Sue Shadrick, personal representative of the Estate of William Harold Shadrick, deceased
Wilfredo Grana, M.D.
from Calhoun Circuit Court (CV-12-900400)
medical-malpractice action, Sue Shadrick
("Shadrick"), as personal representative of the
estate of William Harold Shadrick, deceased
("William"), appeals from a summary judgment
entered by the Calhoun Circuit Court in favor of Wilfredo
Grana, M.D. We affirm.
October 29, 2010, William presented to the emergency room of
the Northeast Alabama Regional Medical Center ("the
hospital"), reporting that he had been experiencing
shortness of breath and chest pain. An emergency-room
physician, Dr. Gary Moore, concluded that William had
suffered a heart attack. Dr. Moore placed separate telephone
calls to Osita Onyekwere, M.D., who was the cardiologist on
call at the time, and to Dr. Grana, who is a board-certified
internist and a hospitalist for the hospital. Dr. Moore
discussed William's condition with Dr. Onyekwere and Dr.
Grana. Thereafter, Dr. Grana admitted William to the
to Dr. Grana's deposition testimony, when William was
admitted to the hospital, his blood pressure was low, his
troponin levels were elevated, his heart rate was elevated,
he had fluid in his lungs, and he had "crackles in the
bases" of his lungs (which may be indicative of
pneumonia). An electrocardiogram and other tests, including
an echocardiogram, indicated that William had experienced a
"non-ST elevation" heart attack. According to the
testimony in this case, a non-ST elevation heart attack
requires close monitoring but not necessarily immediate
invasive care. In contrast, an ST elevation heart attack is
more serious and requires immediate treatment.
Grana testified that, based on the echocardiogram, he
believed that William was in cardiogenic shock, which means
that his heart was unable to pump enough blood to meet his
body's needs. Dr. Grana testified that he believed an
emergency heart catheterization was necessary, which would
have revealed the reason for the cardiogenic shock, such as a
blocked blood vessel. As an internist, however, Dr. Grana
could not perform that invasive procedure.
Grana telephoned Dr. Onyekwere at approximately 6:00 p.m. the
evening William was admitted to the hospital. Dr. Grana
testified at deposition that, during his consultation with
Dr. Onyekwere, he relayed to Dr. Onyekwere that William had
low blood pressure, an elevated heart rate, elevated troponin
levels, and fluid in his lungs. He also testified that he
told Dr. Onyekwere that he believed William was in
cardiogenic shock and that Dr. Onyekwere should see William
before Dr. Onyekwere went home for the night. When asked if
he relayed to Dr. Onyekwere his opinion that William needed
an emergency heart catheterization, Dr. Grana answered:
"I told [Dr. Onyekwere] that it would be a good idea to
transfer [William] to the [intensive-care unit]." In her
appellant's brief, Shadrick states that Dr. Grana
testified that he did indeed inform Dr. Onyekwere of his
specific opinion that William needed a heart catheterization.
his telephone conversation with Dr. Grana, Dr. Onyekwere went
home for the night without personally seeing William. He did,
however, have a "nurse extender" monitor William at
the hospital. The next morning, Dr. Grana learned that
William's condition had worsened and that Dr. Onyekwere
had not yet seen William. Dr. Onyekwere's nurse extender
told Dr. Grana that William was being transferred to the
hospital's intensive-care unit and that Dr. Onyekwere was
en route to the hospital. At approximately 12:50 p.m., an
emergency code was relayed over the hospital's
public-address system indicating that a patient had suffered
cardiac arrest; that patient was William. Dr. Onyekwere still
had not personally seen William at that point. William later
died from insufficient oxygen to his brain. A heart
catheterization performed after William had suffered cardiac
arrest indicated that he had heart blockages that might have
been bypassed through surgery had they been discovered
sued Dr. Onyekwere and Dr. Grana. She settled her claims
against Dr. Onyekwere, and Dr. Grana filed a motion for a
support of his summary-judgment motion, Dr. Grana submitted
an affidavit averring that his care of William met or
exceeded the applicable standard of care. He also moved the
trial court to strike the standard-of-care testimony of
Shadrick's designated expert witness, Dr. James Bower,
and to preclude Dr. Bower from providing such testimony in
support of Shadrick's claims. Dr. Grana argued that Dr.
Bower is not a similarly situated health-care provider in
relation to Dr. Grana because Dr. Bower is a board-certified
cardiologist, not a board-certified internist or a
hospitalist as is Dr. Grana. See generally Holcomb v.
Carraway, 945 So.2d 1009, 1012 (Ala. 2006) (indicating
that a plaintiff in a medical-malpractice case ordinarily
must present the testimony of a "similarly situated
health-care provider" in order to demonstrate that the
defendant's care fell below the applicable standard of
care). The trial court granted Dr. Grana's motion to
strike Dr. Bower's testimony and his motion for a summary
judgment. Shadrick appealed.
to Shadrick, Dr. Grana testified at deposition that, during
his telephone consultation with Dr. Onyekwere on the evening
William was admitted to the hospital, Dr. Grana relayed his
specific opinions that Dr. Onyekwere needed to see William
that night, that William was in cardiogenic shock, and that
William needed an emergency heart catheterization. Dr.
Onyekwere, however, denied during his deposition that Dr.
Grana had expressed those opinions to him. According to Dr.
Onyekwere, his consultations with Dr. Grana and Dr. Moore
were "routine" and left him with the impression
that William's condition did not constitute a cardiac
emergency necessitating the immediate hands-on attention of a
cardiologist. Rather, he believed that William's most
serious problems were pneumonia and sepsis, which is a blood
infection, and were not cardiac in nature. Thus, based on
what she asserts is conflicting testimony, Shadrick argues
that there is a factual dispute that should be resolved by a
jury. Shadrick asserts that, if a jury believes Dr.
Onyekwere's version of events, then Shadrick has
established that Dr. Grana breached the applicable standard
a general rule, in a medical-malpractice action, the
plaintiff is required to produce expert medical testimony to
establish the applicable standard of care and a breach of
that standard of care, in order to satisfy the
plaintiff's burden of proof." Anderson v.
Alabama Reference Labs., 778 So.2d 806, 811 (Ala. 2000).
As noted, the trial court refused to allow Shadrick's
expert witness, Dr. Bower, to testify that Dr. Grana's
alleged acts and omissions fell below the applicable standard
of care. Thus Dr. Grana argued, and the trial court agreed,
Shadrick was unable to present the necessary expert testimony
and her claims therefore fail.
concedes that expert testimony is typically required in
medical-malpractice cases. In the present case, however, she
relies on an exception to the general rule, which applies in
medical situations "'"where want of skill or
lack of care is so apparent ... as to be understood by a
layman, and requires only common knowledge and experience to
understand it."'" Anderson, 778 So.2d
at 811 (quoting Tuscaloosa Orthopedic Appliance Co. v.
Wyatt, 460 So.2d 156, 161 (Ala. 1984), quoting in turn
Dimoff v. Maitre, 432 So.2d 1225, 1226-27 (Ala.
1983)). Shadrick asserts that Dr. Grana simply failed to
inform Dr. Onyekwere that an emergency existed and that a
layperson is capable, without the aid of expert testimony, of
concluding that that failure constitutes a breach of the
applicable standard of care.
there is a dispute as to whether Dr. Grana, in consulting
with Dr. Onyekwere, used the term "emergency" in
describing William's condition or conveyed the specific
opinions he had formed regarding William's diagnosis and
the best course of treatment, it has not been disputed that
Dr. Grana informed Dr. Onyekwere that William was
experiencing low blood pressure, an elevated heart rate,
elevated troponin levels, and fluid in his lungs. Dr.
Onyekwere also did not deny during deposition that he was
made aware of William's electrocardiogram, and he
specifically confirmed that he was alerted to the fact that
William had experienced a non-ST elevation heart attack.
Moreover, although Dr. Onyekwere denied that Dr. Grana
conveyed his specific opinion that William was in cardiogenic
shock, Dr. Onyekwere's testimony indicates that Dr. Grana
did indeed inform Dr. Onyekwere that William's
echocardiogram indicated a "low ejection fraction,"
which the record suggests means that William's heart was
not pumping enough blood to meet his bodily needs:
"Q. [By Shadrick's counsel:] Did you know on
Saturday morning [the day after William was admitted to the
hospital] when you spoke with [the nurse extender] about her
visit with Mr. Shadrick that an echo had already been done
and you knew the results?
"A. [By Dr. Onyekwere:] It must have slipped my mind
somehow when I was talking with her. I said get an echo if it
hasn't been done. But obviously going through the
records, yes, the echo had been done, and I believe it was
part of my discussion with Dr.--Dr. Grana that the patient
had a low EF and so--
"Q. Low EF is ejection fraction?
"Q. Significantly low, wasn't ...