoms and signs of preterm labor regardless of risk factor profile; (3)

assessing the cervix, “as the very definition of preterm labor requires this

assessment, via visual inspection, digital examination, or effecting the performance

of ultrasonography[;]” and (4) not discharging the patient incompletely assessed and

potentially treated for preterm labor, in order to avoid tragic preterm birth in some

precarious setting. As to the nurses’ specific departures from the standards of care,

Dr. Wheeler opines that they failed to properly assess Carnahan’s preterm labor risk

factors, failed to recognize her symptoms and signs indicative of preterm labor,

failed to assess the cervix in possible preterm labor, and discharged a patient in

possible preterm labor with a CBC test pending.

      With respect to damages and proximate cause, Dr. Wheeler opines that if the

nurses had satisfied their applicable standards of care, Carnahan would have been

found to be in preterm labor, which would have led to hospital admission followed

by bedrest, hydration, IV antibiotics, fetal and uterine monitoring, tocolysis 10 with

      10
          “Tocolysis” is defined as the “inhibition of uterine contractions.”
https://merriam-webster.com/medical/tocolysis (last accessed 11/19/2020).
                                          8
magnesium sulfate, beta-mimetics or non-steroidal anti-inflammatories. He further

reasons that those therapies can prolong gestation and provide time for the

administration of corticosteroids. Dr. Wheeler explains that “the most beneficial

intervention for patients in true preterm labor is the administration of

corticosteroids[,]” which “significantly reduce[] the incidence and severity of

neonatal respiratory distress syndrome . . . intraventricular hemorrhage . . .

necrotizing enterocolitis . . . and neonatal mortality.” Ultimately, Dr. Wheeler

concludes that “[i]n reasonable medical probability, if Ms. Carnahan had been

treated within the standards of care outlined above, she could have carried M.Y.

sufficient time such that corticosteroid administration would have reduced the

significant medical morbidity with which she suffers to this day.” Moreover, Dr.

Wheeler’s report links the breaches in the standard of care that he found to M.Y’s

injuries, explaining that “[b]ut for the negligent care Ms. Carnahan received form

Christus St. Elizabeth, it is medically probable [M.Y.’s] damages would be

prevented, or significantly reduced.”

                             III. Standard of Review

      In health care liability cases, we review a trial court’s ruling on a motion to

dismiss based on the adequacy of an expert report for an abuse of discretion. See

Abshire v. Christus Health Southeast Tex., 563 S.W.3d 219, 223 (Tex. 2018); Van

Ness v. ETMC First Physicians, 461 S.W.3d 140, 142 (Tex. 2015) (per curiam); Am.

                                         9
Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 877–78 (Tex.

2001). “A trial court abuses its discretion if it acts in an arbitrary or unreasonable

manner without reference to any guiding rules or principles.” Bowie Mem’l Hosp. v.

Wright, 79 S.W.3d 48, 52 (Tex. 2002) (per curiam). A trial court’s ruling does not

constitute an abuse of discretion simply because the appellate court would have ruled

differently under the circumstances. See id.; Hendryx v. Duarte, No. 09-18-00070-

CV, 2019 WL 1065052, at *4 (Tex. App.—Beaumont Mar. 7, 2019, no pet.) (mem.

op.). In reviewing a report’s sufficiency under this standard, “we consider only the

information contained within the four corners of the report.” Abshire, 563 S.W.3d at

223 (citing Palacios, 46 S.W.3d at 878). In determining whether the report contains

the requisite information, we view the entirety of the report rather than isolating

specific portions or sections. See Baty v. Futrell, 543 S.W.3d 689, 694 (Tex. 2018);

Van Ness, 461 S.W.3d at 144.

      Likewise, we use an abuse of discretion standard when reviewing a trial

court’s decision that an expert in a health care liability case is qualified to express

opinions about whether the patient’s medical care violated the standards applicable

to the provider. See Broders v. Heise, 924 S.W.2d 148, 151 (Tex. 1996) (“The

qualification of a witness as an expert is within the trial court’s discretion. We do

not disturb the trial court’s discretion absent clear abuse.”); Hendryx, 2019 WL
1065052, at *5 (applying abuse of discretion standard for an expert’s qualifications

                                          10
to express opinions about whether the medical care a patient received violated the

applicable standards). We defer to the trial court on close calls concerning an

expert’s qualifications. See Larson v. Downing, 197 S.W.3d 303, 304–05 (Tex.

2006). An expert’s knowledge cannot be inferred, and the basis for his qualifications

must be evident in the report or CV. In re McAllen Med. Ctr., Inc., 275 S.W.3d 458,

463 (Tex. 2008) (orig. proceeding).

                       IV. Law and Statutory Framework

      The Act requires a claimant to serve an expert report on each party against

whom a health care liability claim is asserted within 120 days of a defendant filing

an answer. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351(a). The statute defines

“expert report” as

      a written report by an expert that provides a fair summary of the
      expert’s opinions as of the date of the report regarding applicable
      standards of care, the manner in which the care rendered by the
      physician or health care provider failed to meet the standards, and the
      causal relationship between that failure and the injury, harm, or
      damages claimed.
Id. § 74.351(r)(6).

      The report need not marshal all the plaintiff’s proof but must set forth the

expert’s opinions on the standard of care, breach, and causation. Columbia Valley

Healthcare Sys., L.P. v. Zamarripa, 526 S.W.3d 453, 460 (Tex. 2017). If the

defendant challenges the report, the court must decide whether it constituted “a

good-faith effort to comply” with the statute. Wright, 79 S.W.3d at 52. A “good-
                                         11
faith effort” (1) informs the defendants of the specific conduct the plaintiffs call into

question and (2) provides a basis for the trial court to conclude the claims have merit.

Baty, 543 S.W.3d at 693–94.

      Texas Civil Practice and Remedies Code section 74.351(r)(5) provides the

following experts are qualified:

      (B) with respect to a person giving opinion testimony regarding
      whether a health care provider departed from accepted standards of
      health care, an expert qualified to testify under the requirements of
      Section 74.402;

      (C) with respect to a person giving opinion testimony about the causal
      relationship between the injury, harm, or damages claimed and the
      alleged departure from the applicable standard of care in any health care
      liability claim, a physician who is otherwise qualified to render
      opinions on such causal relationship under the Texas Rules of Evidence
      ....

Tex. Civ. Prac. & Rem. Code Ann. § 74.351(r)(5)(B)–(C). Section 74.402 provides

in pertinent part:

      (b) In a suit involving a health care liability claim against a health care
      provider, a person may qualify as an expert witness on the issue of
      whether the health care provider departed from accepted standards of
      care only if the person:

             (1) is practicing health care in a field of practice that involves the
             same type of care or treatment as that delivered by the defendant
             health care provider, if the defendant health care provider is an
             individual, at the time the testimony is given or was practicing
             that type of health care at the time the claim arose;

             (2) has knowledge of accepted standards of care for health care
             providers for the diagnosis, care, or treatment of the illness,
             injury, or condition involved in the claim; and
                                           12
             (3) is qualified on the basis of training or experience to offer an
             expert opinion regarding those accepted standards of health care.

      (c) In determining whether a witness is qualified on the basis of training
      or experience, the court shall consider whether, at the time the claim
      arose or at the time the testimony is given, the witness:

             (1) is certified by a licensing agency of one or more states of the
             United States or a national professional certifying agency, or has
             other substantial training or experience, in the area of health care
             relevant to the claim; and

             (2) is actively practicing health care in rendering health care
             services relevant to the claim.
Id. § 74.402(b)–(c). The statute further explains that “practicing health care”

includes:

      (1) training health care providers in the same field as the defendant
      health care provider at an accredited educational institution; or

      (2) serving as a consulting health care provider and being licensed,
      certified, or registered in the same field as the defendant health care
      provider.
Id. § 74.402 (a)(1)–(2). Finally, with respect to an expert qualified to opine on

causation, the statute provides,

      a person may qualify as an expert witness on the issue of the causal
      relationship between the alleged departure from accepted standards of
      care and the injury, harm, or damages claimed only if the person is a
      physician and is otherwise qualified to render opinions on that causal
      relationship under the Texas Rules of Evidence.
Id. § 74.403(a).

                                          13
      The expert offering the opinions in the report must be qualified to render those

opinions.

      To be qualified to opine that an institutional health-care provider
      breached the applicable standard of care, a person must have
      “knowledge of accepted standards of care for health care providers for
      the diagnosis, care, or treatment of the illness, injury, or condition
      involved in the claim” and be “qualified on the basis of training or
      experience to offer an expert opinion regarding those accepted
      standards of health care.”

Mem’l Hermann Health Sys. v. Heinzen, 584 S.W.3d 902, 911 (Tex. App.—Houston

[14th Dist.] 2019, no pet.) (quoting Tex. Civ. Prac. & Rem. Code Ann §

74.402(b)(2), (b)(3)). Further,

      [w]hile it is true that for certain medical-negligence claims against non-
      physicians, a person is qualified to render an expert report only if the
      person is or was engaged in a field of health-care practice “that involves
      the same type of care or treatment as that delivered by the defendant
      health care provider . . . at the time the testimony is given or . . . at the
      time the claim arose,” that requirement applies only “if the defendant
      health care provider is an individual.”
Id. (quoting Tex. Civ. Prac. & Rem. Code Ann. § 74.402(b)(1)). Because the hospital

is not an individual, this provision does not apply to a doctor’s report regarding the

care the hospital provided through its nursing staff. See id. at 911–12 (citing Harvey

v. Kindred Healthcare Operating, Inc., 578 S.W.3d 638, 644–46 (Tex. App.—

Houston [14th Dist.] 2019, no pet.) (determining subsection inapplicable to an expert

report addressing a claim against a hospital for its nursing staff’s conduct)). A person

may be qualified to render an expert opinion regarding the applicable standard of

                                           14
care for hospital nursing staff based on previously acquired experience. See, e.g., id.

at 912; see also Zamarripa, 526 S.W.3d at 461 n.37 (noting that the trial court was

within its discretion to determine the nurse was qualified to offer opinions on

applicable standards of care for labor and delivery nurses based on prior experience,

even though she currently worked as a hematology-oncology nurse). “Section

74.351(r)(5)(B) does not require an expert to have the same specialty as the health

care provider she evaluates.” Zamarripa, 526 S.W.3d at 461 n.37 (citations omitted).

However, an expert offering an opinion on causation in a claim under the Act must

be “a physician who is otherwise qualified to render opinions on such causal

relationship under the Texas Rules of Evidence[.]” Tex. Civ. Prac. & Rem. Code

Ann. § 74.351(r)(5)(C).

      We are “cautioned that while ‘there is no validity, if there ever was, to the

notion that every licensed medical doctor should be automatically qualified to testify

as an expert on every medical question,’ the TMLA’s test for ‘expert qualifications

should not be too narrowly drawn.’” Benge v. Williams, 548 S.W.3d 466, 472 (Tex.

2018) (quoting Larson, 197 S.W.3d at 305; Broders, 924 S.W.2d at 152).

      The Texas Supreme Court has explained that obtaining an expert’s opinions

early in the litigation is a way to reduce frivolous lawsuits. See Palacios, 46 S.W.3d

at 877; see also Baty, 543 S.W.3d at 692. “[T]he purpose of evaluating expert reports

is to deter frivolous claims, not to dispose of claims regardless of their merits.”

                                          15
Certified EMS, Inc. v. Potts, 392 S.W.3d 625, 631 (Tex. 2013) (citation and internal

quotations omitted).

                                     V. Analysis

      With the above statutory framework and standard of review in mind, we turn

to the hospital’s complaints that Dr. Wheeler is unqualified to render an expert

opinion in this case and that his opinions did not constitute a good-faith effort to

comply.

A. Issue Two: Dr. Wheeler’s Qualifications and “No Report”

      Christus challenges Dr. Wheeler’s qualifications, arguing “the issue is not

whether Dr. Wheeler was qualified as an obstetrician or gynecologist, but whether

his expertise renders him an expert regarding the diagnosis, care, or treatment of the

condition involved in this case.” Christus asserts that Dr. Wheeler’s report

constitutes “no report[.]” While we agree that not every licensed physician will be

qualified to testify regarding every medical issue, we note that the test for Dr.

Wheeler’s expert qualifications should not be too narrowly drawn. See Benge, 548
S.W.3d at 472 (citations omitted).

      The four corners of the report and accompanying CV discuss Dr. Wheeler’s

extensive obstetrical and gynecological training. Christus disagrees that Dr.

Wheeler’s report and CV establish his qualifications to opine on the standard of care

applicable to the nurses. Specifically, Christus contends that

                                         16
      nothing in his CV or report establishes that he has any training or
      experience that would form the basis for his opinions as to the standard
      of nursing care for a preterm obstetrical patient in a hospital setting.
      Nothing indicates he has worked as an obstetrician treating pregnant
      women, who present to the hospital with abdominal pain in the second
      trimester of pregnancy and subsequently deliver babies prematurely.

      Without offering an opinion regarding whether Christus has tried to construct

the expert qualification test too narrowly, we believe the trial court was well within

its discretion to conclude, based on the information provided in the report and CV,

that Dr. Wheeler’s extensive training and experience practicing as an Ob/Gyn,

himself working as a nurse, and working with nurses delivering babies as well as

teaching them, rendered him qualified to offer opinions even as the appellants have

framed the issues. Essentially, Christus complains that Dr. Wheeler’s focus as a

subspecialist in the field of reproductive endocrinology means he is unqualified in

the larger field of obstetrics and that the trial court could not determine he was

qualified. We disagree. Reproductive endocrinology is part of the larger umbrella of

obstetrics and gynecology. Dr. Wheeler’s CV shows that he has continuously been

recertified by the American College of Obstetricians and Gynecologists, and in

addition to his role as a reproductive endocrinologist, he works as an obstetrician

and gynecologist on a locum tenens basis.

      In his report, Dr. Wheeler describes that he has “edited and helped with the

publication of documents for the Nurses Association of the American College of

Obstetricians and Gynecologists (“NAACOG”) [and] reviewed hospital policies
                                         17
pertaining to nursing care, including policies and procedures within Labor &

Delivery units.” Further, in his report he explains that he has “worked side-by-side

with nurses at various educational levels, nurse-midwi[v]es, and physician assistants

. . . and taught these professionals a variety of subjects in Ob/Gyn, including topics

in Obstetrics.” Dr. Wheeler also wrote in the report that “[t]he depth and breadth of

my clinical experiences, in both medicine and nursing, make me a reasonable

physician to review the clinical aspects of minor M.Y.’s case.”

      Christus isolates portions of Dr. Wheeler’s report and CV focusing on

reproductive endocrinology while ignoring the rest of his training and practice. Yet,

we must view the report and CV in their entirety, rather than examining isolated

portions. See Baty, 543 S.W.3d at 694. Dr. Wheeler’s CV establishes that he

continues to practice as an Ob/Gyn with occasional locum tenens placement.

Likewise, he is a Diplomat with the American Board of Obstetrics and Gynecology

since 1989 and was recertified as recently as 2019. Dr. Wheeler’s CV also reveals

that from 2006, he has had consulting privileges at the Woman’s Hospital of Texas.

See Tex. Civ. Prac. & Rem. Code Ann. § 74.402(a)(2) (noting that “practicing health

care” includes “serving as a consulting health care provider and being licensed,

certified, or registered in the same field as the defendant health care provider”).

      To the extent the hospital argues that Dr. Wheeler is unqualified, and

therefore, his report constitutes “no report,” such argument lacks merit. The hospital

                                          18
relies heavily on Scoresby v. Santillan in support of this argument. However, the

Texas Supreme Court explained that “[a]n inadequate expert report does not indicate

a frivolous claim if the report’s deficiencies are readily curable.” See 346 S.W.3d
546, 556 (Tex. 2011). The Court further explained that it had “rejected the argument

that a deficient report is no report.” Id. at 556 (citing Ogletree v. Matthews, 262
S.W.3d 316, 320–21 (Tex. 2007)).

      Based on the foregoing, we cannot say the trial court acted without reference

to guiding rules or principles when it determined that Dr. Wheeler was qualified as

an expert to render opinions on the standard of care pertaining to nurses, breaches of

those standards of care, and how those failures proximately caused the injuries in

this case. Accordingly, we disagree with the hospital’s contention that Dr. Wheeler

was unqualified, and therefore, his report constituted “no report.” The trial court was

well within its discretion in determining Dr. Wheeler is qualified, and we overrule

the hospital’s first issue. We defer to the trial court on close calls concerning an

expert’s qualifications. See Larson, 197 S.W.3d at 304–05 (explaining deference

given to trial court on close calls concerning expert’s qualifications); see also

Wright, 79 S.W.3d at 52 (explaining a trial court’s ruling does not constitute an abuse

of discretion simply because an appellate court would rule differently under the

circumstances).

B. Issue Two: Section 74.351 and Good Faith Effort

                                          19
      In their second issue, Christus complains that Dr. Wheeler’s report was

“legally and materially deficient and failed to constitute an objective good faith

effort to meet the requirements of section 74.351[(a).]”11 In conducting our analysis

of whether the expert report constitutes a “good-faith effort,” we must determine

whether it (1) informs Christus of the specific conduct the Claimants call into

question and (2) provides a basis for the trial court to conclude the claims have merit.

See Baty, 543 S.W.3d at 693–94. Dr. Wheeler provides the standard of care

applicable to the nurses, he describes the nurses’ specific conduct that deviated from

those standards, and how those deviations proximately caused the injury in question.

Therefore, the trial court again acted within its discretion in determining the report

reasonably informs Christus of the specific conduct the Claimants complain of and

provides a basis for the trial court to conclude the claims have merit; thus, it

constitutes a good-faith effort. See id.

      Dr. Wheeler outlines the factors that placed Ms. Carnahan at a higher risk of

preterm labor. He opines that the standards of care applicable to the hospital’s nurses

in this case included: (1) the proper assessment of risk factors of preterm labor; (2)

recognition of subtle symptoms and signs of preterm labor regardless of risk factor

      11
         Appellants incorporate two sub-issues with this argument; however, since
we have determined that the report and Dr. Wheeler’s accompanying CV provide a
basis for the trial court to determine he is qualified as an expert, we focus on the
hospital’s primary issue, which is whether the report constituted a good faith effort
to comply with the statute.
                                           20
profile; (3) assessing the cervix, as the very definition of preterm labor requires this

assessment, via visual inspection, digital examination, or effecting performance of

ultrasonography; and (4) not discharging the patient incompletely assessed and

potentially treated for preterm labor, in order to avoid tragic preterm birth in some

precarious setting. Dr. Wheeler opines that the nurses departed from each of the

foregoing standards of care by failing to do each of those things.

      Dr. Wheeler further explains that if the nurses had satisfied the applicable

standards of care, Carnahan would have been found to be in preterm labor, “hospital

admission would have followed with bedrest, hydration, intravenous antibiotics,

continues [sic] fetal and urine monitoring, and tocolysis with magnesium sulfate,

beta-mimetics or non-steroidal anti-inflammatories.” Dr. Wheeler states in his report

that this would have “prolonged gestation” and “provide time” for “the most

beneficial intervention for patients in true preterm labor [which] is the administration

of corticosteroids.” He further explains that the administration of “antenatal

corticosteroids significantly reduced the incidence and severity of neonatal

respiratory distress syndrome” and “intraventricular hemorrhage[,]” which were

some of the complications M.Y. suffered. In sum, Dr. Wheeler’s report specifies the

standards of care, the nurses’ departures from those standards by failing to assess for

specific key indicators which would have led to the timely identification of Ms.

Carnahan’s preterm labor such that there would have been time to administer

                                          21
appropriate care to prolong gestation and to administer corticosteroids, thus

preventing or significantly reducing M.Y.’s damages.

      In Baty v. Futrell, the Texas Supreme Court determined that the expert’s

opinions contained in the report satisfied the good-faith effort the statute requires for

standard of care, breach, and causation. See id. at 697–98. There, the Court explained

the expert

      does not opine that [the doctor] was negligent merely because the
      cataract surgery was unsuccessful or because [the plaintiff] suffered
      permanent nerve damage or vision loss. Inserting the needle into the
      optic nerve is not a result, good or bad; it is conduct that allegedly
      caused a bad result in this case. And it is this specific conduct that [the
      expert] opines falls below the standard of care.
      ...

      [The expert]’s report is sufficient for the same reason: it states a specific
      action—sticking the optic nerve with the retrobulbar needle—[the
      doctor] was supposed to avoid doing when administering the
      retrobulbar block. Further, the report highlights the known increased
      risk associated with the procedure following the initial inadequate
      block attempt, noting an alternative procedure that may be employed in
      that situation. The report’s express reference to an alternative method
      provides some indication of what [the doctor] should have done
      differently. Additional detail is simply not required at this stage of the
      proceedings.
Id. at 696–97 (citations omitted). Similarly, Dr. Wheeler explains that “[r]isk factors

for preterm birth and labor . . . include complications like heart or lung or renal

disease, infection including urinary tract infection (“UTI”), and . . . obesity.” Dr.

Wheeler outlines the symptoms Carnahan presented with and her increased risk of

preterm labor, based on certain factors, which included her extreme obesity and her
                                           22
“positive history of E. coli UTI.” Dr. Wheeler also explains the various methods the

nurses should have employed to assess the cervix, the thinning or “effacing” of

which is a critical sign of preterm labor. Here, the options were visual inspection

using a colposcope, and digital examination, alone or in conjunction with

ultrasonography. The report further indicates the nurses did none of these. Rather, it

notes the vaginal exam was ordered “per unit standard” and “deferred.” Dr. Wheeler

also explains how checking for infection utilizing tests like a CBC, is part of a

complete assessment of the patient, and failing to obtain complete results prior to

discharging Carnahan likewise departed from the nurses’ standard of care resulting

in a missed opportunity to identify the severe chorioamnionitis.12 Despite the

      12
         In its reply, the hospital is critical of Dr. Wheeler’s opinion that the nurses
failed to “not discharge” Ms. Carnahan, because Dr. Wheeler did not identify how
they could have intervened in the discharge and argues that is something the doctor
controls and that the standards constituted the practice of medicine. Assuming,
without deciding that this is true, Dr. Wheeler cites other failures by the nurses,
including failure to assess the cervix which resulted in the missed preterm labor. See
Certified EMS, Inc. v. Potts, 392 S.W.3d 625, 630 (Tex. 2013) (holding expert report
summarizing the standard of care, its breach, and causation “even if as to one theory
only” entitles the claimant to proceed with suit). The report explains that this critical
assessment could have been performed by a vaginal exam, which had been ordered
“per unit standard” but the nurses failed to do. See Tex. Occ. Code Ann. §
301.002(2)(A), (C), (H) (explaining that nursing includes “observation, assessment,
intervention, evaluation, rehabilitation, care and counsel . . . of a person who is ill,
injured, infirm, or experiencing a change in normal health processes[,]”
administration of physician-ordered treatment, and development of a nursing care
plan) (emphasis added).
                                           23
hospital’s arguments to the contrary, “[a]dditional detail is simply not required at

this stage of the proceedings.” See id.

      In its brief, the hospital focuses on an “analytical gap” argument, complaining

of Dr. Wheeler’s opinion that “M.Y.’s problems are ‘clearly attributable’ to her

‘markedly preterm delivery’” and faults him for not ruling out other causes for

M.Y.’s injuries, like the chorioamnionitis. In Abshire, the Texas Supreme Court

rejected similar arguments. See Abshire, 563 S.W.3d at 225–26 (rejecting notion that

an analytical gap existed where report adequately linked expert’s conclusions to the

facts). The hospital’s contentions would have us address the merits of Dr. Wheeler’s

causation opinions versus alternate causes of M.Y.’s injuries. Courts have been clear

that we are not to engage in an analysis of the merits at this preliminary stage. See
id. at 226 (noting focus is if the expert has explained how the negligent conduct

caused the injury but the believability of the explanation should be litigated later in

the proceedings); Hendryx, 2019 WL 1065052, at *5; see also Baylor Med. Ctr. at

Waxahachie v. Wallace, 278 S.W.3d 552, 562 (Tex. App.—Dallas 2009, no pet.)

(explaining “[n]othing in section 74.351 suggests the preliminary report is required

to rule out every possible cause of the injury, harm, or damages claimed”).

      Dr. Wheeler’s report informs the hospital of the specific conduct complained

of and provides a basis for the trial court to conclude the claims have merit,

constituting a good-faith effort to comply. See Baty, 543 S.W.3d at 693–94. We

                                          24
further determine the expert report is not materially deficient as to standard of care,

breach, and causation as it outlines applicable standards of care, how the nurses

breached those standards in this particular case by identifying the specific tasks and

assessments they should have undertaken, and how those failures prevented the

identification of preterm labor signs that would have allowed for appropriate

treatment, including but not limited to administration of antenatal corticosteroids,

which would have reduced specific co-morbidities M.Y. now faces as a result of her

preterm birth. Since the report sufficiently identifies the applicable standard of care

and links the nurses’ alleged breaches with M.Y.’s injuries, we hold the trial court

did not abuse its discretion in denying Christus’s motion to dismiss. See Abshire,
563 S.W.3d at 227. We overrule the hospital’s second issue.

                                   VI. Conclusion

      Because the expert report and accompanying CV listed the expert’s

qualifications and linked the nurses’ breaches of the applicable standards of care to

M.Y.’s injuries, it allowed the trial court to conclude the report met the Act’s

requirements. We overrule the hospital’s issues and uphold the trial court’s order

denying the motion to dismiss.

      AFFIRMED.
                                               ________________________________
                                                       CHARLES KREGER
                                                             Justice

                                          25
Submitted on October 20, 2020
Opinion Delivered December 3, 2020

Before McKeithen, C.J., Kreger, and Horton, JJ.

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