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Shadrick v. Grana

Supreme Court of Alabama

October 26, 2018

Sue Shadrick, personal representative of the Estate of William Harold Shadrick, deceased
v.
Wilfredo Grana, M.D.

          Appeal from Calhoun Circuit Court (CV-12-900400)

          SELLERS, JUSTICE.

         In this 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.

         Introduction

         On 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.[1] Dr. Moore discussed William's condition with Dr. Onyekwere and Dr. Grana. Thereafter, Dr. Grana admitted William to the hospital.

         According 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.

         Dr. 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.

         Dr. 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.

         After 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.[2] 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 earlier.

         Shadrick sued Dr. Onyekwere and Dr. Grana. She settled her claims against Dr. Onyekwere, and Dr. Grana filed a motion for a summary judgment.[3]

         In 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.

         Discussion

         According 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 of care.

         "As 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.

         Shadrick 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.

         Although 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?
"A. Yes.
"Q. Significantly low, wasn't ...

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