Court Opinion

ID: 4051202
Source: CourtListenerOpinion
Date Created: 2016-09-29 01:30:17.720473+00
Date Added: 2024-06-11T13:56:46.945451
License: Public Domain

THE KLEIN LAW FIRM
ALEXANDER B. KLEIN III                        2000 THE LYRIC CENTRE              MYRIAM K. LEGGE
       BOARD CERTIFIED                         440 LOUISIANA STREET                  OF COUNSEL
  PERSONAL INJURY TRIAL LAW
    TEXAS BOARD OF LEGAL                      HOUSTON, TEXAS 77002
        SPECIALIZATION
                                                   (713) 650-1111
  ALSO LICENSED IN COLORADO
                                              FACSIMILE (713) 227-1121

                                                                                   03/04/15

                                                 March 4, 2015

   Mr. Christopher A. Prine                                                       Via eFiling
   Clerk, 14th Court of Appeals
   301 Fannin Street, Suite 245
   Houston, Texas 77002

             Re:       Appellate Cause No. 14-14-00112-CV; Debra C. Gunn, M.D.,
                       Obstetrical and Gynecological Associates, P.A., and Obstetrical and
                       Gynecological Associates, P.L.L.C. vs. Andre McCoy, as Permanent
                       Guardian of Shannon Miles McCoy, an Incapacitated Person; In the
                       Fourteenth Court of Appeals, Houston, Texas

   Dear Mr. Prine:

          I am writing to provide the McCoy family’s response to the post-submission
   letter brief submitted by Debra C. Gunn, M.D.

             I.        Dr. Brewer’s causation testimony is legally sufficient.

          The position taken by Dr. Gunn in her letter brief is curious given the fact that
   she told the jury that she had “no opinions” about the topic of proximate cause1, or
   the accuracy of Dr. Brewer’s blood loss calculations2. Dr. Gunn testified at trial that
   she not only lacked the “expertise” to testify about the cause of Shannon’s code and
   brain damage,3 she also told the jury that, if someone wanted to calculate Shannon’s
   blood loss on the 14th, they needed to ask Dr. Brewer:

             1
                  RR. Vol. 10, 28:4-15.
             2
                  RR. Vol. 10, 151:7-152:4.
             3
                  RR. Vol. 10, 123:9-16.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 2

       Q:     Did you do these calculations?

       A:     I didn't do those exact calculations. No, sir, I did not.

       Q:     I see. So if we back up to around 7:27 in the morning where Dr. Brewer
              had said about 25 percent of the blood volume was lost when her
              hemoglobin was 5.5. Do you agree or disagree with that number?

       A:     You would have to ask Dr. Brewer.

RR. Vol. 9, 277:4-11 (emphasis added).

       Despite these concessions, Dr. Gunn’s recent correspondence reads more like
a pre-trial report from a defense expert explaining her rebuttal points on causation
rather than a letter brief on legal sufficiency. Although Dr. Gunn has admitted that
she is unqualified to address the issue, her letter brief explores the factual minutiae
of Dr. Brewer’s testimony in attempt to convince this Court that Dr. Brewer and the
jury got it wrong on causation, but her experts got it right. And, as a result, this Court
should find that Dr. Brewer’s causation testimony amounts to no evidence at all.

       Dr. Gunn’s argument ignores the fundamental tenet of reviewing a no evidence
point on appeal–when causation evidence (e.g., evidence about a disputed fact) falls
within the zone of reasonable disagreement, the reviewing appellate court is
prohibited from invading the fact finding role of the jury to sustain a no-evidence
challenge. City of Keller v. Wilson, 168 S.W.3d 802, 822 (Tex. 2005); Morrell v.
Finke, 184 S.W.3d 257, 272 (Tex.App.–Fort Worth 2005, pet. denied). Dr. Brewer
provided legally sufficient evidence on the issue of proximate cause, and Appellants
lost the “battle of the experts” at trial. While Dr. Gunn invites this Court to sit as the
thirteenth juror and re-try this case on causation, the invitation to substitute a different
decision for the one reached by the jury in this case should be declined.

      In a battle of competing experts, the jury has the sole responsibility to
determine the credibility of the witnesses and the weight to be given to their
testimony. Morrell v. Finke, 184 S.W.3d 257, 272 (Tex.App.–Fort Worth 2005, pet.
denied). The jury alone gets to decide which expert’s testimony on causation should
be accepted or rejected in reaching its verdict. Morrell, 184 S.W.3d at 272; Wilson,
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 3
168 S.W.3d at 822. On appeal, when the losing party complains that the expert
testimony the jury relied on to reach its verdict is legally insufficient, the reviewing
court is not free to re-weigh the evidence, re-try the case, and set aside the jury’s
verdict. Morrell, 184 S.W.3d at 272. This is true even if the reviewing court feels
that a different result based on the same evidence is more reasonable. Morrell, 184
S.W.3d at 272.

       If Texas law really means what it says, e.g., that all evidence in support of the
jury’s finding on proximate cause must be considered in the light most favorable to
the verdict; and, all reasonable inferences to be drawn from the evidence concerning
proximate cause, including Dr. Brewer’s testimony, must be made in favor of
supporting the jury’s verdict, the legal sufficiency challenge to Dr. Brewer’s
testimony should be overruled. Wilson, 168 S.W.3d at 821. Nearly twenty-five years
ago, this Court made the following observation that provides an enduring backdrop
against which Dr. Gunn’s legal sufficiency challenge should be viewed:

      Even if we as the reviewing court might view the circumstances of this
      tragic case contrary to the way the jury did, we cannot become a
      thirteenth juror and substitute our judgment for theirs. In a battle of
      competing evidence, it is the sole obligation of the jury to determine the
      credibility of the witnesses and to weigh their testimony. ... And it is our
      obligation to see that the process was fair and carried out according to
      the rules. We cannot under any circumstances re-try the case.

Warner v. Hurt, 834 S.W.2d 404, 408–09 (Tex.App.–Houston [14th Dist.] 1992, no
writ); see also Morrell, 184 S.W.3d at 272. Here, the jury was free to believe Dr.
Brewer’s causation testimony over the opinions expressed by the defense experts.
The jury was free to accept the McCoy’s theory of the case, and to reject Appellants’
theory of the case. In cases like this one, where reasonable jurors could resolve
conflicting causation evidence either way, a reviewing court must presume they did
so in favor of the prevailing party. Wilson, 168 S.W.3d at 822. Turning now to the
specific points argued by Dr. Gunn, the briefing below shows that her no evidence
challenge to Dr. Brewer’s testimony should be overruled.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 4

       II.     Dr. Gunn’s attempt to establish the incorrectness of Dr. Brewer’s
               blood loss calculations for the jury misses the mark on proximate
               cause.

       Contrary to Dr. Gunn’s contention, the answer to Justice Boyce’s question is
“yes;” there was evidence presented to the jury showing a mechanism of injury
independent of Shannon’s blood loss. That mechanism was twofold: (1) Dr. Gunn’s
negligent failure to order and administer fresh frozen plasma (“FFP”) to Shannon on
the 14th , and (2) the negligent ordering and administration of Lasix–a diuretic drug
that caused Shannon to experience fluid volume loss independent of the blood loss
she was experiencing from the DIC. Each of these causation mechanisms is discussed
below.

       A.      If Shannon had been administered FFP on the 14th, as required by
               the standard of care, her blood would have been able to effectively
               coagulate or clot, stopping the blood loss from the DIC.

      Several undisputed facts are relevant to this aspect of Dr. Brewer’s causation
testimony. They are as follows:

       1.      Shannon was suffering from DIC and actively bleeding at the time Dr.
               Gunn was caring for her on September 14, 2004.

       2.      DIC is a blood clotting disorder that compromises the human body’s
               coagulation mechanism that naturally occurs as a defensive response to
               bleeding by destroying the clotting factors in the blood.4

       3.      Shannon’s blood was not coagulating on the 14th because the DIC had
               depleted or destroyed her clotting factors as evidenced by the abnormal

       4
         RR. Vol. 8, 160:8-16, 162:7-13, 163:4-15, 164:1-7 (Dr. Brewer’s testimony about how
DIC causes the body to consume, not produce, blood clotting factors); RR. Vol. 13, 219:7-10 (Dr.
Alexander, Appellants’ maternal fetal medicine expert, testified that DIC causes the destruction of
coagulation factors in the blood).
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 5

                changes in her PT, PTT, FSP, platelet, and fibrinogen lab values on the
                14th.5

        4.      To fix the coagulation problem, fresh frozen plasma or “FFP” is
                administered to the patient to give the human body what it needs
                (plasma) to make the coagulation factors that enable the blood to clot
                and stop the patient’s blood loss.6

        5.      Shannon “needed” FFP on the 14th because it was “vital” to her
                condition.7

        6.      When caring for a DIC patient, such as Shannon, the appropriate
                standard of medical care requires the treating physician to order and
                administer FFP to the patient so that the patient’s blood may coagulate
                effectively to stop the patient’s blood loss from the DIC.8

       5
         RR. Vol. 12, 230:5-9 (Dr. Aubuchon’s testimony); RR. Vol. 8, 160:8-16, 162:7-13, 163:4-
15, 164:1-7 (Dr. Brewer’s testimony). Dr. Brewer relied on objective foundational data (the
abnormal changes in Shannon’s PT, PTT, FSP, and fibrinogen) to explain to the jury how and why
Shannon’s blood had lost the ability to effectively clot. Vol. 8, 160:8-16, 162:7-13, 166:11-15,
184:1-21; see also RR. Vol. 16B, 109-10:McCoy 0273-74 (Plaintiff’s Exhibit 7). Dr. Brewer
explained that Shannon’s PT level changed in response to receiving the FFP ordered by Dr. Jacobs;
however, it never normalized on the 14th. RR. Vol. 8, 184:1-21; see also RR. Vol. 16B, 109-
10:McCoy 0273-74 (Plaintiff’s Exhibit 7). Also, Shannon’s FSP and fibrinogen levels remained
abnormal on all of the labs drawn on the 14th, further indicating that Shannon’s inability to clot was
never corrected to normal. RR. Vol. 16B, 109-10:McCoy 0273-74 (Plaintiff’s Exhibit 7).
       6
           RR. 164:12-23, 167:16-24 (Dr. Brewer’s testimony about how and why FFP is given to
a DIC patient to replace clotting factors); RR. Vol. 9, 257:4-10 (Dr. Gunn testified that FFP is given
to the patient to replace the clotting factors that are lost from bleeding); RR. Vol. 12, 221:12-15 (Dr.
Aubuchon testified that plasma contains proteins that cause or promote normal coagulation of the
blood); RR. Vol. 13, 26:15-16 (Dr. Aubuchon testified that plasma is “FFP.”).
       7
          RR. Vol. 13, 251:24-253:2 (Dr. Alexander testified that Shannon needed FFP and that it
was vital to her condition).
       8
         RR. Vol. 9, 257:4-10, 257:19-24 (Dr. Gunn testified that it was her responsibility to
administer FFP to Shannon to replace the clotting factors she had lost due to bleeding).
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 6

       7.       Dr. Gunn was 100% negligent in failing to order or administer any FFP
                to Shannon on the 14th.

None of these facts have been challenged on appeal. The factual finding Appellants
are attempting to re-arrange on appeal (guised in the parlance of a legal sufficiency
challenge) is whether Dr. Gunn’s negligence in this regard made a difference in terms
of preventing Shannon’s ultimate outcome. The answer is–of course it did–because
the jury had legally sufficient evidence upon which to base this conclusion at trial.

       As Dr. Brewer explained to the jury, what Shannon needed to treat her DIC
(independent of giving her a massive blood transfusion to replace red blood cells) was
a mechanism to make her blood coagulate to stop the blood loss she was experiencing
on the 14th .9 That mechanism, which Dr. Gunn was negligent in failing to provide,
was the administration of fresh frozen plasma or “FFP.”10 Independent of replacing
Shannon’s lost blood volume with packed red blood cells, Shannon’s body needed
to receive FFP so that her blood could effectively clot to overcome the blood loss
caused by the DIC.11 Dr. Brewer explained as follows:

       Q:       And tell us, is the purpose of the FFP to replace those clotting
                factors so that you can correct the DIC so the patient stops
                bleeding?

       A:       That's correct.

RR. Vol. 9, 190:17-20 (emphasis added).

       9
           RR. Vol. 8, 205:11-206:17, 223:15-225:12, 214:9-215:8, 282:9-15, 282:17-19, 282:25-
283:3, 225:1-12, 223:10-12 (Dr. Brewer’s direct exam); RR. Vol. 9, 190:5-20 (Dr. Brewer’s re-
direct exam); see also RR. Vol. 9, 257:4-10, 257:19-24 (Dr. Gunn’s testimony that Shannon needed
FFP and it was her responsibility to give it to her); RR. Vol. 13, 251:24-253:2 (Dr. Alexander
testified that Shannon needed FFP and that it was vital to her condition).
       10
            Id. at Footnote 9.
       11
            See Footnote 9.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 7

       Q:      Assume with me hypothetically that the defendant wants to come in here
               and say no, I verbally ordered FFP, we don't see any evidence of that in
               the nursing notes or the blood bank records or the administration
               records, do we?

       A:      No, we don't and in addition to that, actually there was a lot of stuff
               being done. And it was all documented, A, B, C, D, E, F. And the
               FFP was the only thing that was missing.

       Q:      And was FFP, an actual order for FFP that Shannon get the FFP, critical
               that morning?

       A:      It was critical that morning.

RR. Vol. 9, 190:5-16 (emphasis added).

       Q:      In your opinion, was it critical that Shannon receive the FFP?

       A:      Absolutely critical. Because you can replace blood until the cows
               come home, but if you can’t clot and you have an open wound like
               inside the uterus, they’re going to continue to bleed.12 And so you
               basically put the blood in and the blood comes out, and without
               clotting factors, you cannot control the coagulation disorder.

       Q:      Did it represent a breach in the standard of care to fail to order the FFP?

       A:      I believe it did.

       Q:      Did Shannon need the FFP?

       A:      She absolutely needed it.

       12
           Dr. Brewer explained that when the placenta separates away from the wall of the uterus,
it leaves a big area that bleeds like a big scab, and the patient’s clotting factors have to be replaced
so that this area can clot properly. RR. Vol. 8, 223:15-225:12.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 8

      Q:    Did Shannon continue to lose blood volume because she didn’t get the
            FFP?

      A:    At least partially because she didn’t get the FFP.

RR. Vol. 8, 205:11 - 206:17 (emphasis added).

      Q:    When you looked at the infusion records[,] blood bank records[,] and
            nursing records, was there any FFP infusing around 10:00 o’clock in the
            morning ...[?]

      A:    There was not.

      Q:    They were never ordered were they?

      A:    They couldn’t have been ordered or the blood bank would have
            released them.

      Q:    According to the medical record, the last unit of FFP was infused
            around 3:51 in the morning, and that was the unit ordered –essentially,
            ordered by Dr. Jacobs, correct?

      A:    That’s my understanding.

      Q:    Now, is there any way to defend Dr. Gunn’s management of Shannon
            with a complete absence of FFP, fresh frozen plasma, between the time
            she came on board and the time she took Shannon to the operating
            room?

      A:    There is no defense of that in my opinion.

      Q:    Was FFP absolutely critical to taking care of this lady?

      A:    It was absolutely critical.

RR. Vol. 8, 214:9 - 215:8.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 9

      Dr. Brewer also testified that, if Shannon had been properly resuscitated with
FFP, blood, and platelets, Shannon’s outcome would have been completely different:

      A:    If she had been adequately resuscitated [with blood, platelets and
            FFP] and she had bled the amount that she bled from 11:00 o'clock
            to 2:00 o'clock and had been taken to the operating room, I believe
            with reasonable certainty that they would have put her to sleep,
            intubated her, taken her uterus out, and she would have woken up
            intact, except missing her uterus.

RR. Vol. 8, 282:9-15 (emphasis added).

      A:    As you look through where all this blood loss occurred, it was all
            cumulative. And I think I've stated several times that she didn't get
            enough clotting factors. You can pore the blood in, but the blood
            just keeps coming out if you can't clot it.

RR. Vol. 8, 282:17-19, 282:25-283:3 (emphasis added).

      Q:    What does that mean: Fundus is boggy and that when they massaged it,
            there was a large amount of bleeding?

      A:    So the way I read this is, it's kind of what I was describing earlier,
            if you don't -- if you don't replace the clotting factors, you put blood
            in and blood comes out because she had a raw bed where the
            placenta was detached.

RR. Vol. 8, 223:10-22 (emphasis added).

      Q:    When it got to the point that the uterus began to become unable to
            contract back down, is it foreseeable to get even more bleeding when
            you've got uncontrolled DIC?

      A:    That's correct exactly what happens.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 10

      Q:     Is that exactly the position the defendant put herself in by not taking the
             right steps throughout the earlier part of the day?

      A:     I think not replacing the clotting factors has a lot to do with the
             uterine atony.

      Q:     That means not getting the FFP?

      A:     That's right.

RR. Vol. 8, 225:1-12 (emphasis added).

       Dr. Brewer’s causation testimony sufficiently established that the negligent
failure to provide Shannon with FFP was a substantial factor in bringing about her
brain damage and without this negligence Shannon’s brain damage would not have
occurred. RR. Vol. 8, 205:11-206:17, 223:15-225:12, 214:9-215:8, 282:9-15,
282:17-19, 282:25-283:3, 225:1-12, 223:10-12; RR. Vol. 9, 190:5-20.

       Dr. Brewer established that, if Dr. Gunn had actually ordered and administered
the 4 units of FFP to Shannon that she claimed to have verbally ordered on the 14th,
it would have made a difference in preventing Shannon’s brain damage because, in
reasonable medical probability, the FFP administration would have enabled
Shannon’s blood to coagulate and stop the blood loss she had experienced before
1:00 p.m. on the 14th . Id. Shannon never got the FFP that she needed to make her
blood clot effectively because Dr. Gunn never ordered it. According to Dr. Brewer,
this negligence in failing to order and administer the FFP proximately caused
Shannon’s brain damage because Shannon continued to bleed (because her blood
couldn’t coagulate), resulting in her ultimate cardiovascular de-compensation into
hemorrhagic shock, cardiac arrest and brain damage:

      1.     Dr. Brewer testified that Shannon’s lack of blood, lack of circulating
             blood volume, proximately caused her brain damage because she didn’t
             have adequate blood flow and oxygen delivery to her brain. RR.
             8:258:16-25; RR. 8:261:9-17.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 11

      2.    Dr. Brewer testified that it was Dr. Gunn’s responsibility to keep this
            from happening by ordering the administration of more blood and blood
            products, especially FFP, to keep this from happening. RR. 8:261:18-
            22.

      3.    Dr. Brewer testified that, given Shannon’s profound blood loss, it was
            foreseeable that Shannon would go into V-fib. RR. 8:248:14-19; RR.
            8:245:1-5; 8:259:8-23.

      4.    Dr. Brewer testified that, as a result of the V-fib, Shannon’s heart was
            not beating properly, resulting in inadequate blood flow and oxygen to
            her brain. RR. 8:247:12-248:4.

      5.    Dr. Brewer testified that, when Shannon went into V-fib, she was down
            for about 11 minutes; and, during CPR, she was down for an additional
            20 minutes. RR. 8:248:4-13.

      6.    Dr. Brewer testified that the V-fib was basically a cardiac arrest because
            Shannon’s heart stopped pumping properly. RR. 8:252:7-10.

      7.    Dr. Brewer testified that the V-fib resulted in lack of oxygen to
            Shannon’s brain. RR. 8:256:8-12.

      8.    Dr. Brewer testified that Shannon’s lack of blood, lack of circulating
            blood volume caused her heart to go into V-fib. RR. 8:258:24-259:1.

      9.    The arterial blood gases taken from Shannon after she went into V-fib
            showed metabolic acidosis, e.g. a pH of 6.9 (7.35-7.40 normal) , a base
            excess of -24. RR. 8:252:13-253:14.

      10.   Shannon’s blood gases were consistent with someone who has suffered
            global brain damage from oxygen deprivation; and, that the EEG study
            was consistent with this analysis. 8:259:24-260:2.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 12

      11.   The evidence of metabolic/lactic acidosis proves that all of Shannon’s
            tissues, including her brain, were extremely low in oxygen. RR
            8:254:16-19.

      12.   Dr. Brewer testified that, in reasonable medical probability, if Shannon’s
            DIC had been correctly (non-negligently) treated by Dr. Gunn,
            Shannon’s brain damage would not have occurred. RR. 8:250:13-18.

      13.   Dr. Brewer testified that her opinion concerning the cause of Shannon’s
            brain damage was medically superior to the other possible causes that
            she excluded. RR. 8:279:18-280:5.

      Dr. Brewer also testified that her causation analysis was confirmed by the
following medical evidence regarding the etiology of Shannon’s brain damage:

      1.    Dr. Brewer testified that the neurological assessment of Shannon
            performed by the treating neurologist at Women’s Hospital confirmed
            her causation analysis; and, Dr. Brewer described her causation opinions
            in the context of the causation diagram the treating neurologist included
            in Shannon’s medical records (RR 8:261:23-262:15; RR. 8:263:6-20;
            Plaintiffs’ Exhibit 5);

      2.    Dr. Brewer testified that her causation analysis was consistent with and
            confirmed by the seventeen (17) neurology consults from St. Luke’s
            Hospital (the hospital where Shannon was taken to treat her brain injury)
            all of which agreed that Shannon suffered permanent brain damage from
            lack of blood flow and oxygen to the brain (RR. 8:263:21-264:16;
            Plaintiffs’ Exhibit 8A-8Q);

      3.    Dr. Brewer testified that her causation analysis was confirmed by
            Shannon’s abnormal EEG results that showed evidence of anoxic brain
            injury (RR 8:257:19-25);

      4.    Dr. Brewer testified that her causation analysis was confirmed by
            Shannon’s arterial blood gas results, showing evidence of profound
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 13

            metabolic acidosis consistent with oxygen deprivation from blood loss
            (RR 8:254:16-19); and,

      5.    Dr. Brewer testified that her causation analysis was confirmed by the
            radiology report discussing the head CT results at St. Luke’s Hospital,
            showing radiological evidence that Shannon had suffered severe
            ischemic brain damage (RR. 8:266:20-23).

       Dr. Brewer also testified that her causation analysis was confirmed by ruling
out or excluding other plausible causes for Shannon’s brain damage:

      1.    Dr. Brewer testified about how and why the CT of the head and
            neurology reports from St. Luke’s Hospital ruled out intracranial
            bleeding and CVA or stroke as a possible cause for Shannon’s brain
            damage (RR. 8:266:13-16); (RR. 8:270:19-271:22);

      2.    Dr. Brewer testified about how and why she ruled out a pulmonary
            embolism as a possible cause for Shannon’s brain damage (RR.
            8:271:15-272:2);

      3.    Dr. Brewer testified about how and why she ruled out amniotic fluid
            embolism as a possible cause for Shannon’s brain damage (RR.
            8:272:7-19);

      4.    Dr. Brewer testified about how and why she ruled out infection as a
            possible cause for Shannon’s brain damage (RR. 8:272:20-273:7); and,

      5.    Dr. Brewer testified about how and why she ruled out Dr. Alexander’s
            uterine atony theory (RR. 8:281:21-283:5), and Dr. Steiner’s micro-
            thrombi theory as possible causes for Shannon’s brain damage. RR.
            8:284:14-292:14.

       In this case, Shannon’s blood clotting system was deactivated by the DIC and
not working anymore. RR. Vol. 8, 163:4-15, 164:1-7. To fix this problem, Dr.
Brewer testified that Shannon needed to receive FFP so that the clotting factors and
cells that enable the blood to coagulate could be replaced, preventing further blood
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 14

loss and permanent injury to Shannon. RR. Vol. 8, 164:12-23, 167:16-24, 205:11-
206:17, 223:15-225:12, 214:9-215:8, 282:9-15, 282:17-19, 282:25-283:3, 225:1-12,
223:10-12; RR. Vol. 9, 190:5-20.

      The fact that Shannon needed FFP to enable her blood to clot was neither
contested at trial, nor on appeal. In fact, Dr. Alexander testified that FFP was “vital”
for Shannon and that she “needed” it on the 14th . RR. Vol. 13, 251:24-253:2. Dr.
Gunn testified that Shannon needed FFP and it was her responsibility to give it to her
on the 14th . RR. Vol. 9, 257:4-10, 257:19-24. As Dr. Gunn pointed out, Shannon’s
complete inability to coagulate prevented her from receiving an epidural because, if
she bled in the small space around her spinal cord from the insertion of the epidural
needle, should could become paralyzed. RR. Vol. 10, 69:6-16. These facts are also
undisputed on appeal.

       While the issue of whether Dr. Gunn ever made a “verbal” or “telephone” order
for FFP was disputed at trial, the jury resolved the conflicting evidence on this issue
in favor of Shannon, finding Dr. Gunn negligent, in part, for failing to order and
administer FFP. The jury also found that Dr. Gunn’s negligence in this regard
proximately caused Shannon’s permanent brain damage. Through the above-
referenced testimony of Dr. Brewer, along with the causation findings documented
by the treating neurologists in Shannon’s medical records, the jury was provided with
more than a scintilla of evidence to establish that Dr. Gunn’s negligent failure to
order and administer FFP to Shannon proximately caused her brain damage.

       Dr. Brewer explained to the jury that the administration of FFP would have, in
reasonable medical probability, made a critical difference in enabling Shannon’s
blood to coagulate effectively thereby stemming and stopping the blood loss and
preventing Shannon’s brain damage. The testimony by Dr. Brewer was based on
reliable foundational data and medical science, not ipse dixit conclusions or
unfounded assumptions.

      Dr. Brewer established for the jury that Shannon needed to receive FFP to
make her blood clot and to overcome the DIC. Shannon didn’t receive any FFP on
September 14, 2004 because Dr. Gunn never ordered it, negligently violating the
standard of care in this case. This negligence was a substantial factor in bringing
about Shannon’s brain damage in this case because, in the absence of the FFP,
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 15

Shannon’s blood was unable to coagulate, resulting in Shannon’s continued blood
loss followed by hemodynamic instability, cardiovascular collapse, hypovolemic
shock, cardiac arrest, and hypoxic encephalopathy. At least that’s what the jury
concluded after hearing all the evidence presented by both sides, including Dr.
Brewer’s testimony and the causation findings documented in the medical records by
Shannon’s treating neurologists.

       Think about it this way, if the complete failure to administer FFP to Shannon
on the 14th was not a proximate cause of Shannon’s brain damage, why did Appellants
so ferociously attempt to establish (but couldn’t) that the treating nurses were
allegedly responsible for failing to follow Dr. Gunn’s alleged “telephone order” for
4 units of FFP on the 14th ?13 Appellants’ no evidence/legal sufficiency point on
causation should be overruled.

       B.     The negligent ordering and administration of Lasix caused Shannon
              to experience fluid volume loss independent of the blood loss she
              was experiencing from the DIC.

       Lasix is a diuretic drug that causes the patient to urinate. Urination, in turn,
results in fluid loss from the body. Dr. Brewer testified that Lasix was
contraindicated for Shannon because she was bleeding, and that the Lasix
administration made Shannon’s condition “worse.” RR. Vol. 8, 218:1-220:2, RR.
Vol. 8,220:18-22, RR. Vol. 8,220:23-222:12, RR. Vol. 8, 270:11-16. Contrary to
Dr. Gunn’s assertion in her letter brief, Dr. Brewer testified that Dr. Gunn was
negligent in giving Shannon Lasix, and that this negligence was a proximate cause
of Shannon’s brain damage. RR. Vol. 8, 218:1-220:2, RR. Vol. 8,220:18-22, RR.
Vol. 8,220:23-222:12, RR. Vol. 8, 270:11-16.

       13
           The evidence showed (which the jury believed) that Dr. Gunn never wrote any orders for
FFP on the 14th. RR. Vol. 8, 214:9 - 215:8. (Dr. Brewer’s testimony); RR. Vol. 9, 259:16-21,
261:11-13, 261:14-19 (Dr. Gunn’s testimony); RR. Vol. 13, 253:5-8 (Dr. Alexander’s testimony).
While Dr. Gunn claimed to have issued a telephone order for FFP, there was no documentation in
any of Shannon’s medical records of any written order or telephone order being made by Dr. Gunn
for fresh frozen plasma. Indeed, the hospital blood bank employee, Ms. Fowler, testified that she
thawed out 2 units of FFP on her own to be “proactive;” however, she did not have any
documentation to prove that the FFP had been ordered by Dr. Gunn. RR. Vol. 14, 93:8-94:16, 97:2-
6, 105:18-19.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 16

      So why is it that the treating physician shouldn’t do what Dr. Gunn did with
respect to the Lasix administration in a patient situated like Shannon? Dr. Collins,
Shannon’s treating cardiologist, perhaps said it best:

      Q:    Our bodies, yours, mine, and Shannon's, all have a built in physiologic
            response to bleeding; isn't that right?

      A:    Yes.

      Q:    And when we begin to bleed and our body senses that we're losing our
            volume of fluids, our body compensates by stopping the urine
            production, correct?

      A:    Yes.

      Q:    Because our body wants to save its fluids and doesn't want to
            unnecessarily expel any in the form of urine, correct?

      A:    Yes.

RR. Vol. 14, 65:25-66:11.

      Q:    So when you have these patients who have DIC and are bleeding, what
            the doctors are trying to do and the nurses are trying to do is to increase
            their volume with blood, blood products and IV's, correct?

      A:    Yes.

      Q:    Sure. When you have a patient that is bleeding from, for example DIC,
            what you see is the patient's body tries to compensate for that loss of
            fluid volume by either halting the production of urine or cutting it back
            significantly, correct?

      A:    Yes.

RR. Vol. 14, 65:14-24.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 17

      Q:    Did you ever order Lasix for Shannon?

      A:    No, sir.

      Q:    You understand how Lasix works, correct?

      A:    Yes.

      Q:    Would you want to give Lasix to a patient situated like Shannon who
            was bleeding with DIC?

      A:    I wouldn't have given it.

      Q:    Why is it that you would not have given Lasix to a patient like Shannon
            who had DIC and was bleeding?

      A:    Well, it wouldn't do any good.

RR. Vol. 14, 64:16-25.

      Dr. Collins’ testimony corroborated what Dr. Brewer had explained to the jury
in her testimony, e.g., the Lasix administration wouldn’t do any good because it
would cause Shannon to urinate, compounding the blood loss problem by further
depleting her fluid volume and making Shannon’s condition “worse”:

      Q:    At 10:15, what information did the nurses reveal about Shannon's
            condition?

      A:    At 10:15, they said that -- there was a report of a decrease in urine
            output.

      Q:    Now, what does that tell someone who knows what they're doing who
            is managing a patient like Shannon?

      A:    Part of what urine output tells you in, especially in a young, healthy
            patient, is it tells you how well her kidneys are being profused. And
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 18

            that's kind of a fancy way of just basically saying: Is there blood
            flow to the kidneys? Are they getting enough? Because what
            happens is the blood goes through the kidneys and gets filtered out,
            and it produces urine as a result of that. So if your urine output is
            down, is decreased, that means that your blood flow to the kidney,
            particularly in this kind of situation, is probably decreased. So it's
            really an important thing to be followed.

      Q:    Is it a warning sign?

      A:    It absolutely is a warning sign, particularly in the context of this
            patient.

RR. Vol. 8,218:2-25.

      Q:    How did the defendant respond to this warning sign?

      A:    She gave her drug called Lasix. And Lasix is a diuretic which means
            it makes you urinate more.

      Q:    Is that the right thing to do?

      A:    Not in the scenario where her volume was down so far. We use Lasix
            for fluid overload; in other words, too much fluid, we need to get rid
            of some water. We use Lasix for people with congestive heart
            failure, where there is too much fluid in their heart. In the context
            of bleeding, it's contraindicated.

      Q:    Did ordering the Lasix make it worse for Shannon?

      A:    Probably.

      Q:    Was the Lasix exactly what you didn't want to order?

      A:    It was one of the things you didn't want to order.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 19

      Q:    What did it tell you about the defendant's understanding of what she was
            doing when she ordered Lasix around 10:15 in the morning when the
            nurses told her the urinary output was down?

      A:    Well, the way I looked at that is she didn't really understand what
            was happening to the patient.

RR. Vol. 8,219:1-220:2.

      Q:    Was it negligent of the defendant to order Lasix that morning, failing to
            act reasonably and prudent?

      A:    It was failing to act reasonably and prudently, yes.

RR. Vol. 8,220:18-22.

      Q:    Now, at around 10:50 in the morning, what, in fact, was related to the
            defendant from the nurses?

      A:    10:50 phone report: Urinary output of 35 in 1 the last hour. That
            was after Lasix. And how I interpret that is if she had had too much
            fluid, she would have made a lot of urine. But it says to me that, in
            fact, she was fluid low; in other words, she didn't have enough fluid
            in her veins to actually increase her urine output.

      Q:    Let's back up. There is this dose of Lasix given that is supposed to cause
            someone to make a lot of urine, correct? Yet, after the dose was given,
            the nurses called up and reported that there was only, what?

      A:    35 Mls.

      Q:    35 MLs. That's?

      A:    It's like that.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 20

      Q:    A third of a cup?

      A:    (The witness nods.)

      Q:    What should that tell a physician who knows what they're doing when
            they give a dosage of Lasix like that and get a third of Dixie cup of urine
            afterward?

      A:    I think it tells a reasonable physician that that's not the appropriate
            treatment, that that's not going to fix the problem.

      Q:    But what did the defendant do in response to that?

      A:    Eventually, she gave her a second dose.

      Q:    Was it negligent to give the second dose of Lasix; that is, failing to act
            reasonably and prudently?

      A:    I believe it was.

      Q:    Is that the opposite of what Shannon needed?

      A:    That is the opposite of what Shannon needed.

      Q:    Is there anyway to defend giving these two doses of Lasix?

      A:    I think the only defense of that is she didn't understand what was
            going, what was happening with the patient.

RR. Vol. 8,220:23-222:12.

        After being provided with the definition of proximate cause, Dr. Brewer
testified that the negligence of Dr. Gunn, including the Lasix administration,
proximately caused Shannon’s brain damage:
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 21

      Q:     And was the negligence of these things we've outlined, was that a
             proximate cause of what we see here?

      A:     I believe it is.

      Q:     Or the proximate cause?

      A:     It is the proximate cause, yes.

RR. Vol. 8, 270:11-16.

       In sum, Dr. Brewer’s testimony concerning the negligent Lasix administration
and how the administration of a diuretic to a bleeding patient making a third of a
Dixie cup of urine was causally linked to Shannon’s brain damage in this case was
legally sufficient. Appellants’ no evidence/legal sufficiency point on causation
should be overruled.

      III.   The letter brief points raised by Dr. Gunn do not establish that Dr.
             Brewer’s causation testimony was legally insufficient.

      A.     The blood loss “re-calculations” performed by Dr. Gunn in her
             letter brief do not prove that Dr. Brewer’s causation testimony was
             legally insufficient.

        The fallacy of Dr. Gunn’s attack on Dr. Brewer’s blood loss analysis by
attempting to re-calculate it on appeal is that Dr. Gunn told the jury that, if someone
wanted to calculate Shannon’s blood loss on the 14th, they needed to ask Dr. Brewer,
not her. RR. Vol. 9, 277:4-11. Dr. Gunn told the jury that she had no basis to dispute
the blood loss calculations performed by Dr. Brewer; and, that, even though she sat
in the courtroom and watched Dr. Brewer calculate Shannon’s blood loss for the jury,
she never went back to re-calculate them:

      Q:     Do you agree or disagree with Dr. Brewer that around 8:00 o'clock in
             the morning that Shannon had lost 25 percent of her blood volume, or
             you just don't have an opinion?
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 22

      A:    I don't have an opinion.

      Q:    When it comes to the hemoglobin that came back at 7.5, I believe, that
            afternoon, Dr. Brewer made the adjustments and calculations and said
            at that point Shannon was down 22 percent in her blood volume. Do you
            agree with that, disagree or just not have an opinion?

      A:    I don't have an opinion.

      Q:    And then at around 1:00 o'clock -- excuse me. I misspoke about the
            hemoglobin. This came back at 1:00 o'clock, but she did the calculations
            of input and output and around 11:00, she said 22 percent?

      A:    No opinion.

      Q:    So then around a little after 1:00 o'clock, we see a hemoglobin of 7.5,
            but when you allow for the bleeding and what was replaced, Dr. Brewer
            said 33 to 44 percent of Shannon's blood volume was gone. Do you
            agree with those calculations, disagree with them, or do you just not
            have an opinion?

      A:    I don't have an opinion.

      Q:    Do you believe that if you're going to undertake the serious job of
            managing a patient that you know has DIC that part of your job is to
            perform calculations to know where she is in terms of her blood
            volume?

      A:    Yes.

      Q:    Yet, when we look at this chart, we don't see any calculations
            whatsoever, do we?
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 23

       A:      My calculations were not part of the medical chart, no.14

RR. Vol. 10:151:7-152:13.

       Q:      And have you redone those calculations to give us opinions as to where
               you thought Shannon was at 8:00 o'clock in the morning or 11:00 in the
               morning or 1:00 in the afternoon?

       A:      I've not redone those calculations, no.

RR. Vol. 10:152:14-18.15

       How can Appellants credibly argue on appeal that Dr. Brewer’s blood loss
calculations are ipse dixit conclusions with no factual basis whatsoever, when Dr.
Gunn herself didn’t disagree with them at trial, didn’t re-calculate them for the jury
to demonstrate their alleged inaccuracy, and told the jury that, if they wanted to know
how much blood Shannon lost, they needed to ask Dr. Brewer? Dr. Aubuchon, the
defense transfusion medicine expert, never disputed the blood loss calculations
performed for the jury by Dr. Brewer. RR. Vol. 12, 53:3-5. Neither did Dr.
Alexander, the defense maternal fetal medicine expert. RR. Vol. 13, 240:4-10. On
cross-examination, Dr. Brewer offered to re-calculate the blood loss for defense
counsel by going back through the input and output records (“I’s and O’s”), but
defense counsel refused. RR. Vol. 9, 219:9-12. So, at the end of the day, the jury was
left with the uncontested evidence provided by Dr. Brewer about Shannon’s blood
loss. Dr. Gunn’s letter brief on this issue should be overruled.

       14
          Dr. Gunn testified that she performed blood loss calculations similar those which Dr.
Brewer performed in front of the jury at the time she was caring for Shannon, but she never produced
them, or made them a part of the medical records. RR. Vol. 9, 277:13-18; Vol. 10, 34:16-24.
       15
           Neither Dr. Aubuchon, nor Dr. Alexander, disputed the blood loss calculations performed
for the jury by Dr. Brewer. RR. Vol. 12, 53:3-5; RR. Vol. 13, 240:4-10.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 24

       B.       Dr. Brewer’s blood loss calculations were supported by the reliable
                foundational data contained in Shannon’s medical records.

       The point of the blood loss analysis performed by Dr. Brewer was to show the
jury that Dr. Gunn had plenty of warning signs to tell her what was going on with
Shannon and that she needed to stop Shannon’s bleeding by doing something
different with respect to her treatment of Shannon, including giving Shannon FFP
to enable her blood to clot effectively and to not make her fluid volume loss and
hypovolemia16 worse by administering a diuretic. While Dr. Gunn alleges on appeal
that Dr. Brewer’s blood loss calculations are “unsupported estimates,” the reality of
what Dr. Brewer did to establish this point for the jury is anchored in the reliable,
objective foundational data contained in the medical records.

       This data included Shannon’s total blood volume on admission,17 changes in
Shannon’s lab values18 (e.g., her hemoglobin, hematocrit, platelet, PT, PTT, FSP, and
fibrinogen levels), Shannon’s vital signs (e.g., age, weight, pregnancy status, heart
rate, breathing rate, and blood pressure), Shannon’s fluid intake (e.g., IV fluids, red
blood cells, and platelets), and Shannon’s fluid output (e.g., blood loss and urinary
output). RR. Vol. 8 8:187:22-191:3, 191:20-192:10, 193:7-194:8, 198:11-199:3,
199:11-200:22, 201:4-7, 203:13-25, 210:18-213:1, 213:4-18, 218:2-220:2, 220:23-
222:12, 248:20-249:6; RR. Vol. 9, 196:14-25, RR. Vol. 9, 197:1-17, RR. Vol. 9,
207:7-208:15; see also RR. Vol. 16B 109-111:McCoy 0273-275 (Plaintiffs’ Exhibit
7).

        Dr. Brewer calculated that Shannon’s total blood volume was approximately
6.7 liters of blood (18 units) when she arrived at the hospital. RR. Vol. 8, 187:4-21;
RR. Vol. 9, 197:13-17, 207:7-208:15. Appellants never disputed this testimony at
trial. Dr. Brewer testified that, according to the changes in Shannon’s lab results
concerning her hemoglobin, platelet, FSP, and fibrinogen levels, as well as the fluid
input and output data contained medical records, Shannon lost approximately 1,400

       16
          Dr. Gunn testified that the term “hypovolemia” means that the patient’s “circulatory
system did not have enough fluid and blood to support bodily functions.” RR. Vol. 10, 92:12-17.
       17
            RR. Vol. 9, 197:13-17, 207:7-208:15.
       18
            RR. Vol. 9, 196:14-25.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 25

mL of blood (1.4 liters/4-5 units) before the delivery of her daughter. RR. Vol. 9,
196:14-25. Dr. Brewer testified that, according to this same foundational data,
Shannon lost another 1,600 mL of blood in the ICU, totaling approximately 3,000 mL
of blood loss. RR. Vol. 9, 197:1-12. Dr. Brewer’s testimony about Shannon’s blood
loss was based on Shannon’s total estimated blood volume, the changes in Shannon’s
lab values, as well as the information concerning Shannon’s fluid input and output
documented in the medical records. RR. Vol. 8 8:187:22-191:3, 191:20-192:10,
193:7-194:8, 198:11-199:3, 199:11-200:22, 201:4-7, 203:13-25, 210:18-213:1,
213:4-18, 218:2-220:2, 220:23-222:12, 248:20-249:6; RR. Vol. 9, 196:14-25, RR.
Vol. 9, 197:1-17, RR. Vol. 9, 207:7-208:15; see also RR. Vol. 16B 109-111:McCoy
0273-275 (Plaintiffs’ Exhibit 7).

      All of this data was analyzed and synthesized for the jury by Dr. Brewer to
provide them with an understanding about how and why Shannon was bleeding, how
much blood Shannon had lost and was continuing to loose before 1:00 p.m. (despite
being transfused with blood and platelets), what Shannon’s body was doing
physiologically to compensate for the blood loss (e.g., increased heart rate, increased
breathing rate, drop in urine output, drop in blood pressure), and why Shannon
needed to receive FFP to stop her blood loss and prevent the monumental disaster
that Dr. Gunn caused by her own negligence. Id.

       The medical records show that Shannon was administered 3,400 mL of blood
and blood products in the operating room (15 units of packed red blood cells, 16 units
of FFP, and 8 units of platelets) to replace the clotting factors and blood volume that
Dr. Gunn negligently allowed Shannon to lose on the 14th. RR. 16A, 131:McCoy
0121, 137:McCoy 0127 (Plaintiff’s Exhibit 7). If Dr. Brewer’s blood loss
calculations for the jury were really “unsupported estimates,” why is it that her
estimation of Shannon’s blood loss before 2:10 p.m. on the 14th (3,000 mL) is so close
to the documented amount of blood volume replaced in the operating room (3,400
mL)? RR. 16A, 131:McCoy 0121, 137:McCoy 0127 (Plaintiff’s Exhibit 7). Dr.
Brewer’s blood loss calculations were supported by the reliable foundational data
contained in Shannon’s medical records, and this letter brief point should be
overruled.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 26

       C.      Dr. Gunn’s argument about the relationship between Shannon’s
               bleeding and uterine atony is supported by the medical records.

       Dr. Brewer testified that Shannon’s uterine atony had to be analyzed in context.
RR. Vol. 8, 281:21-283:5. Dr. Brewer testified that the uterine atony was a by-
product of the massive blood loss Shannon experienced prior to 1:00 p.m. on the 14th.
RR. Vol. 8, 281:21-283:5. Dr. Brewer testified that, if Shannon had been adequately
resuscitated, but experienced the same amount of bleeding she did between 1:00 p.m.
to 2:00 p.m. on the 14th , she would have come out of the surgery “intact,” indicating
that uterine atony was not the cause of Shannon’s brain damage. RR. Vol. 8, 281:21-
283:5. Dr. Brewer also testified that her opinions regarding Shannon’s uterine atony
were based, in part, on her experience as qualified expert in caring for these patients,
as well as the evidence concerning Shannon’s enormous blood loss prior to 1:00 p.m.;
and, the fact that none of Shannon’s clotting factors were replaced through the
administration of FFP. RR. Vol. 8, 249:11-250:25, 225:6-12, 281:21-283:5. Dr.
Brewer’s testimony concerning the exclusion of uterine atony as a possible cause for
Shannon’s outcome was supported by the reliable foundational data contained in
Shannon’s medical records. This letter brief point should be overruled.

       D.      Dr. Brewer’s testimony about Shannon’s internal bleeding was
               based on the evidence contained in the medical records.

       While Dr. Brewer said that Shannon had blood “pouring out,” she never said
that all of Shannon’s blood loss came out of her vagina. RR. Vol. 8, 249:2-6. Dr.
Brewer testified that Shannon had visible blood loss from the vagina19, as well as
internal bleeding into the wall of the uterus. RR. Vol. 8, 223:10-224:18, 225:1-20.
This testimony is based on the documented findings contained in the medical records.

       19
          Dr. Brewer testified that, according to the medical records, Shannon had a large amount
of bleeding at 12:00 p.m. on the 14th, and expelled a large amount of blood from the vagina at 12:45
p.m. on the 14th. RR. Vol. 8, 223:10-14, 229:2-6. According to Dr. Gunn’s discharge summary,
Shannon had approximately 800 to 1,000 cc’s of blood and clots at the perineum at 1:28 p.m. RR.
Vol. 16A, 42:McCoy 0032 (Plaintiff’s Exhibit 7). The intensive medicine physician called by Dr.
Gunn, Nancy J. Esper, M.D., documented in her note that Shannon’s vaginal bleeding was
“uncontrollable” on the 14th and that the same level of blood loss was present at the time of surgery.
RR. Vol. 16A, 85:McCoy 0075 (Plaintiff’s Exhibit 7).
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 27

       The medical records showed (and Dr. Gunn agreed in her testimony) that the
ultrasound performed at 5:25 a.m. showed retro-placental bleeding (bleeding behind
the placenta), and that all the blood vessels in the uterus were completely filled with
clotted blood. RR. Vol. 10, 67:16-22, 120:11-19. Dr. Gunn documented in her
discharge summary that Shannon’s uterus was “engorged” with blood “throughout
the muscle layers[,]” and that the vaginal vault was “filled” with blood clots. RR.
16A, 42-43:McCoy 0032-33 (Plaintiff’s Exhibit 7). Dr. Gunn documented in her
operative report from the hysterectomy surgery that Shannon had “obvious bleeding
into the uterine musculature.” RR. 16A, 131:McCoy 0121 (Plaintiff’s Exhibit 7).
Dr. Gunn also documented in her operative report that “[t]he ICU bed had blood
throughout from the head of the bed to the foot.” RR. 16A, 132:McCoy 0122
(Plaintiff’s Exhibit 7). If Shannon wasn’t really losing that much blood, and her
bleeding was really improving, as Dr. Gunn claims in her letter brief, why was it
necessary to give Shannon 3,400 mL of blood and blood products in the operating
room? Dr. Brewer’s testimony about Shannon’s internal blood loss is supported by
the reliable foundational data contained in Shannon’s medical records. This letter
brief point should be overruled.

       E.      The lab results do not negate Dr. Brewer’s testimony about
               Shannon’s blood loss.

       Dr. Gunn claims that Shannon’s lab results negate Dr. Brewer’s testimony that
Shannon continued to bleed after delivery, but this point makes no sense in light of
the documented facts contained in the medical records. Shannon’s hemoglobin level
on the first set of labs ordered by Dr. Jacobs was abnormally low at 8.6 (10.2-14.9
normal). RR. Vol. 16B, 111:McCoy 0275 (Plaintiff’s Exhibit 7). At 7:20 a.m. on
the 14th , Shannon’s hemoglobin level dropped from 8.6 to 5.5–a critically low level.20
RR. Vol. 16B, 111:McCoy 0275 (Plaintiff’s Exhibit 7).

       20
          According to Shannon’s lab records, a hemoglobin of 6.90 is a critically low level;
accordingly, a 5.5 level and a 4.0 level are obviously critically low. RR. Vol. 16B, 111:McCoy
00275 (Plaintiff’s Exhibit 7). The lab results are highlighted and attached to this response along
with Dr. Esper’s documentation that Shannon’s hemoglobin level was 4.0 before she was taken to
surgery.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 28

      Importantly, while the lab results show that Shannon’s hemoglobin level was
   21
7.8 at 1:15 p.m., Dr. Esper documented in her note that, according to a “stat” blood
draw in the ICU, Shannon’s hemoglobin level had dropped to 4.0 at the time she
was taken to the operating room at 2:10 p.m. RR. Vol. 16A, 88:McCoy 0078
(Plaintiff’s Exhibit 7) (emphasis added). The other lab values discussed by Dr.
Brewer were equally consistent with her causation opinions concerning Shannon’s
blood loss. RR. Vol. 16B, 109-10:McCoy 00273-74 (Plaintiff’s Exhibit 7).

       Specifically, Shannon’s PT, FSP, and fibrinogen levels (indicators of
Shannon’s blood clotting ability) never normalized between the first lab results
obtained at 10:15 p.m. on the 13th and the last labs that were drawn at 1:16 p.m. on
the 14th before Shannon was taken to the operating room. RR. Vol. 16B, 109-
10:McCoy 00273-74 (Plaintiff’s Exhibit 7). Shannon’s PT level went up from 17.2
(10.8-13.5 normal) at 7:27 a.m. on the 14th to 18.2 at 1:16 p.m., indicating that
Shannon’s blood clotting mechanism was never corrected to normal before she was
taken to the operating room. RR. Vol. 16B, 109-10:McCoy 00273-74 (Plaintiff’s
Exhibit 7). Shannon’s FSP and fibrinogen levels never improved and were always
abnormal from 7:27 a.m. to 1:16 p.m., further indicating that Shannon’s ability to clot
never changed from abnormal to normal before she was taken to the operating room.
RR. Vol. 16B, 109-10:McCoy 00273-74 (Plaintiff’s Exhibit 7). Shannon’s clotting
factors were so abnormal she was medically deprived of epidural anesthesia during
delivery so that she would avoid the probable risk of becoming paralyzed. RR. Vol.
8, 180:3-22. Not only did Dr. Brewer discuss this fact with the jury, so did Dr. Gunn.
RR. Vol. 10, 69:6-16. None of these lab values negate Dr. Brewer’s opinions
concerning Shannon’s blood loss or causation. This letter brief point should be
overruled.

        21
           Dr. Gunn relies on this hemoglobin value to argue that Shannon’s condition was
“improving;” this argument ignores the fact that Shannon’s hemoglobin level never normalized. The
hemoglobin level of 7.8 is abnormally low and Dr. Brewer accounted for this rise in hemoglobin in
her causation analysis by explaining to the jury that Shannon’s hemoglobin level went up because
of the packed red blood cells that were administered to her prior to 1:15 p.m.
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 29

      F.     Dr. Brewer’s causation testimony was not based on ipse dixit
             assumptions.

       Ipse dixit means: “I say it is so; therefore, so it is.” According to Dr. Gunn,
Dr. Brewer expected the jury to accept her causation opinions as valid simply because
she said they were. Seriously, is that really what Dr. Brewer did? The totality of Dr.
Brewer’s causation analysis shows that this characterization is way off base, and that
her testimony was legally sufficient to link-up Dr. Gunn’s negligence to Shannon’s
brain damage.

      Abraham Lincoln was once similarly accused of such high-handedness. In
response, this is what he had to say:

      I want to say that, in the first place, I have made no charge of any sort
      upon my ipse dixit. I have only arrayed the evidence tending to prove
      it, and presented it to the understanding of others, saying what I think it
      proves, but giving you the means of judging whether it proves it or not.
      This is precisely what I have done. I have not placed it upon my ipse
      dixit at all.22

Dr. Brewer’s testimony on causation was detailed and comprehensive, not ipse dixit.
Dr. Gunn cites to the Pollock and Wilson opinions to assert her argument, but these
decisions are unavailing. A cursory comparison of the expert causation opinions in
Pollock and those expressed by Dr. Brewer reveals that Dr. Brewer’s causation
analysis passes muster. When it comes to Wilson, Dr. Brewer’s causation testimony
falls squarely within the legal sufficiency requirements set forth in this case. Dr.
Gunn’s letter brief point on this issue should be overruled.

      22
        Abraham Lincoln, Political Debates Between Lincoln and Douglas 38-39 (Cleveland:
Burrows Bros. Co. 1897).
Mr. Christopher A. Prine, Clerk
March 4, 2015
Page 30

      G.     The summary judgment was properly granted because Appellants
             failed to introduce any evidence to establish a fact issue on nursing
             negligence.

        As Justice Boyce’s comments at oral argument made clear, Appellants
submitted no evidence in response to the McCoy family’s motion for summary
judgment to establish a fact issue on whether anything the nurses did, or failed to do,
in this case proximately caused Shannon’s brain damage. Dr. Gunn’s letter briefing
on this point should be overruled.

       In closing, one final thought is worth mentioning here. If Dr. Gunn had
devoted as much time to caring for Shannon on September 14, 2004 as she has in
attempting to explain in her appellate briefing why the jury and Dr. Brewer got it
wrong on the issue of proximate cause, imagine what would have happened to
Shannon? The McCoy family respectfully requests that the points raised by Dr. Gunn
in her letter briefing be overruled, and the trial court’s judgment should be affirmed.

                                              Very truly yours,

                                              J. Todd Trombley

JTT:peb
Enclosures

cc:   Mr. Jim Hund                                Via Facsimile No. (806) 783-8710
                                                                      and eService
      Mr. Jeffery T. Nobles                       Via Facsimile No. (713) 960-1527
                                                                      and eService
      Ms. Barbara Hilburn                         Via Facsimile No. (713) 224-5358
                                                                      and eService
      Mr. Michael C. Feehan                       Via Facsimile No. (713) 652-6000
                                                                      and eService
EXHIBIT 7
10122104                                                                          The Woman's Hospital of Texas Laborator-Y                                                  3
0620                                                                                  7800 Fannin, Houston. TX 77054
MEDICAL DIRECTOR: Bradley Wertman. H.D.
                                                                                                   *** INPATIENT DISCHARGE SUMMARY REPORT     ***
Patient: MCCOY.SHANNON                                              IF00019169487            (Continued)

I                                                  ..                          *** COAGULATlDN    *** (continued)                                                                I
    Date                  -------------------------------------SEP/14104---------------------------- ---------
    Time                       2330          1810          1502        1316           0727            0727                                     Reference         Units
   F'SP                   1~5<20 *                     ~5<20"'            E2o *           ~20 *         I              r20(ac ) *    I               (<5)     ug/!IL
   RVVT PATIENT           I                            I                  I                  I
                                                                                                       ~

                                                                                                            II1.4Cadl If                 I          (0 .0-1.1)    RATIO
   DVVTC                  I                            I.                 I                  I              10.9 tt                 35. 7Canl H                        I             I              I             I     (23 .7-34 2) SECONDS
    F!BRINOGEN         · . lll93Cao l L                                                       I             I              I             I        (351-773)   rrg/dl
    FSP                   I                            11>20 *                                I             I              I             I               (<5)     ug/ITL
    R- TIME.             . 17.3                        I           I·     ..
                                                                          I                                 I              I             I
    K-TIME               17.9                        I I           I                                        I              I             I
NOTES:     (abl   RESULTS CALLED TO FELICIA AT 1539 09/14/04 BY F.LAB .IZD.
                  EXT 3203
           Arv    ...., . ...... u .. ,.. .

                  v  -~- ·~ 89114/64 8118                                           --   ·                 --                                                                        -
           Cal) RESULTS VERIFIED BY REPEAT                        ANALYSIS
           Cam) RESULTS VERIFIED BY REPEAT                        ANALYSIS/
                RESULTS CALLED TO AMBER
                READ BACK & C~FIRMED? Y
                BY F.LAB.YMC 09/14/04 0118
           (an) RESULTS VERIFIED BY REPEAT                        ANALYSIS
           Cao) RESULTS VERIFIED BY REPEAT                        ANALYSIS

Patient: MCCOY,SHANNON                                            Age/Sex: 35/F              Acct#f00019169487       Un1t#f000435351

                                                                                                                                              Miles-l\,1cCoy      000273
10/22/04                                                                                             The Woman's Hospital of Texas Laboratory
                                                                                                                                                      C)                                                   2
0620                                                                                                     7800 Fannin. Houston, TX 77054
MEDICAL      DIRE~TOR:      Bradley Wertman. H.D.
                                                                                                                             ***    INPATIENT DISCHARGE SUMMARY REPORT ***
Patient: MCCOY .SHA!iNON                       ..                             #F00019169487                      (Continued}                                                                          :

I                                                                      ..                       *** HEMATOLOJY ***               ~cont inued2                                                                  I
    Date                    ----------------SEP/14104--------- -------                                                SEP/13/04
    Time                          1316          0727         0017                                                        2215                                                Reference        Units
· Mrnc
  RD.ol
                           '1                             133.8                                                   lijl.
                                                                                                                  pa.s7 Hl              II            1                  1        <32-35}
                                                                                                                                                                             (11 .8-14.8)
                                                                                                                                                                                               !1T1/dl
                                                                                                                                                                                                      s
  PLt
                            I
                             1189                         ~ - ~H                            ko6                             I                     l
  PlT liJRPH REV             I                            l.TOL                 I                 I            I                   j(l}                  I (m)                I                I           (NORHAL>

        Date                          --------------- -SEP/14/04----·-···-------                   SEP/13104
        Time                               1316          0727          0017                           2215                                                          Reference        Units
        lolBC                         I                     129-.7 H                             1123 .8 H             I                    I                I      (4.5 -11.2)       K/nm3
        RBC                           I                     12 14 D'*l                           !3 .67                                     I                I     (3.42-5.20)        M/ flll'J
         H68                          I                     l5.5(n ) O'*L                        118 .6 L                                   I                I     (10 .2-14.9}        gm/L
        HCT                           I ...                 116 .3 D'*t.                         1127 .2 L                                  I                I     (Jl.3·4A 8)               %
        MCV '                         I                     I6L                                  174     l                                  I                I            (81-95)          f1.
        MCH                           I                     125.8 l                              123 .4 L                                   I                I            (27-34)          pg

    NOTES :         (a) RESULTS CALLED TO KASSANDRA
                        AT 1831 09114/04 BY F.LAB . IZD.
                    (b) CRITICAL VALUE CALLED TO TROY RN AT 1457 ON 09/14/04
                        BY F.LAB.EOA.
                    (C) RESULTS VERIFIED BY REPEAT ANALYSIS
                        NOTIFICATION OF RESULTS BROADCAST TO ELENOIR BY F.LAB.TTT
                        AT 0609. 09/15/04.
                    (d) NOTIFICATION OF RESULTS BROADCAST TO SELENA BY F.LAB.KAI
                        AT 0210. 09/15/04.
                    (e) RESULTS CALLED TO KASSANDRA
                        AT 1830 09/14/04 BY F.LAB . IZO.
                    (f) RBC MORPH NORMAL
                    (g) RBC t-'IJRPH NORMAL
                    (h) RBC MORPH NORMAL
                    (i) RBC HORPH NORMAL
-                              ""''       no   T   U'\nn'
                                                                                                         ... ..
                    (lc)NORMAL PLT HORPH.                                                                              ·-     - - --                                                              -- -
                    {1) NORMAL PLT MORPH.
                        Sl. DECREASE