Evans v. Med. Ctr. of Cent. Ga.

359 Ga.App. 797

860 S.E.2d 100

EVANS et al.

v.The MEDICAL CENTER OF CENTRAL GEORGIA.

A21A0256

Court of Appeals of Georgia.

June 16, 2021

Tracey Lynn Dellacona, Jarome Emile Gautreaux, Macon, John David Hadden, Roger Frank Krause, Atlanta, GEORGE LEE PHILLIPS JR, for Appellant.

John David Hadden, Atlanta, Tracey Lynn Dellacona, Jarome Emile Gautreaux, Macon, Roger Frank Krause, Atlanta, George Lee Phillips Jr., Macon, for Appellant.

Roy Harold Meeks Jr., Amanda Wilson Speier, Atlanta, for Appellee.

Miller, Presiding Judge.

Brandy Evans, individually and as the administrator of the estate of Ralph Moss (collectively "Evans"), appeals from the trial court's order granting summary judgment on her claims for medical malpractice against nurse Briana Stelmachers and the Medical Center of Central Georgia ("MCCG"). Evans argues that the trial court erred in granting summary judgment because the evidence presented a fact issue as to whether the defendants’ negligence proximately caused Moss's death. We agree and therefore reverse the trial court's judgment.

Summary judgment is proper when there is no genuine issue of material fact and the movant is entitled to judgment as a matter of law. In reviewing a grant or denial of summary judgment, we owe no deference to the trial court's ruling and we review de novo both the evidence and the trial court's legal conclusions. Moreover, we construe the evidence and all inferences and conclusions arising therefrom most favorably toward the party opposing the motion. In doing so, we bear in mind that the party opposing summary judgment is not required to produce evidence demanding judgment for it, but is only required to present evidence that raises a genuine issue of material fact.

(Citations and punctuation omitted.) Swint v. Alphonse , 348 Ga. App. 199, 199-200, 820 S.E.2d 312 (2018). "To defeat a motion for summary judgment the respondent does not have to present conclusive proof to rebut the movant's evidence; if the respondent produces or points to any specific evidence, even slight , in the record giving rise to a triable issue of material fact, then summary judgment must be denied." (Citation and punctuation omitted; Emphasis supplied.) Peach Blossom Dev. Co. v. Lowe Elec. Supply Co. , 300 Ga. App. 268, 269, 684 S.E.2d 398 (2009).

So viewed, the record shows that on July 26, 2014, 57-year-old Ralph Moss was transported by ambulance to MCCG's Emergency Department after he complained of vomiting and chest pain that radiated to his left arm. Moss arrived at the Emergency Department at 12:28 p.m., and he was not experiencing chest pain at that time. Briana Stelmachers, a nurse in the Emergency Department, assessed Moss and, based on standing orders, performed an electrocardiagram ("ECG")¹ and troponin level blood test. Moss's ECG was initially read as "Borderline ECG - Preliminary - MD Must Review STAT," and emergency room physician Dr. Nathan Stokes subsequently interpreted the ECG as showing "no ischemic changes."² A troponin test was performed at 1:24 p.m., and it revealed that Moss's troponin level was elevated at 0.09ng/mL, above the normal range of 0-0.08ng/mL.

To assure that each patient presenting to the emergency department with chest pain receives the proper diagnosis and that heart attack core measures are addressed, MCCG's internal policy requires a physician, nurse practitioner, or physician assistant to assign patients to one of four order set tracks. Nurses are to follow orders on the assigned track, so if a patient has not been assigned a track, the policy provides that the nurse should ask the physician for track orders. Tracks 1–3 are for patients with chest pain of certain or probable cardiac origin and require, among other things, serial ECGs and serial troponin testing. Track 4 is for patients with chest pain of probable non-cardiac origin and does not require serial testing. Stelmachers initially triaged Moss as "Level III," but Dr. Stokes did not assign Moss to a track, and Stelmachers did not approach Dr. Stokes about placing Moss on one.

Dr. Stokes evaluated Moss at 1:50 p.m. Moss told Dr. Stokes that he had recently undergone a stress test and the results were negative. Based on Moss's physical exam and history, Dr. Stokes documented several risk factors for heart attack, including a history of high cholesterol and COPD and a family history of coronary artery disease, hypertension, and diabetes. Moss told Dr. Stokes that he had no nausea or vomiting. Although Moss had complained of those symptoms to EMS and Nurse Stelmachers, Dr. Stokes could not recall whether he saw the report documenting Moss's complaints of those symptoms before he decided to discharge Moss.

Moss was discharged from the Emergency Department at 2:42 p.m, having received a single ECG and single troponin test. Dr. Stokes entered the discharge instructions and Stelmachers went over them with Moss. The discharge paperwork advised Moss that, based on his exam, the exact cause of his chest pain was unknown but his condition did not appear to be serious and the pain did not appear to be coming from his heart. Moss died the next day, at his home, of an acute myocardial infarction.

Moss's widow brought the instant medical malpractice action against Drs. Stokes and Kalambur Panchapakesan, Nurse Stelmachers, and MCCG, alleging that they failed to follow proper protocols when Moss visited the Emergency Department with chest pain, which led to Moss being prematurely discharged and caused his death. Mrs. Moss voluntarily dismissed her claims against Dr. Panchapakesan. After Mrs. Moss died during litigation, the Mosses’ daughter, Evans, was substituted as the plaintiff. Evans reached a settlement with Dr. Stokes, leaving only the claims regarding Nurse Stelmachers pending.

Nurse Stelmachers and MCCG moved for summary judgment, and the trial court granted their motion, concluding that any alleged negligence by Stelmachers was not the proximate cause of Moss's premature discharge because there was undisputed evidence that Dr. Stokes would have discharged Moss even if Stelmachers had questioned his decision. This appeal followed.

In her sole enumeration of error, Evans argues that the trial court erred when it granted summary judgment to MCCG because the totality of the evidence surrounding Moss's discharge created a fact issue as to whether Stelmachers's alleged negligence proximately caused Moss's death. We agree.

To recover in a medical malpractice case, a plaintiff must show not only a violation of the applicable medical standard of care but also that the purported violation or deviation from the proper standard of care is the proximate cause of the injury sustained. In other words, a plaintiff must prove that the defendants’ negligence was both the cause in fact and the proximate cause of his injury.

(Citation omitted.) Knight v. Roberts , 316 Ga. App. 599, 603 (1), 730 S.E.2d 78 (2012).

Causation in a medical malpractice action must be established through expert testimony because the question of whether the alleged professional negligence caused the plaintiff's injury is generally one for specialized expert knowledge beyond the ken of the average layperson. But Georgia case law requires only that an expert state an opinion regarding proximate causation in terms stronger than that of medical possibility, i.e., reasonable medical probability or reasonable medical certainty. And causation may be established by linking the testimony of several different experts and must be determined in light of the evidentiary record as a whole. Furthermore, it is well established that questions regarding causation are peculiarly questions for the jury except in clear, plain, palpable and undisputed cases.

(Punctuation and citations omitted). Central Ga. Women's Health Center, LLC v. Dean , 342 Ga. App. 127, 134 (1) (b), 800 S.E.2d 594 (2017). See also Moore v. Singh , 326 Ga. App. 805, 809 (1), 755 S.E.2d 319 (2014) (same).

In his deposition, Dr. Stokes testified that he decided to discharge Moss because Moss was asymptomatic while at the hospital, had recently had a negative stress test, had an unremarkable ECG, and had unremarkable vital signs while at the hospital. Although Moss's troponin level was slightly elevated, Dr. Stokes considered that to be clinically unremarkable. As to the order tracks, Dr. Stokes stated that, in practice, initiating a formal track is optional; physicians use or omit components from various tracks as they see fit. If Dr. Stokes would have assigned Moss to a formal track, it would have been Track 4 for probable non-cardiac origin chest pain, which, as noted above, does not require subsequent ECGs or troponin testing. Dr. Stokes stated that if Stelmachers had approached him and questioned his decision to discharge Moss, he still would have discharged Moss unless Stelmachers shared some additional information with him. He further stated that, even knowing everything in the record, he was not aware of any facts that should have raised a concern prior to discharge.

Evans presented expert witness testimony from September Lee Evans, R. N., who testified that, based on Moss's history and complaints when he arrived at the Emergency Department, Stelmachers should have triaged him as the more urgent Level II rather than Level III. According to Nurse Evans, Stelmachers further breached the standard of care by failing to complete the required triage form, and Nurse Evans explained that a completed form reflecting all of Moss's symptoms might have caused Dr. Stokes to order serial ECG or troponin tests. In addition, Stelmachers failed to advocate for Dr. Stokes to place Moss on a formal track order, or at least to conduct more testing such as a serial ECG and serial troponin test, and this lack of advocacy was a breach of the standard of care in light of Moss's borderline ECG and elevated troponin level. Nurse Evans noted that if Dr. Stokes was not receptive, a nurse can go up the chain of command to advocate...