Springhill Hospitals, Inc. v. Critopoulos

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Justia Opinion Summary

Defendants Springhill Hospitals, Inc., Dennis Rushing, Ashley Flemming and Janel Ostriehmerer appealed a judgment entered in favor of Plaintiff Dimitrios Critopoulos. Plaintiff was admitted to the hospital for a heart catheterization. While in the hospital's cardiac-intervention unit, Defendant Rushing noticed discoloration and blisters on Plaintiff's neck and spine. Nineteen days after he was admitted for cardiac care, Plaintiff was released from the hospital. Plaintiff was subsequently admitted to a different infirmary and treated for the discoloration and blisters, which were found to be ulcers. He filed a medical-malpractice action against Defendants for failing to treat the ulcers when he was under their care for the catheterization. Defendants alleged on appeal to the Supreme Court that errors at trial warranted a reversal of the outcome. The Supreme Court reviewed the trial court record and applicable authority, and concluded that the trial court exceeded its discretion when it ruled in favor of Plaintiff. The Court reversed the trial court's judgment and remanded the case for the entry of a judgment as a matter of law in favor of Defendants.

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REL: 11/18/2011 Notice: T h i s o p i n i o n i s s u b j e c t t o f o r m a l r e v i s i o n b e f o r e p u b l i c a t i o n i n t h e advance s h e e t s o f Southern R e p o r t e r . R e a d e r s a r e r e q u e s t e d t o n o t i f y t h e R e p o r t e r o f D e c i s i o n s , A l a b a m a A p p e l l a t e C o u r t s , 300 D e x t e r A v e n u e , M o n t g o m e r y , A l a b a m a 3 6 1 0 4 - 3 7 4 1 ((334) 2 2 9 - 0 6 4 9 ) , o f a n y t y p o g r a p h i c a l o r o t h e r e r r o r s , i n o r d e r t h a t c o r r e c t i o n s may b e made b e f o r e t h e o p i n i o n i s p r i n t e d i n Southern R e p o r t e r . SUPREME COURT OF ALABAMA OCTOBER TERM, 2011-2012 1090946 Springhill Hospitals, Inc., e t a l . v. Dimitrios Critopoulos Appeal WISE, from Mobile C i r c u i t (CV-08-900551) Court Justice. The defendants, Springhill S p r i n g h i l l Memorial H o s p i t a l Hospitals, ("Springhill"), Inc., d/b/a Dennis Rushing, A s h l e y F l e m i n g , and J a n e l O s t r i e c h m e r e r ( h e r e i n a f t e r referred 1090946 to c o l l e c t i v e l y in as " t h e d e f e n d a n t s " ) , favor of the p l a i n t i f f , Facts a p p e a l from a judgment Dimitrios Critopoulos. and P r o c e d u r a l History On A p r i l 10, 2 0 0 6 , C r i t o p o u l o s was a d m i t t e d Memorial April Hospital 11, 2006, artery-bypass surgery, unit. April t o undergo a heart catheterization. Dr. D i m i t r i s K y r i a z i s p e r f o r m e d graft ("CABG") Critopoulos Critopoulos was was on Critopoulos. admitted to the a On cardiac- After the cardiac-recovery i n the cardiac-recovery unit until 16, 2 0 0 6 , when he was t r a n s f e r r e d t o t h e c a r d i a c - s t e p - down o r c a r d i a c - i n t e r v e n t i o n u n i t . 14, to Springhill 2006, before Critopoulos A r o u n d 11:50 a.m. on A p r i l was transferred, Rushing, r e g i s t e r e d n u r s e who w o r k e d i n b o t h t h e c a r d i a c - r e c o v e r y cardiac-intervention units performed Critopoulos. During that reassessment, discoloration on the back of s u b s e q u e n t l y moved C r i t o p o u l o s approximately a and reassessment Rushing Critopoulos's of noticed neck. from t h e bed t o a c h a i r . 1:50 p.m., R u s h i n g was h e l p i n g C r i t o p o u l o s a a He At back t o b e d when he n o t i c e d a b l i s t e r on t h e b a c k o f C r i t o p o u l o s ' s neck and a stage I decubitus 2 or pressure ulcer on 1090946 Critopoulos's released coccyx. On April 19, 2006, Critopoulos from the h o s p i t a l . On A p r i l 2 0 , 2 0 0 6 , C r i t o p o u l o s went t o M o b i l e a hospital breath, was i n Mobile, where d i f f i c u l t y breathing, he complained of shortness a sacral pressure open wound i n t h e p o s t e r i o r o f h i s n e c k . Infirmary, of u l c e r , and an The p l a s t i c surgeon a t t h e h o s p i t a l d e t e r m i n e d t h a t s u r g e r y was n o t n e c e s s a r y f o r C r i t o p o u l o s ' s wounds a t t h a t t i m e and t h a t t h e wounds c o u l d be t r e a t e d w i t h l o c a l wound c a r e a n d b y a p p l y i n g m e d i c i n e s t o t h e wounds. Critopoulos was subsequently released from the admitted to Mobile hospital. On May 8, 2006, C r i t o p o u l o s was a g a i n I n f i r m a r y because the s a c r a l pressure The u l c e r was debrided Critopoulos was Critopoulos continued until late u l c e r had g o t t e n by the p l a s t i c released surgeon a t t h a t from the h o s p i t a l to receive treatment time. 11, 2006. f o r h i s wounds 2009. On A p r i l 8, 2008, C r i t o p o u l o s f i l e d a action on May worse. against Springhill, Rushing, 3 medical-malpractice Fleming, Ostriechmerer, 1090946 and S c o t t Holcombe. Holcombe were S p r i n g h i l l who On July 1 Rushing, a l l nurses in Fleming, the Ostriechmerer, cardiac-recovery unit 2009, Holcombe and the defendants filed "Objections to Q u a l i f i c a t i o n s of P l a i n t i f f ' s Nursing Penny J o n e s , R.N.," and The in this trial, care of provided care f o r C r i t o p o u l o s . 10, trial and a motion case to exclude her s t a r t e d on J a n u a r y Penny J o n e s , a r e g i s t e r e d n u r s e who management, testified as Expert, testimony. 11, 2010. At p r a c t i c e d i n wound- Critopoulos's expert r e g a r d i n g the s t a n d a r d of c a r e . an witness Jones t e s t i f i e d t h a t Rushing, F l e m i n g , Holcombe, and O s t r i e c h m e r e r had b r e a c h e d t h e s t a n d a r d of care in this case by not performing an assessment to d e t e r m i n e C r i t o p o u l o s ' s r i s k o f d e v e l o p i n g p r e s s u r e u l c e r s ; by not t u r n i n g and w h i l e he was repositioning Critopoulos every two hours a p a t i e n t i n t h e c a r d i a c - r e c o v e r y u n i t ; and by not d e v e l o p i n g a p l a n of care f o r the p r e v e n t i o n of p r e s s u r e ulcers. She also testified that Fleming and Rushing had C r i t o p o u l o s i n i t i a l l y i n c l u d e d L o r e t t a Beckham, M a r y F o o t e , M e l o d y E r n e s t , and B e t t y B r i n k m a n as d e f e n d a n t s . On J a n u a r y 28, 2009, t h e p a r t i e s e n t e r e d a " S t i p u l a t i o n o f D i s m i s s a l as t o D e f e n d a n t s L o r e t t a Beckham, M e l o d y E r n e s t , B e t t y B r i n k m a n , and Mary F o o t e . " On F e b r u a r y 5, 2009, t h e t r i a l c o u r t d i s m i s s e d Beckham, E r n e s t , B r i n k m a n , and F o o t e with prejudice. 1 4 1090946 b r e a c h e d t h e s t a n d a r d o f c a r e by n o t p r o v i d i n g c o m p l e t e wound assessments a f t e r the p r e s s u r e u l c e r developed. At t r i a l , d e f e n s e moved t o e x c l u d e J o n e s ' s t e s t i m o n y on t h e g r o u n d she was not a s i m i l a r l y situated health-care provider § 6-5-548, A l a . Code 1975. court denied. verdict in On favor case-in-chief of a l l the e v i d e n c e , which January of under f o r a judgment as a m a t t e r o f l a w a t t h e c l o s e o f C r i t o p o u l o s ' s again a t the c l o s e that The t r i a l c o u r t d e n i e d t h e m o t i o n . Holcombe and t h e d e f e n d a n t s f i l e d m o t i o n s and the 19, 2010, Critopoulos the and jury the trial returned a against Rushing, O s t r i e c h m e r e r , F l e m i n g , and S p r i n g h i l l i n t h e sum o f $ 3 0 0 , 0 0 0 . The jury also returned a verdict i n favor of Scott Holcombe and a g a i n s t C r i t o p o u l o s . On their F e b r u a r y 11, 2010, motions the defendants f o r a j u d g m e n t as a l t e r n a t i v e , f o r a new t r i a l . to the the motion. On a renewal of a m a t t e r o f law o r , i n the C r i t o p o u l o s f i l e d an o p p o s i t i o n F e b r u a r y 26, 2010, defendants' motion. filed This appeal the t r i a l court denied followed. Standard of Review "'The standard of review a p p l i c a b l e to w h e t h e r an e x p e r t s h o u l d be p e r m i t t e d t o testify i s well settled. The m a t t e r i s "largely discretionary with the trial 5 1090946 c o u r t , and t h a t c o u r t ' s j u d g m e n t w i l l n o t be disturbed absent an abuse of discretion." Hannah v. G r e g g , B l a n d & B e r r y , I n c . , 840 So. 2d 839, 850 (Ala. 2 0 0 2 ) . We now r e f e r t o t h a t s t a n d a r d as a t r i a l court's "exceeding i t s d i s c r e t i o n . " See, e.g., V e s t a F i r e I n s . C o r p . v. M i l a m & Co. C o n s t r . , I n c . , 901 So. 2d 84, 106 (Ala. 2004) ("Our review of the record supports the c o n c l u s i o n t h a t the trial c o u r t d i d not exceed i t s d i s c r e t i o n i n f i n d i n g t h a t J o n e s was p r o p e r l y q u a l i f i e d as an e x p e r t u n d e r R u l e 7 0 2 [ , Ala. R. Evid.,] and in considering his t e s t i m o n y . " ) . However, t h e s t a n d a r d i t s e l f has n o t c h a n g e d . ' " K y s e r v. 2 00 5)." R o b i n s o n v. (Ala. Harrison, B a p t i s t Health C i v . App. 908 So. Sys., 2d Inc., 914, 24 So. 918 3d (Ala. 1119, 2009). "'"The s t a n d a r d o f r e v i e w a p p l i c a b l e to a motion for directed verdict or j u d g m e n t n o t w i t h s t a n d i n g t h e v e r d i c t [now referred to as a preverdict and a p o s t v e r d i c t m o t i o n f o r a j u d g m e n t as a m a t t e r of l a w ] i s i d e n t i c a l to the s t a n d a r d u s e d by t h e t r i a l c o u r t i n g r a n t i n g o r d e n y i n g t h e m o t i o n s i n i t i a l l y . Thus, when reviewing the trial court's ruling on e i t h e r m o t i o n , we d e t e r m i n e w h e t h e r t h e r e was sufficient evidence to produce a c o n f l i c t warranting jury consideration. And, l i k e t h e t r i a l c o u r t , we must v i e w any evidence most favorably to the non-movant."' 6 1125 1090946 " G l e n l a k e s R e a l t y Co. v. Norwood, 721 So. 2d 177 ( A l a . 1998) ( q u o t i n g B u s s e y v. J o h n Deere 531 So. 2d 860, 863 ( A l a . 1 9 8 8 ) ) . " Parker v. W i l l i a m s , 977 So. 2d 476, 480 174, Co., ( A l a . 2007) . Discussion In t h i s erroneously case, the d e f e n d a n t s argue t h a t the allowed Penny J o n e s t o t e s t i f y as standard-of-care similarly expert because, they argue, as r e q u i r e d by § court Critopoulos's she s i t u a t e d h e a l t h - c a r e p r o v i d e r as t o t h e defendants, trial was not a individual 6-5-548, A l a . Code 1975. The A l a b a m a M e d i c a l L i a b i l i t y A c t , § 6-5-480 e t s e q . and § 6-5-540 et seq., Ala. Code 1975, includes regarding medical-malpractice the following provisions claims: "(a) I n any a c t i o n f o r i n j u r y o r damages o r wrongful death, whether i n c o n t r a c t or i n t o r t , a g a i n s t a h e a l t h care p r o v i d e r f o r breach of the standard o f c a r e , t h e p l a i n t i f f s h a l l have the b u r d e n o f p r o v i n g by s u b s t a n t i a l e v i d e n c e t h a t t h e health care provider failed to exercise such reasonable care, skill, and d i l i g e n c e as other s i m i l a r l y s i t u a t e d h e a l t h c a r e p r o v i d e r s i n t h e same general line of practice ordinarily have and e x e r c i s e i n a l i k e case. "(b) Notwithstanding any p r o v i s i o n of the Alabama Rules of E v i d e n c e t o the c o n t r a r y , i f the h e a l t h c a r e p r o v i d e r whose b r e a c h o f t h e s t a n d a r d o f c a r e i s c l a i m e d t o have c r e a t e d t h e c a u s e o f a c t i o n i s n o t c e r t i f i e d by an a p p r o p r i a t e A m e r i c a n b o a r d as b e i n g a s p e c i a l i s t , i s n o t t r a i n e d and experienced i n a m e d i c a l s p e c i a l t y , o r does n o t h o l d h i m s e l f o r 7 1090946 h e r s e l f o u t as a s p e c i a l i s t , a ' s i m i l a r l y s i t u a t e d h e a l t h c a r e p r o v i d e r ' i s one who meets a l l o f t h e following qualifications: "(1) I s l i c e n s e d b y t h e a p p r o p r i a t e r e g u l a t o r y b o a r d o r a g e n c y o f t h i s o r some other state. "(2) I s t r a i n e d a n d e x p e r i e n c e d i n t h e same d i s c i p l i n e o r s c h o o l o f p r a c t i c e . "(3) Has practiced i n the same d i s c i p l i n e or school of p r a c t i c e during the year p r e c e d i n g the date t h a t the a l l e g e d breach of the standard of care occurred. II " ( e ) The p u r p o s e o f t h i s s e c t i o n i s t o e s t a b l i s h a relative standard of care for health care p r o v i d e r s . A h e a l t h c a r e p r o v i d e r may t e s t i f y as an e x p e r t w i t n e s s i n any a c t i o n f o r i n j u r y o r damages a g a i n s t a n o t h e r h e a l t h c a r e p r o v i d e r b a s e d on a b r e a c h o f t h e s t a n d a r d o f c a r e o n l y i f he o r she i s a 'similarly s i t u a t e d h e a l t h c a r e p r o v i d e r ' as d e f i n e d above." § 6-5-548, A l a . Code 1975 (emphasis added). "Standard care" i s defined a s : "The standard of care i s that level of such reasonable care, s k i l l , a n d d i l i g e n c e as o t h e r s i m i l a r l y s i t u a t e d h e a l t h c a r e p r o v i d e r s i n t h e same general line of p r a c t i c e , ordinarily have a n d e x e r c i s e i n l i k e cases. A breach of the standard of c a r e i s t h e f a i l u r e by a h e a l t h c a r e p r o v i d e r t o comply w i t h t h e s t a n d a r d o f c a r e , which failure proximately causes personal injury or wrongful death. This d e f i n i t i o n applies to a l l actions f o r i n j u r i e s o r damages o r w r o n g f u l d e a t h w h e t h e r i n 8 of 1090946 c o n t r a c t o r t o r t and w h e t h e r b a s e d on i n t e n t i o n a l o r u n i n t e n t i o n a l conduct." § 6 - 5 - 5 4 2 ( 2 ) , A l a . Code 1975 In this case, (emphasis added). Ostriechmerer, Rushing, Holcombe, F l e m i n g were a l l n u r s e s i n t h e c a r d i a c - r e c o v e r y unit. and Each was r e s p o n s i b l e f o r t h e t o t a l c a r e o f C r i t o p o u l o s i m m e d i a t e l y f o l l o w i n g h i s CABG. Penny J o n e s t e s t i f i e d t h a t , a t t h e t i m e o f t r i a l , licensed has to p r a c t i c e nursing been licensed there t e s t i f i e d t h a t she was she was i n N o r t h C a r o l i n a and t h a t she since 1995 or 1996. c e r t i f i e d as a wound-care She n u r s e by t h e Wound, Ostomy and C o n t i n e n c e N u r s e s S o c i e t y and t h a t she also certified as a wound specialist by also the was American A s s o c i a t i o n o f Wound Management. With regard high school to her t r a i n i n g , Jones t e s t i f i e d that after she c o m p l e t e d h e r a s s o c i a t e ' s d e g r e e i n n u r s i n g . A f t e r she c o m p l e t e d h e r d e g r e e , she s t a r t e d b e d s i d e n u r s i n g . J o n e s t e s t i f i e d t h a t she h a d w o r k e d i n t h e i n t e n s i v e - c a r e u n i t ("ICU"); t h a t she h a d w o r k e d a little b i t i n the emergency r o o m ; t h a t she h a d w o r k e d i n n u r s i n g h o m e s ; and t h a t she "worked ... j u s t about everywhere room." 9 except f o r the had operating 1090946 Jones obtained school testified that her bachelor's and testified obtained that she l a t e r degree. degree master's that testified her p a r t i c u l a r that she focus was subsequently i n 1989. degree cardiopulmonary s t u d i e s , which includes but to school and A f t e r t h a t , she went b a c k t o her master's f o r her returned focused the heart at a She also respiratory and t h a t h e r w o r k i n c l u d e d weaning p a t i e n t s i n t h e ICU from on and l u n g s , the lungs. worked h o s p i t a l i n Los Angeles, C a l i f o r n i a , she Jones there ventilators. J o n e s t e s t i f i e d t h a t , i n 1992, she moved t o Durham, N o r t h Carolina, ("Duke"). clinical policies and in and went work She t e s t i f i e d nurse specialist and p r o c e d u r e s t r e a t i n g pressure the mid-1990s, Jones to a t Duke that University she i s t h e there and that f o r Duke r e g a r d i n g ulcers. Hospital wound-management she wound wrote management Jones f u r t h e r t e s t i f i e d she s t a r t e d a " c o n s u l t the that, s e r v i c e " a t Duke. stated: " T h e r e ' s a c o n s u l t s e r v i c e t h a t we have a t Duke H o s p i t a l , a n d I r u n t h a t s e r v i c e , w h i c h means t h a t p e o p l e -- o t h e r n u r s e s , t h e p h y s i c i a n s w i l l a s k us t o come a n d s e e a p a t i e n t who h a s a wound, a n d t h e wound c o u l d be a n y t h i n g f r o m a p o s t - s u r g i c a 1 wound that hasn't healed, a diabetic foot ulcer, skin t e a r s , p r e s s u r e u l c e r s , p r e t t y much -- b u r n s , p r e t t y much any k i n d o f wound t h a t you m i g h t t h i n k o f , 10 1090946 w e ' l l see a p a t i e n t and d e t e r m i n e w h a t we s h o u l d be -- w h a t we s h o u l d do f o r t h e wound t o h e l p i t t o h e a l as w e l l as what t h e p a t i e n t needs t o do t o h e l p t h e wound t o h e a l . " (Emphasis added.) Jones testified that w r i t e s p o l i c i e s f o r Duke. as a clinical She specialist also t e s t i f i e d she also t h a t Duke has " S k i n C a r e Champion P r o g r a m " t h a t i n v o l v e s b e d s i d e n u r s e s have been specially u l c e r s ; that back and trained in those s p e c i a l l y train other the prevention nurses and to prevent pressure her administrator on their ulcers. developed a standard patients with chronic pressure ulcers, patients i n I C U s who had testified that and pressure floors; and the that Jones t e s t i f i e d of skin that She care that she called that she regarding care of which standard recently she also t e s t i f i e d wounds, that go n u r s e s what d e v e l o p e d a p r o g r a m t h a t i s now t h e Wound Management I n s t i t u t e . had who t r a i n e d bedside nurses then spent a l o t of time i n t h a t program t e a c h i n g t o do of a the would of undergone include care included cardiac-bypass surgery. Jones she had provided wound-management s e r v i c e s to c a r d i a c p a t i e n t s s i n c e the mid-1990s; t h a t , t h a t time u n t i l the time of t r i a l , 11 she had provided from hands-on 1090946 wound-management c a r e and t o c r i t i c a l p a t i e n t s i n an I C U s e t t i n g ; t h a t she was p r o v i d i n g s u c h c a r e as r e c e n t l y as t h e F r i d a y before the trial started. She further testified s p e c i f i c t o wound c a r e a n d p r e v e n t i n g p r e s s u r e t a u g h t d o c t o r s , n u r s e s , and o t h e r h e a l t h - c a r e take care of cardiac She f u r t h e r t e s t i f i e d provided patients that, that, u l c e r s , she h a d p r o v i d e r s how t o i n an i n t e n s i v e - c a r e setting. on a v e r a g e 10 t i m e s a week, she w o u n d - c a r e management t o p a t i e n t s who h a d r e c e n t l y undergone c a r d i a c - b y p a s s surgery a n d who were i n t h e I C U . J o n e s t e s t i f i e d t h a t as a wound-management s p e c i a l i s t she w o u l d p e r f o r m some o f t h e same c l i n i c a l s e r v i c e s as a r e g u l a r c a r d i a c - c a r e n u r s e p e r f o r m e d . She w o u l d c h e c k v i t a l s i g n s a n d conduct skin assessments. e i t h e r w r i t i n g or reviewing She w o u l d care p l a n s . also participate i n The F r i d a y b e f o r e t h e t r i a l was t h e l a s t t i m e she h a d p r o v i d e d wound-management t o a c a r d i a c p a t i e n t i n an i n t e n s i v e - c a r e testified cardiac that patients she had treated to detect or setting. managed and p r e v e n t p r e s s u r e care She a l s o postoperative ulcers t h a t she h a d done s o as r e c e n t l y as t h e week b e f o r e and trial. However, J o n e s t e s t i f i e d t h a t she h a s n o t p r a c t i c e d as an intensive-care cardiac nurse. She a l s o t e s t i f i e d t h a t she h a d 12 1090946 never provided direct, hands-on p a t i e n t s l i k e C r i t o p o u l o s , who in the she cardiac-recovery had was unit. Jones she had stability not, of a measures. as fresh a staff had staff nurse nurse, She to post-recovery further testified had j u s t had determined post-CABG p a t i e n t n o t w o r k e d i n an I C U a for to testified the the that surgery A d d i t i o n a l l y , she p r o v i d i n g hands-on complete c a r e . she as i n immediate n e v e r s e e n a CABG p a t i e n t who implement p r e v e n t i v e that care cardiac purpose further testified s e t t i n g as a b e d s i d e n u r s e of that since 1992. Jones testified that she had reviewed Critopoulos's m e d i c a l records, p a r t i c u l a r l y h i s v i t a l s i g n s , d u r i n g h i s time i n the c a r d i a c - r e c o v e r y he was stable enough t e s t i f i e d t h a t she had dedicated that, u n i t and to turn. t h a t she had On determined cross-examination, work, she had not gone t o t h e surgery; cardiac-recovery u n i t f o r the purpose of p r o v i d i n g hands-on p r e v e n t i v e care a p a t i e n t ; t h a t she had o n l y gone t o t h e c a r d i a c - r e c o v e r y as e d u c a t i o n a l and she n e v e r w o r k e d as a s t a f f n u r s e i n a u n i t to p a t i e n t s coming d i r e c t l y out of c a r d i a c i n her that s u p p o r t f o r t h e n u r s e s who t h a t , a t Duke, t h e p r e v e n t i o n 13 for unit worked i n the u n i t ; of pressure sores in cardiac 1090946 recovery was done b y t h e n u r s i n g had developed. she does n o t p r o v i d e a staff nurse. Jones t e s t i f i e d care Also, s t a f f b a s e d on p r o t o c o l s she t h a t , excluding to fresh postoperative on c r o s s - e x a m i n a t i o n , wound p a t i e n t s as the following occurred: "[DEFENSE COUNSEL:] Right. And you don't c o n s i d e r y o u r s e l f t o be an e x p e r t on n u r s i n g care when i t comes t o e v a l u a t i n g t h e c a r d i a c s t a t u s o f a p o s t - C A B G p a t i e n t i n r e c o v e r y , do y o u ? "[JONES:] I w o u l d be a b l e t o e v a l u a t e their b l o o d p r e s s u r e , t h e i r mean a r t e r i a l p r e s s u r e . So some p i e c e s of i t , c e r t a i n l y , I can. But the o v e r a l l , no. "[DEFENSE COUNSEL:] I a s k e d y o u on page 120 o f y o u r d e p o s i t i o n : 'You w o u l d n o t c o n s i d e r y o u r s e l f t o be an e x p e r t on n u r s i n g when i t comes t o e v a l u a t i n g c a r d i a c s t a t u s o f a post-CABG p a t i e n t i n r e c o v e r y ; i s t h a t c o r r e c t ? ' A n d what was y o u r a n s w e r ? "[JONES:] that That i t i s c o r r e c t . "[DEFENSE COUNSEL:] right? "[JONES:] An u n q u a l i f i e d c o r r e c t ; i s Correct. "[DEFENSE COUNSEL:] A n d y o u ' r e n o t q u a l i f i e d t o p r o v i d e continuous hands-on care t o a p a t i e n t i n c a r d i a c r e c o v e r y , a r e you? "[JONES:] N o t w i t h o u t a d d i t i o n a l t r a i n i n g , no. "[DEFENSE COUNSEL:] q u a l i f i e d , a r e you? Okay. 14 care, A n d y o u ' r e n o t ACLS 1090946 "[JONES:] No. "[DEFENSE COUNSEL:] "[JONES:] believe. What i s A C L S ? Advanced cardiac life support, I "[DEFENSE COUNSEL:] A l l r i g h t . A n d t h a t w o u l d be s o m e t h i n g t h a t any n u r s e w o r k i n g i n c a r d i a c r e c o v e r y w o u l d have t o b e ? "[JONES:] I would c e r t a i n l y hope s o . "[DEFENSE COUNSEL:] A l l r i g h t . And s o , you w o u l d n o t be a b l e t o p r o v i d e a d v a n c e d c a r d i a c l i f e s u p p o r t t o a p a t i e n t i n need i n c a r d i a c recovery, would you? "[JONES:] Correct. "[DEFENSE COUNSEL:] Now, i n t h i s c a s e , we have h e a r d t e r m s s u c h as c a r d i a c o u t p u t , c a r d i a c i n d e x , o t h e r t e r m s t h a t w i l l be d i s c u s s e d a n d a p p l i c a b l e t o p a t i e n t s coming o u t o f c a r d i a c s u r g e r y , c o r r e c t ? "[JONES:] I'm s o r r y . I h a v e n ' t h e a r d about c a r d i a c index or output. you "[DEFENSE COUNSEL:] A l l r i g h t . reviewed the v i t a l signs? "[JONES:] testimony W e l l , you s a i d I did. "[DEFENSE COUNSEL:] Okay. L e t me j u s t -- l e t ' s l o o k a t some o f t h e s e . And I b e l i e v e t h i s , i n f a c t , may be t h e f i r s t page o r f i r s t s e t o f v i t a l s i g n s when Mr. C r i t o p o u l o s came o u t o f s u r g e r y . See a t t h e b o t t o m i t ' s A p r i l 1 1 t h , w h i c h was t h e d a y he came o u t o f s u r g e r y , c o r r e c t ? "[JONES:] Correct. 15 1090946 II "[DEFENSE COUNSEL:] And O s t r i e c h m e r e r was h i s n u r s e ; i s t h a t "[JONES:] Nurse right? Janel Yes. "[DEFENSE COUNSEL:] Okay. A n d J a n e l w o u l d h a v e entered these e n t r i e s presumably, c o r r e c t ? "[JONES:] P r e s u m a b l y , yeah. "[DEFENSE COUNSEL:] Okay. S o , coming o u t o f s u r g e r y , Mr. C r i t o p o u l o s h a d some b l o o d pressures taken. One s u c h p r e s s u r e was an MAP. What i s t h a t ? "[JONES:] Mean a r t e r i a l pressure. "[DEFENSE COUNSEL:] Do y o u know what t h e n u r s e s were l o o k i n g f o r i n a number w i t h r e g a r d t o t h e MAP w i t h Mr. C r i t o p o u l o s ? "[JONES:] S p e c i f i c t o Mr. C r i t o p o u l o s , no. "[DEFENSE COUNSEL:] Okay. Do y o u know how t h a t number, MAP h e r e , w h i c h i s 82, w o u l d t h a t be an appropriate mean arterial pressure f o r Mr. C r i t o p o u l o s coming o u t o f s u r g e r y ? "[JONES:] I t was my a s s u m p t i o n i t was, g i v e n t h a t h i s b l o o d p r e s s u r e was i n t h e n o r m a l r a n g e . "[DEFENSE COUNSEL:] A l lright. So, s a y i n g h i s p r e s s u r e was i n t h e n o r m a l r a n g e , "[JONES:] you're right? Y e s , i t ' s 126 o v e r -- i s t h a t 60? "[DEFENSE COUNSEL:] A n d s o , a n d t h e MAP o f 82 was a p p r o p r i a t e f o r h i m ? "[JONES:] As b e s t I u n d e r s t o o d , y e s . 16 1090946 "[DEFENSE COUNSEL:] A n d what a b o u t t h e p u l s e , 112? "[JONES:] A l i t t l e h i g h . I didn't anticipate t h a t was t o o h i g h c o m i n g o u t o f s u r g e r y . "[DEFENSE COUNSEL:] A l l r i g h t . A n d l e t ' s l o o k at the medicated d r i p s . What m e d i c a t e d d r i p s was Mr. C r i t o p o u l o s on a t t h e t i m e ? "[JONES:] He's on some neosynephrine and n i t r o g l y c e r i n . "[DEFENSE COUNSEL:] c a l c u l a t e d t o do? And what epinephrine, are those "[JONES:] The f i r s t two, t h e e p i n e p h r i n e a n d neosynephrine, a r e what's c a l l e d v a s o a c t i v e drugs, which a r e m e d i c a t i o n s t h a t h e l p t o keep t h e b l o o d p r e s s u r e i n t h e normal range. And n i t r o g l y c e r i n i s -- t h e b e s t way t o d e s c r i b e i t i s f o r y o u r h e a r t . "[DEFENSE COUNSEL:] A n d t h o s e a r e m e d i c a t i o n s t h a t a n u r s e i n c a r d i a c r e c o v e r y w o u l d p o s s i b l y have t o a d j u s t f r o m t i m e t o t i m e d e p e n d i n g on t h e c h a n g e s in blood pressure of the patient? "[JONES:] Yes. "[DEFENSE COUNSEL:] Okay. A r e y o u q u a l i f i e d t o make t h o s e k i n d o f a d j u s t m e n t s i n those k i n d o f medications f o r a patient? "[JONES:] F o r p o s t - s u r g i c a l , no, I w o u l d n ' t be qualified f o r that. "[DEFENSE COUNSEL:] Okay. A l l right. And under hemodynamic monitoring, we have cardiac o u t p u t , 4.1 e x c u s e me, 4.8; i s t h a t c o r r e c t ? "[JONES:] Yes. 17 1090946 "[DEFENSE COUNSEL:] A l l r i g h t . Do y o u know i f t h a t i s an a p p r o p r i a t e number f o r Mr. C r i t o p o u l o s coming out o f s u r g e r y ? "[JONES:] I do n o t . "[DEFENSE COUNSEL:] That's not something that you m o n i t o r ? "[JONES:] No. "[DEFENSE COUNSEL:] A l l r i g h t . What a b o u t t h e c a r d i a c i n d e x o f 2.2, do y o u know i f t h a t ' s an a p p r o p r i a t e number f o r Mr. C r i t o p o u l o s c o m i n g o u t o f surgery? "[JONES:] I do n o t . I t ' s n o t s o m e t h i n g I w o u l d monitor. "[DEFENSE COUNSEL:] What i s SVR? Okay. What a b o u t t h e SVR? "[JONES:] Oh, g o s h . T h a t ' s m a k i n g me go b a c k . I d o n ' t remember enough t o be a b l e t o e x p l a i n i t . "[DEFENSE COUNSEL:] Okay. How a b o u t s y s t e m i c vascular resistance? Does t h a t s o u n d f a m i l i a r ? "[JONES:] C o u l d be. "[DEFENSE COUNSEL:] y o u know w h e t h e r t h a t ' s Mr. C r i t o p o u l o s ? "[JONES:] "[DEFENSE what t h a t i s ? "[JONES:] Okay. And i t i s 1206. Do an a p p r o p r i a t e number f o r I do n o t . COUNSEL:] Okay. CVP, What's that? Yes. "[DEFENSE COUNSEL:] 18 do y o u know 1090946 "[JONES:] C e n t r a l venous p r e s s u r e . "[DEFENSE COUNSEL:] "[JONES:] A n d i t i s one. Uh-huh. "[DEFENSE COUNSEL:] Do y o u know i f t h a t ' s an a p p r o p r i a t e number f o r Mr. C r i t o p o u l o s ? "[JONES:] Seems a l i t t l e l o w , b u t I d o n ' t know what t h e y were s h o o t i n g f o r , f o r h i m . "[DEFENSE COUNSEL:] Okay. S o , a l l o f t h e s e t h i n g s t h a t we've t a l k e d a b o u t , b l o o d p r e s s u r e s , t h e c a r d i a c o u t p u t , c a r d i a c i n d e x , SVR, CVP, m e d i c a t e d d r i p s , a l l o f t h o s e t h i n g s have t o be m o n i t o r e d b y the nurses working i n c a r d i a c recovery, c o r r e c t ? "[JONES:] Yes. "[DEFENSE COUNSEL:] Okay. v e r y c l o s e l y , aren't they? "[JONES:] They a r e . And t h e y ' r e watched They s h o u l d be. "[DEFENSE COUNSEL:] B e c a u s e most o f t h e t i m e , t h e n u r s e s w o r k one t o one w i t h t h e p a t i e n t o r p o s s i b l y one t o t w o ; i s t h a t r i g h t ? "[JONES:] surgery, yes. I t ' s very typical right after "[DEFENSE COUNSEL:] Right. Okay. But t h i s k i n d o f m o n i t o r i n g i s n o t s o m e t h i n g t h a t y o u do? "[JONES:] N o t a l l o f i t . As I m e n t i o n e d , I do m o n i t o r and l o o k a t b l o o d p r e s s u r e and p u l s e . "[DEFENSE COUNSEL:] "[JONES:] Okay. And oxygen 19 saturation. 1090946 "[DEFENSE COUNSEL:] d i s c u s s e d , y o u do n o t ? "[JONES:] But the other we N o t t y p i c a l l y , no. "[DEFENSE COUNSEL:] Now, do m o n i t o r p a t i e n t s on a b a l l o o n pump? "[JONES:] items you typically No. "[DEFENSE COUNSEL:] A n d as a d i r e c t care p r o v i d e r , you've n e v e r had t o w e i g h t h e competing risks o f r e p o s i t i o n i n g a post-CABG p a t i e n t i n r e c o v e r y , h a v e you? "[JONES:] P o s t - C A B G p e r s o n , no. "[DEFENSE COUNSEL:] A l l right. Now, i f t o m o r r o w a t Duke U n i v e r s i t y H o s p i t a l y o u were t o l d to report t o the cardiac recovery u n i t of the h o s p i t a l and b e g i n c a r i n g f o r p a t i e n t s i n c a r d i a c r e c o v e r y on a d a y - t o - d a y b a s i s , y o u w o u l d n ' t f e e l c o m f o r t a b l e i n d o i n g t h a t , w o u l d you? "[JONES:] c a r e , no. No. Not i n p r o v i d i n g a l l of t h e i r "[DEFENSE COUNSEL:] Now, y o u ' v e i n d i c a t e d t h a t s o m e t i m e s i t m i g h t n o t be a p p r o p r i a t e t o move a p a t i e n t i n cardiac recovery. I t h i n k you a l l u d e d t o t h a t e a r l i e r , d i d n ' t you? "[JONES:] Yes. "[DEFENSE COUNSEL:] Okay. And I t h i n k you've i n d i c a t e d t h a t , i n y o u r o p i n i o n , b a s e d on t h e r e v i e w o f Mr. C r i t o p o u l o s ' s v i t a l s i g n s , some o f w h i c h were i n c l u d e d on t h e document we j u s t l o o k e d a t , t h a t you, N u r s e J o n e s , w o u l d h a v e no p r o b l e m i n t u r n i n g Mr. C r i t o p o u l o s , c o r r e c t ? "[JONES:] Correct. 20 1090946 "[DEFENSE COUNSEL:] basis, correct? "[JONES:] A n d t h a t -- on a t w o - h o u r Yes. "[DEFENSE COUNSEL:] A n d t h a t was t h e w h o l e t i m e t h a t he was i n r e c o v e r y ? "[JONES:] Yes. "[DEFENSE COUNSEL:] A l l r i g h t . A n d y o u came t o t h a t c o n c l u s i o n b y , as y o u s a y , r e v i e w i n g h i s v i t a l signs, right? the "[JONES:] R e v i e w i n g t h e v i t a l s i g n s a n d some o f c a r e t h a t was p r o v i d e d , y e s . "[DEFENSE COUNSEL:] R i g h t . And you t h i n k i t ' s i m p o r t a n t t o r e v i e w t h e v i t a l s i g n s a n d [be] a b l e t o come t o t h a t c o n c l u s i o n t h a t he c o u l d be t u r n e d , correct? "[JONES:] Sure. "[DEFENSE COUNSEL:] A l l r i g h t . And you w o u l d certainly expect any nurse to review Mr. Critopoulos's v i t a l signs before undertaking the task of t u r n i n g him, c o r r e c t ? "[JONES:] Yes. "[DEFENSE COUNSEL:] A n d i t w o u l d c e r t a i n l y n o t be w i t h i n t h e a p p r o p r i a t e s t a n d a r d o f c a r e t o t u r n him w i t h o u t e v a l u a t i n g t h o s e v i t a l s i g n s , w o u l d i t ? "[JONES:] Correct." Regarding the q u a l i f i c a t i o n s has o f an e x p e r t stated: 21 witness, this Court 1090946 " I n M e d l i n v. C r o s b y , 583 So. 2d 1290 (Ala. 1991), t h i s Court e s t a b l i s h e d a framework under § 6-5-548[, A l a . Code 1975,] f o r d e t e r m i n i n g w h e t h e r an e x p e r t w i t n e s s i s q u a l i f i e d t o t e s t i f y i n a medical m a l p r a c t i c e case. Pursuant to M e d l i n , the t r i a l c o u r t must a n s w e r t h e f o l l o w i n g questions before determining that an expert witness is ' s i m i l a r l y s i t u a t e d ' as t o t h e d e f e n d a n t : " ' ( 1 ) What i s t h e s t a n d a r d o f c a r e a l l e g e d t o have b r e a c h e d ? ( 2 ) I s t h e d e f e n d a n t " h e a l t h care p r o v i d e r " a s p e c i a l i s t i n the d i s c i p l i n e or s c h o o l of p r a c t i c e of the standard of care that the court has p r e v i o u s l y d e t e r m i n e d i s a l l e g e d t o have been b r e a c h e d ? ( 3 ) Does t h e p r o f f e r e d e x p e r t w i t n e s s q u a l i f y as a "similarly s i t u a t e d h e a l t h care p r o v i d e r " under the s u b s e c t i o n determined i n the second step t o apply?' "583 So. HealthTrust, 2d a t 1293." I n c . v. C a n t r e l l , 689 So. 2d 822, 826 (Ala. 1997). In t h i s case, the defense p r e s e n t e d evidence t h e f a c t t h a t C r i t o p o u l o s was CABG s u r g e r y . that, during The the in critical establishing condition after defense a l s o presented evidence time was he in recovery, indicating Critopoulos i s s u e s w i t h p o s t o p e r a t i v e b l e e d i n g and h i g h p o t a s s i u m The on defense presented a ventilator recovery unit and much as f u r t h e r testimony of the time he in t o h i s r e a c t i o n when he 22 the was had levels. that Critopoulos was the was cardiacturned or 1090946 repositioned. The d e f e n s e also presented testimony regarding the p o t e n t i a l r i s k s of t u r n i n g or r e p o s i t i o n i n g C r i t o p o u l o s a t c e r t a i n times. F i n a l l y , the defense presented testimony t h a t C r i t o p o u l o s was a t r i s k o f d e a t h d u r i n g some o f t i m e he was i n the cardiac-recovery unit the d i f f e r e n t The risks first and t h a t n u r s e s f o r such a c r i t i c a l l y had t o p r i o r i t i z e ill patient. q u e s t i o n we must a n s w e r t o d e t e r m i n e Jones i s s i m i l a r l y situated to the i n d i v i d u a l whether defendants i s what i s t h e s t a n d a r d o f c a r e a l l e g e d t o have b e e n b r e a c h e d i n this case. whether measures I t i s true Fleming, to that Rushing, prevent the this and case addresses Ostriechmerer development of the issue took pressure proper ulcers. However, t h e o v e r w h e l m i n g i s s u e i s w h e t h e r t h e m e a s u r e s t a k e n by t h e n u r s e s i n t h i s c a s e c o m p o r t e d w i t h t h e s t a n d a r d o f c a r e f o r a post-CABG p a t i e n t l i k e C r i t o p o u l o s . I n Dempsey v. P h e l p s , 700 So. 2d 1340 Dempsey, an o r t h o p a e d i c s u r g e o n , p e r f o r m e d ( A l a . 1997), Dr. surgery to correct a c l u b f o o t on t h e P h e l p s e s ' s o n . A f t e r t h e s u r g e r y , p o r t i o n s o f t h e s o n ' s f o o t h a d t o be a m p u t a t e d . On a p p e a l , Dr. Dempsey a r g u e d t h a t Dr. F r a n k C a t i n e l l a , t h e P h e l p s e s ' e x p e r t w i t n e s s , was n o t a " s i m i l a r l y s i t u a t e d h e a l t h c a r e p r o v i d e r " a n d t h a t 23 1090946 the trial regarding of care court erred the standard when i t allowed of care. Catinella With regard to t e s t i f y to the standard t h a t was a l l e g e d t o have b e e n b r e a c h e d i n t h a t t h i s Court case, stated: "As t o q u e s t i o n ( 1 ) , Dempsey m a i n t a i n s that the s t a n d a r d o f c a r e a l l e g e d t o be b r e a c h e d h e r e i s t h a t o f an o r t h o p e d i c s u r g e o n p r o v i d i n g c a r e f o r a c h i l d a f t e r clubfoot surgery. Dempsey a r g u e s t h a t Dr. C a t i n e l l a , who i s a b o a r d - c e r t i f i e d c a r d i o v a s c u l a r t h o r a c i c s u r g e o n , was n o t q u a l i f i e d t o t e s t i f y as t o t h i s standard of care. However, we a g r e e w i t h t h e t r i a l c o u r t t h a t t h i s case concerned 'a v a s c u l a r m a t t e r , n o t an o r t h o p e d i c m a t t e r ' -- i n o t h e r w o r d s , t h a t t h e P h e l p s e s ' c l a i m s r e g a r d e d Dr. Dempsey's alleged f a i l u r e to properly t r e a t the c h i l d ' s foot d u r i n g t h e p o s t - s u r g e r y phase f o r t h e c i r c u l a t o r y and v a s c u l a r problems t h a t developed a f t e r the s u r g e r y a n d c a s t i n g o f t h e f o o t . These p r o b l e m s a r e n o t i s o l a t e d t o t h i s t y p e o f s u r g e r y , a n d t h e y do n o t c o n c e r n t h e o r t h o p e d i c s u r g e r y p e r f o r m e d b y Dr. Dempsey; t h e y c o n c e r n t h e t r e a t m e n t o f t h e i n f e c t i o n a f t e r the surgery that r e s u l t e d i n the l o s s of h i s foot. The s t a n d a r d o f c a r e a l l e g e d l y b r e a c h e d was that of a h e a l t h care p r o v i d e r t r e a t i n g a p a t i e n t f o r p o s t - s u r g i c a l v a s c u l a r problems and i n f e c t i o n , which are not s p e c i f i c t o orthopedic surgery." 700 So. 2d a t 1344. Unlike the s i t u a t i o n i n Phelps, nurses in Critopoulos this case took from d e v e l o p i n g the q u e s t i o n whether the proper pressure measures to prevent ulcers i s specifically r e l a t e d t o t h e i r d u t i e s i n c a r i n g f o r C r i t o p o u l o s as n u r s e s i n the cardiac-recovery unit. The o v e r r i d i n g q u e s t i o n 24 i n this 1090946 case i s whether, in light of Critopoulos's condition as a post-CABG p a t i e n t , the n u r s e s took p r o p e r measures t o p r e v e n t the development standard of pressure ulcers. o f c a r e would be that T h e r e f o r e , the proper o f a c a r d i a c - r e c o v e r y nurse t r e a t i n g post-CABG p a t i e n t s t o p r e v e n t p r e s s u r e u l c e r s . The second q u e s t i o n we must health-care provider a specialist the Court has determined ask i s i s the defendant i n the s c h o o l of i s alleged t o have b e e n practice breached. With r e g a r d t o t h i s q u e s t i o n , the defense d i d not p r e s e n t any e v i d e n c e i n d i c a t i n g t h a t R u s h i n g , F l e m i n g , and O s t r i e c h m e r e r were b o a r d - c e r t i f i e d answer the third specialists. question: T h e r e f o r e , we whether Jones qualifies " s i m i l a r l y s i t u a t e d h e a l t h care p r o v i d e r " under § Ala. Code 1 9 7 5 . must next as a 6-5-548(b), 2 S e c t i o n 6-5-548(b), provides, pertinent part: "[A] ' s i m i l a r l y s i t u a t e d h e a l t h care p r o v i d e r ' i s one who meets a l l o f t h e f o l l o w i n g q u a l i f i c a t i o n s : S e c t i o n s 6-5-548(c) and ( e ) , A l a . Code 1975, include p r o v i s i o n s f o r cases i n which the defendant h e a l t h - c a r e p r o v i d e r i s c e r t i f i e d by an A m e r i c a n b o a r d as b e i n g a specialist. However, none o f t h e p a r t i e s c o n t e n d t h a t t h e individual defendants in this case were certified as specialists. T h e r e f o r e , t h o s e p r o v i s i o n s o f § 6-5-548, A l a . Code 1975, do n o t a p p l y . 2 25 1090946 " ( 1 ) I s l i c e n s e d by t h e a p p r o p r i a t e r e g u l a t o r y b o a r d o r a g e n c y o f t h i s o r some other state. " ( 2 ) I s t r a i n e d and e x p e r i e n c e d i n t h e same d i s c i p l i n e o r s c h o o l o f p r a c t i c e . "(3) Has practiced i n the same d i s c i p l i n e or school o f p r a c t i c e during the year p r e c e d i n g the date t h a t the a l l e g e d breach o f the standard o f care occurred." (Emphasis added.) F u r t h e r , t h i s C o u r t has h e l d : "The M e d i c a l L i a b i l i t y A c t does n o t r e q u i r e t h a t the defendant h e a l t h c a r e p r o v i d e r and t h e e x p e r t w i t n e s s have i d e n t i c a l training, experience, or t y p e s o f p r a c t i c e , o r e v e n t h e same s p e c i a l t i e s . To be ' s i m i l a r l y s i t u a t e d , ' an e x p e r t w i t n e s s must be a b l e t o t e s t i f y about t h e s t a n d a r d o f care a l l e g e d t o have b e e n b r e a c h e d i n the procedure that i s i n v o l v e d i n the case." R o d g e r s v . Adams, 657 So. 2d 838, 842 ( A l a . 1 9 9 5 ) . In this c a s e , J o n e s was l i c e n s e d t o p r a c t i c e as a n u r s e i n North Carolina. T h e r e f o r e , she s a t i s f i e d t h e r e q u i r e m e n t s of § 6-5-548(b)(1), A l a . Code 1975. The next experienced question i s whether i n t h e same d i s c i p l i n e were R u s h i n g , Fleming, presented and pressure-ulcer evidence indicating 26 was trained and o r s c h o o l o f p r a c t i c e as and O s t r i e c h m e r e r . J o n e s was t r a i n e d a n d e x p e r i e n c e d management Jones I t i s clear that i n t h e a r e a o f wound-care prevention. that Jones Critopoulos was generally 1090946 q u a l i f i e d t o t e s t i f y as t o t h e s t a n d a r d ulcer prevention. that However, h e r t e s t i m o n y c l e a r l y she was n o t t r a i n e d a n d e x p e r i e n c e d w i t h prevention recovery risks that o f care f o r pressure- of pressure unit, particularly involving fresh she h a d n e v e r preventive ulcers m e a s u r e s ; t h a t she h a d p r o v i d e d care unit. in a to the cardiac- the concerns post-CABG p a t i e n t s . Jones and/or testified nurses provided pressure- f o r postoperative Also, hands-on t r e a t m e n t p a t i e n t s o n l y f o r wound c a r e ; a n d t h a t , a t Duke, t h e c a r d i a c - r e c o v e r y recovery regarding regard s e e n an i m m e d i a t e p o s t - C A B G p a t i e n t f o r to f r e s h postoperative prevention f o r patients indicates patients ulcer- i n the cardiac- her testimony i n d i c a t e d that she was n o t f a m i l i a r w i t h t h e p r o p e r v a l u e s f o r many o f t h e d i f f e r e n t status components t h a t were m o n i t o r e d by t h e n u r s e s cardiac-recovery unit. wound-management specialist, same c l i n i c a l services s u c h as c h e c k i n g participating she Finally, Jones t e s t i f i e d she w o u l d p e r f o r m as d i d a r e g u l a r i n the that, as a some o f the cardiac-care nurse, v i t a l s i g n s , c o n d u c t i n g s k i n assessments, and i n w r i t i n g or reviewing care plans. However, a l s o t e s t i f i e d t h a t , w i t h o u t a d d i t i o n a l t r a i n i n g , she was 27 1090946 not q u a l i f i e d t o p r o v i d e continuous hands-on care t o a p o s t - CABG p a t i e n t i n a c a r d i a c - r e c o v e r y u n i t . Under qualify the unique facts as a " s i m i l a r l y of this situated d e f i n e d by § 6-5-548(b)(2), case, health Jones care A l a . Code 1975. d i d not p r o v i d e r " as C f . Jordan v. B r a n t l e y , 589 So. 2d 680 ( A l a . 1991) ( h o l d i n g t h a t , i n a c a s e i n v o l v i n g t h e m i s i d e n t i f i c a t i o n o f b o d i e s b y an e m e r g e n c y - r o o m nurse, the p l a i n t i f f ' s because expert she h a d n o t w o r k e d years b e f o r e the date Court not s i m i l a r l y i n a hospital of t r i a l n o t an e x p e r t i n e m e r g e n c y - r o o m This was during and had a d m i t t e d situated the three t h a t she was procedures). has p r e v i o u s l y h e l d t h a t even i f an expert witness i s not a s i m i l a r l y s i t u a t e d health-care provider, the e x p e r t can o f f e r t e s t i m o n y about t h e s t a n d a r d o f care a l l e g e d to have b e e n b r e a c h e d i f he o r she i s h i g h l y q u a l i f i e d . HealthTrust, 1992). supra; Critopoulos Dowdy v . L e w i s , 612 So. 2d 1149 has e s t a b l i s h e d t h a t Jones (Ala. i s highly q u a l i f i e d w i t h r e g a r d t o g e n e r a l wound-care t r e a t m e n t prevention of pressure ulcers. See and t h e However, he h a s n o t shown t h a t J o n e s was h i g h l y q u a l i f i e d w i t h r e g a r d t o t h e p r e v e n t i o n o f pressure u l c e r s i n p o s t - C A B G p a t i e n t s who a r e i n a c a r d i a c - 28 1090946 recovery this unit. Therefore, t h a t e x c e p t i o n does n o t a p p l y i n case. For these discretion Jones's reasons, trial court exceeded i t s when i t d e n i e d t h e d e f e n d a n t s ' m o t i o n t o e x c l u d e testimony. Rushing, Fleming, nursing the care came A l s o , the only evidence indicating that and O s t r i e c h m e r e r b r e a c h e d t h e s t a n d a r d o f from Jones. Therefore, the t r i a l court e r r e d when i t d i d n o t e n t e r a j u d g m e n t as a m a t t e r o f l a w i n favor of the i n d i v i d u a l liability defendants, i s premised defendants. on Because the l i a b i l i t y Springhill's of the individual i t i s a l s o e n t i t l e d t o a j u d g m e n t as a m a t t e r o f law i n i t s f a v o r . A c c o r d i n g l y , we r e v e r s e t h e t r i a l court's j u d g m e n t a n d remand t h e c a s e f o r t h e e n t r y o f a j u d g m e n t as a matter of law f o r the defendants. 3 REVERSED AND REMANDED. M a l o n e , C . J . , a n d S t u a r t , P a r k e r , a n d Shaw, J J . , c o n c u r . B a s e d on o u r d i s p o s i t i o n o f t h i s c a s e , we p r e t e r m i t d i s c u s s i o n o f t h e r e m a i n i n g i s s u e s r a i s e d by t h e defendants. 3 29