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Karkoutly v. Guerrero

Court of Appeals of Texas, Thirteenth District, Corpus Christi-Edinburg

December 14, 2017

AHMAD KARKOUTLY, M.D., Appellant,
v.
MARIA GUERRERO, INDIVIDUALLY AND AS REPRESENTATIVE OF THE ESTATE OF MARIA OTILIA ESTRADA, Appellee.

          On appeal from the 138th District Court of Cameron County, Texas.

          Before Justices Rodriguez, Benavides, and Longoria

          MEMORANDUM OPINION

          NELDA V. RODRIGUEZ Justice

         In this interlocutory appeal, appellant Ahmad Karkoutly, M.D. challenges the denial of his motion to dismiss the health care liability claim of appellee Maria Guerrero. We reverse and remand.

          I. Background

         Guerrero filed suit for medical negligence against two hospital entities and nine physicians, including Dr. Karkoutly. Guerrero's petition alleged that on October 9, 2013, her mother Maria Otilia Estrada was admitted to Valley Regional Medical Center, a hospital in Brownsville, Texas. She complained of abdominal pain, nausea, and vomiting, and had a history of colon ailments. Various defendants treated her for several weeks, including multiple surgeries. However, Estrada died, allegedly because the defendants' substandard care caused Estrada to suffer septic shock and respiratory failure.

         To support her claim against Dr. Karkoutly, Guerrero filed an expert report authored by David H. Miller, M.D. Guerrero did not file expert reports concerning any other defendant, and Dr. Karkoutly became the only defendant remaining in the case.

         Dr. Karkoutly filed a motion to dismiss Guerrero's claims, asserting that Dr. Miller's report did not satisfy the requirements of the Texas Medical Liability Act (TMLA). See Tex. Civ. Prac. & Rem. Code Ann. § 74.351 (West, Westlaw through 2017 1st C.S.). Dr. Karkoutly objected to multiple aspects of Dr. Miller's report, including the objection that is the subject of this appeal: conclusory statements and logical inconsistencies in Dr. Miller's opinions on causation. Following a hearing, the trial court denied Dr. Karkoutly's motion to dismiss. This interlocutory appeal followed.

         II. Causation

         By his sole issue on appeal, Dr. Karkoutly contends that Dr. Miller's report is fatally inadequate under the TMLA. In particular, Dr. Karkoutly asserts that the report inadequately addresses the causation element of Guerrero's health care liability claim, offering only a conclusory and internally inconsistent account of how Dr. Karkoutly's acts and omissions caused Estrada's demise.

         A. Dr. Miller's Report

         Dr. Miller began his report by summarizing Estrada's medical records. According to Dr. Miller's report, Estrada presented to the hospital with a history of diverticulitis-a condition of the colon-along with chronic "hypovolemia, " nausea, and vomiting. Estrada's initial screening revealed apparent signs of infection to the point of sepsis, which included an elevated heart rate, respiratory rate, and white blood cell count. Dr. Miller explained that upon her admission to the hospital, Estrada met the criteria for systemic inflammatory response syndrome or "SIRS, " which meant that she was already septic or in danger of developing severe sepsis.

         Estrada was diagnosed with a likely "stricture" in her colon, and on October 15, 2013, she underwent surgery to remove a portion of her colon, with an "ileostomy" (which Dr. Miller described as draining the colon using a tube) and "anastomosis" (which he described as reconnection of the remaining colon). Following her surgery, Estrada was admitted to the intensive care unit under the care of Dr. Karkoutly, who diagnosed her with SIRS. Dr. Karkoutly treated her with antibiotics and noted her continuing signs of sepsis, which worsened in the following days.

         As we read his report, Dr. Miller discussed three potential causes of Estrada's infection. In his opinion, the two "likely" causes of her infection were a rupture of the colon or the failure of the surgical reconnection of her colon following her initial operation. Another "possibl[e]" cause was the perforation of her colon during her pre-operative colonoscopy. Out of these three, Dr. Miller felt that it was "fairly clear from Dr. Karkoutly's daily charting that something" had gone wrong with the surgical reconnection of the colon-i.e., that the reconnection had failed and was leaking fecal matter into the surrounding tissue, causing infection. Beyond his statement that the source was ...


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