Complaint: Doggett v. Tift Regional Health System, Inc., et al
PLAINTIFF’S COMPLAINT FOR DAMAGES
Nature of This Action
1. This medical-malpractice action arises out of medical services negligently provided to 63-year-old Lillie Charlene Doggett (“Charlene Doggett” or “Charlene”) at Tift Regional Medical Center, in Tifton, Georgia (“Tift”), on February 20-24, 2020, resulting in her wrongful death.
2. This action is brought by Charlene’s son, Jason Doggett (“Plaintiff” or “Jason”), individually and on behalf of her estate.
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3. As representative of Charlene’s estate, Plaintiff asserts a claim for harm Charlene suffered as a result of the alleged negligence.
4. Plaintiff also asserts a wrongful-death claim pursuant to OCGA Title 51, Chapter 4, on behalf of all wrongful-death beneficiaries.
5. Pursuant to OCGA § 9-11-9.1, the affidavits of Cardiologist Meldon C. Levy, MD; Cardiothoracic Surgeon Sotiris C. Stamou, MD, PhD; and Internist Jonathan M. Schwartz, MD, MBA, are attached as Exhibit 1-3, respectively. This Complaint incorporates the opinions and allegations in those affidavits.
6. As used here, the phrase “standard of care” means the degree of care and skill ordinarily employed by the medical profession generally under similar conditions and like circumstances as pertained to Defendants’ conduct here.
7. This Complaint relies largely on uncontroversial medical principles and facts.
8. This is a straightforward case:
a. Charlene Doggett, an otherwise healthy 63-year-old mother and grandmother, came to the Tift emergency room (“ER” or “ED”) with severe chest pain, and had a heart attack at the hospital.
b. Even though he found that Charlene’s right coronary artery (“RCA”) was completely blocked, Cardiologist Paul Murray failed to refer her to a hospital, unlike Tift, with the capability to clear or bypass the blockage.
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c. After being prematurely cleared by Cardiologist Jonathan Tronolone without treatment or further investigation, Charlene went home, only to return to the ER the next morning with a second, major heart attack.
d. Dr. Murray then again failed to refer Charlene to another hospital. Despite overwhelming evidence, he failed even to diagnose this second heart attack.
e. Instead, even though Tift lacked both the capability and a plan to provide Charlene definitive care, Internist Cynthia Phillips admitted her to Tift, where she died gradually and painfully from an untreated heart attack.
Parties, Jurisdiction, and Venue1
9. Plaintiff Jason Doggett is a citizen of Georgia.
10. Defendant Paul Michael Murray, MD, is a citizen of Georgia. He may be served with process at his residence, 312 26th Street W., Tifton, GA 31794 (Tift County). Dr. Murray has been properly served with this Complaint.
11. Dr. Murray is subject to the personal jurisdiction of this Court.
OCGA §§ 14-2-510 and 14-3-510 provide identical venue provisions for regular business corporations and for nonprofit corporations:
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“Each domestic corporation and each foreign corporation authorized to transact business in this “Each state domestic shall be corporation deemed to and reside each and foreign to be corporation subject to venue authorized as follows: to transact (1) In civil business in this state shall be deemed to reside and to be subject to venue as follows: (1) In civil proceedings generally, in the county of this state where the corporation maintains its registered office…. (3) In actions for damages because of torts, wrong, or injury done, in the county where the cause of action originated, if the corporation has an office and transacts business in that county; (4) In actions for damages because of torts, wrong, or injury done, in the county where the cause of action originated.”
These same venue provisions apply to Professional Corporations, because PCs are organized under the general “Business Corporation” provisions of the Georgia Code. See OCGA § 14-73. These venue provisions also apply to Limited Liability Companies, see OCGA § 14-111108, and to foreign limited liability partnerships, see OCGA § 14-8-46.
OCGA § 9-10-31 provides that, “joint tort-feasors, obligors, or promisors, or joint contractors or copartners, residing in different counties, may be subject to an action as such in the same action in any county in which one or more of the defendants reside.”
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12. Dr. Murray is subject to venue in this Court because he is a resident of Tift County, and because one of his co-defendants is subject to venue here.
13. At all times relevant to this Complaint, Dr. Murray acted as an employee or other agent of one or more of the following Defendants: Southwell Inc., Tift Regional Medical Center, Inc., Tift Regional Health System, Inc., and Tift Regional Medical Center Foundation, Inc. (together, “Southwell Defendants”).
14. Defendant Southwell Inc. (“Southwell”) is a Georgia nonprofit corporation. Registered Agent: Karen H. Summerlin. Physical address and principal office: 901 East 18th Street, Tifton, GA, 31794 (Tift County). Southwell has been properly served with this Complaint.
15. Southwell is subject to the personal jurisdiction of this Court.
16. Southwell is subject to venue in this Court because Southwell maintains its registered office in Tift County; because the cause of action originated in, and Southwell has an office and transacts business in, Tift County; and because one of Southwell’s co-defendants is subject to venue here.
17. At all relevant times, Southwell was the employer or other principal of Defendant Paul M. Murray and/or Defendant Cynthia L. Phillips. If another entity was his or her employer or other principal during those times, that entity is hereby on notice that, but for a mistake concerning the identity of the proper party, this action would have been brought against that entity.
18. Herein, “Southwell Defendants” refers collectively to: Southwell Inc., Tift Regional Medical Center, Inc., Tift Regional Health System, Inc., and Tift Regional Medical Center Foundation, Inc.
19. Defendant Tift Regional Medical Center, Inc. (“TRMC”) is a Georgia nonprofit corporation. Registered Agent: Karen Summerlin. Physical address and principal office: 901 East 18th Street, Tifton, GA, 31794 (Tift County). TRMC has been properly served with this Complaint.
20. TRMC is subject to the personal jurisdiction of this Court.
21. TRMC is subject to venue in this Court because TRMC maintains its registered office in Tift County; because the cause of action originated in, and
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TRMC has an office and transacts business in, Tift County; and because one of TRMC’s co-defendants is subject to venue here.
22. At all relevant times, TRMC was the employer or other principal of Defendant Paul M. Murray and/or Defendant Cynthia L. Phillips. If another entity was his or her employer or other principal during those times, that entity is hereby on notice that, but for a mistake concerning the identity of the proper party, this action would have been brought against that entity.
23. Defendant Tift Regional Health System, Inc. (“TRHS”) is a Georgia nonprofit corporation. Registered Agent: Karen Summerlin. Physical address and principal office: 901 East 18th Street, Tifton, GA, 31794 (Tift County). TRHS has been properly served with this Complaint.
24. TRHS is subject to the personal jurisdiction of this Court.
25. TRHS is subject to venue in this Court because TRHS maintains its registered office in Tift County; because the cause of action originated in, and TRHS has an office and transacts business in, Tift County; and because one of TRHS’s codefendants is subject to venue here.
26. At all relevant times, TRHS was the employer or other principal of Defendant Paul M. Murray and/or Defendant Cynthia L. Phillips. If another entity was his or her employer or other principal during those times, that entity is hereby on notice that, but for a mistake concerning the identity of the proper party, this action would have been brought against that entity.
27. Defendant Tift Regional Medical Center Foundation, Inc. (“TRMCF”) is a Georgia nonprofit corporation. Registered Agent: Tamara Branch. Physical Address: 901 East 18th Street, PO Box 2650, Tifton, GA, 31793 and/or 901 East 18th Street, Suite 203, Tifton, GA, 31794 (both Tift County). Principal office address: 2406 North Tift Avenue, Suite 203, Tifton, GA, 31794 (Tift County). TRMCF has been properly served with this Complaint.
28. TRMCF is subject to the personal jurisdiction of this Court.
29. TRMCF is subject to venue in this Court because TRMCF maintains its registered office in Tift County; because the cause of action originated in, and TRMCF has an office and transacts business in, Tift County; and because one of TRMCF’s co-defendants is subject to venue here.
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30. At all relevant times, TRMCF was the employer or other principal of Defendant Paul M. Murray and/or Defendant Cynthia L. Phillips. If another entity was his or her employer or other principal during those times, that entity is hereby on notice that, but for a mistake concerning the identity of the proper party, this action would have been brought against that entity.
31. Defendant Jonathan Warren Tronolone, MD, is a citizen of Georgia. He may be served with process at his residence, 1405 Red Fox Trail, Tifton, GA 31793 (Tift County). Dr. Tronolone has been properly served with this Complaint.
32. Dr. Tronolone is subject to the personal jurisdiction of this Court.
33. Dr. Tronolone is subject to venue in this Court because he is a resident of Tift County, and because one of his co-defendants is subject to venue here.
34. At all times relevant to this Complaint, Dr. Tronolone acted as an employee or other agent of one or both of these Defendants: Tronolone Cardiology LLC and Tronolone Medical, LLC.
35. Defendant Tronolone Cardiology LLC (“Tronolone Cardiology”) is a Georgia limited liability company. Registered Agent: Judy Shiflet. Physical Address and principal office: 1499 Kennedy Drive, Suite C, Tifton, GA 31794 (Tift County). Tronolone Cardiology has been properly served with this Complaint.
36. Tronolone Cardiology is subject to the personal jurisdiction of this Court.
37. Tronolone Cardiology is subject to venue in this Court because Tronolone Cardiology maintains its registered office in Tift County; because the cause of action originated in, and Tronolone Cardiology has an office and transacts business in, Tift County; and because one of Tronolone Cardiology’s codefendants is subject to venue here.
38. At all relevant times, Tronolone Cardiology was the employer or other principal of Defendant Jonathan W. Tronolone. If another entity was his employer or other principal during those times, that entity is hereby on notice that, but for a mistake concerning the identity of the proper party, this action would have been brought against that entity.
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39. Defendant Tronolone Medical, LLC (“Tronolone Medical”) is a Georgia limited liability company. Registered Agent: Jonathan W. Tronolone, MD. Physical Address and principal office: 1499 Kennedy Drive, Suite C, Tifton, GA 31794 (Tift County). Tronolone Medical has been properly served with this Complaint.
40. Tronolone Medical is subject to the personal jurisdiction of this Court.
41. Tronolone Medical is subject to venue in this Court because Tronolone Medical maintains its registered office in Tift County; because the cause of action originated in, and Tronolone Medical has an office and transacts business in, Tift County; and because one of Tronolone Medical’s co-defendants is subject to venue here.
42. At all relevant times, Tronolone Medical was the employer or other principal of Defendant Jonathan W. Tronolone. If another entity was his employer or other principal during those times, that entity is hereby on notice that, but for a mistake concerning the identity of the proper party, this action would have been brought against that entity.
43. Defendant Cynthia L. Phillips, DO, is a citizen of Florida. She may be served with process at her residence, 1684 Wingspan Way, Winter Springs, FL 32708-5927. Dr. Phillips has been properly served with this Complaint.
44. Dr. Phillips is subject to the personal jurisdiction of this Court.
45. Pursuant to OCGA § 9-10-93, Dr. Phillips is subject to venue in this Court because the cause of action arose in Tift County and because of one her codefendants is a Georgia resident subject to venue here.
46. At all times relevant to this Complaint, Dr. Phillips acted as an employee or other agent of one or more of the Southwell Defendants.
47. Here, “Southwell Defendants” refers collectively to Defendants Southwell, TRMC, TRHS, and TRMCF.
48. Defendants John/Jane Does 1-10 are those yet-unidentified natural persons and/or entities who may be liable, in whole or in part, for the damages alleged in this Complaint. Once served with process, John/Jane Does 1-10 are subject to the jurisdiction and venue of this Court.
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49. No Defendant has a defense to this action based on undue delay, whether based on the statute of limitations, the statute of repose, laches, or any other similar theory.
50. This Court has subject-matter jurisdiction over this case.
Medical Principles
Heart Anatomy
51. The heart is a hollow muscular organ about the size of a closed fist.
52. The purpose of the heart is to pump blood to the organs and tissues.
53. Blood carries oxygen and nutrients needed to sustain health and life. For that reason, the heart must pump a continuous supply of blood.
54. The heart has four chambers: two atria on top, and two ventricles at bottom.
55. The right side of the heart thus has two chambers: the right atrium and right ventricle. The left side has two chambers: the left atrium and left ventricle.
56. The cardiac cycle is the process by which blood flows through the chambers.
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57. After receiving oxygen-depleted blood from the veins, the right side of the heart pumps this blood out to the lungs for oxygenation. After the blood returns to the heart, the left side pumps the oxygenated blood to the body.
58. The heart’s wall is made up of three layers.
59. The myocardium is the muscular middle layer. It is made up of specialized cells called cardiomyocytes. Cardiomyocytes can stretch and shrink, producing the pumping action of the heart muscle.
60. Necrosis is the medical name for the death of cells in an organ or tissue.
Myocardial necrosis refers to the death of myocardial (heart-muscle) cells.
61. The death of cardiomyocytes damages the myocardium. Damage to the myocardium diminishes or even stops the heart’s ability to pump blood.
62. Myocardial infarction means death of the heart-muscle.
myo = muscle
cardium = heart
infarction = death
63. “Myocardial infarction” is a medical name for a heart attack.
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The Coronary Arteries
64. Like other organs of the body, the heart itself needs the oxygen and nutrients carried in the blood. The heart thus also needs a continuous supply of blood.
65. Arteries are the blood vessels that carry blood from the heart to the body. The coronary arteries are the arteries that carry blood to the heart itself.
66. There are two major branches of the coronary arteries: the right coronary artery (RCA) and the left coronary artery (LCA).
67. The RCA and LCA in turn branch off into smaller arteries. The LCA, for example, branches off into the left anterior descending artery (LAD).
68. Each branch in the network supplies the region of the heart where it runs.
69. The RCA supplies the right atrium, right ventricle, the bottom part of both ventricles, and the back of the interventricular septum (the interior wall separating the ventricles).
70. The posterior descending artery (PDA) runs along the back of the heart and down to its apex (the bottom cap).
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71. The PDA supplies the heart muscle of the bottom 1/3 of the interventricular septum. The PDA also supplies the posterior (back) wall of the left ventricle.
72. Coronary arterial dominance is defined by the major artery that gives rise to the PDA.
73. In a right-dominant heart, the RCA gives rise to the PDA. The RCA thus flows into the PDA.
74. In a right-dominant heart, a blockage in the RCA will cut off blood-flow not only to the regions of the heart supplied by the RCA itself, but also the region supplied further downstream by the PDA.
75. In a right-dominant heart, the RCA supplies about 40% of the myocardium. (In a codominant heart, about 35%, and in left-dominant heart, about 30%.)
76. About 85% of the population has right-dominant hearts.
Coronary Occlusions
77. A coronary occlusion is a blockage in a coronary blood vessel.
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78. A coronary occlusion occurs when a blood-clot forms in a coronary artery that has been narrowed by atherosclerosis.
79. Atherosclerosis is the progressive thickening and hardening of the inner walls of the arteries, caused by fatty deposits known as plaque. As it builds, plaque gradually narrows and hardens the arteries, reducing blood-flow.
80. Ischemia occurs when reduced blood-flow limits delivery of oxygen to the heart, or another organ or tissue.
81. The most common symptom of coronary ischemia is a chest pain known as angina.
Atherosclerosis à Occlusion à Ischemia à Angina
82. Angina is a common symptom of heart attacks.
83. A 100% (complete) occlusion in the mid-RCA is a potentially life-threatening medical emergency.
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84. When a patient has a 100% occlusion in the mid-RCA without collateral circulation, a cardiologist must promptly provide for definitive treatment for the occlusion, such as angioplasty or bypass surgery. If the hospital does not have the capability to provide definitive treatment, the cardiologist must promptly refer the patient to a hospital that does.
Collateral Circulation
85. Collateral circulation refers to the circulation of blood around a blocked artery through a network of tiny blood vessels known as collaterals.
86. Collaterals are not open under normal circumstances. When a blocked artery deprives a region of the heart of oxygen, collaterals in the region may gradually become enlarged and active over time.
87. If that occurs, collaterals may then provide channels for blood to flow around the blockage. These pathways allow blood-flow around the blockage, either to the same artery beyond the blockage, or to another artery, or both.
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88. Collaterals thus provide a natural bypass for blood-flow around an occlusion.
Myocardial Infarction (Heart Attack)
89. A heart attack is a medical emergency. Heart attacks are the leading cause of death worldwide. They are also the leading cause of death in the United States, affecting one in five men and one in six women.
90. Thanks to modern medical advances, the survival rate for those who suffer a heart attack is about 90%.
91. Myocardial infarction is a medical name for a heart attack. Doctors often refer to a heart attack as “myocardial infarction” or simply “an MI.”
Causes of Heart Attacks
92. Myocardial infarction occurs when an occlusion (blockage) in a coronary artery reduces blood-flow to the heart, causing a shortage of oxygen (ischemia) to the myocardial muscle downstream, and in turn damage to the muscle.
Occlusion à Ischemia à Infarction (Heart Attack)
93. Atherosclerosis is usually the root cause of myocardial infarction.
Atherosclerosis à Occlusion à Ischemia à Infarction (Heart Attack)
94. A heart attack typically occurs when plaque breaks off from the inner wall of an artery and further obstructs blood-flow. A blood clot may then form around the ruptured plaque, causing or worsening an occlusion.
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95. A “thrombus” is the medical name for a blood clot. Arterial thrombosis is the medical name for the formation of a blood clot inside an artery.
Atherosclerosis à Plaque Rupture à Thrombus à Occlusion à Ischemia à Infarction (Heart Attack)
96. Sudden stress often causes the thrombus leading to a heart attack. For example, when a person with advanced atherosclerosis sprints or lifts a heavy weight, the heart’s increased demand for oxygen may build pressure in the arteries. The pressure may then dislodge plaque and cause a blood clot.
NSTEMI and STEMI
97. There are two types of myocardial infarction (heart attacks):
• NSTEMI, which stands for Non-ST-elevation myocardial infarction.
• STEMI, which stands for ST-elevation myocardial infarction.
98. Doctors sometimes refer to an NSTEMI as a minor heart attack, and a STEMI as a major heart attack.
99. An NSTEMI typically occurs when there is a significant but partial occlusion in a coronary artery. The occlusion significantly reduces blood-flow.
100. In an NSTEMI, the limited supply of oxygen in the blood reaches the proximal (near) regions of the myocardium, but not the distal (far) regions. As a result, necrosis is typically limited to the distal regions.
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101. After having an NSTEMI, a patient is at a higher risk of a follow-up heart attack and of death.
102. A STEMI occurs when there is a total occlusion in a coronary artery. The occlusion blocks blood-flow.
103. In a STEMI, necrosis starts in the distal region of the heart muscle, and then creeps proximally towards the artery.
104. As a result, if untreated, a STEMI will bring death to the full thickness of the myocardium (heart-muscle).
105. During a STEMI, cardiac muscle starts to die within 20 minutes of the onset of symptoms. For this reason, medical students are taught that “time is muscle.”
106. When a patient is having a STEMI, a cardiologist must diagnose STEMI.
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107. When a patient presents at a hospital with a STEMI, a physician must promptly provide for definitive care for the STEMI. If the hospital does not have the capability to provide definitive care, the physician must refer and transfer the patient emergently to a hospital that does.
Inferior STEMI
108. An inferior STEMI is a STEMI in the bottom (inferior) wall of the heart. About half of all STEMIs are inferior STEMIs.
109. Because the RCA supplies blood to the inferior wall, an inferior STEMI often occurs when a patient’s heart has an occlusion in the RCA. An inferior STEMI is consistent with an occlusion in the mid-RCA.
110. An inferior STEMI is characterized by ST-segment elevation in the inferior leads (II, III, and aVF), and a reciprocal ST-segment depression in lead aVL.
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Heart-Attack Complications
111. The damage the heart suffers during a heart attack may produce serious complications, including arrhythmia, cardiac arrest, and heart failure. Each of these complications can be deadly.
112. An arrhythmia is an abnormal heartbeat, such as beating too quickly (tachycardia), beating too slowly (bradycardia), or beating irregularly. Arrhythmias can develop after a heart attack as a result of damage to the heart muscle or to the electrical system of the heart. Arrhythmias pose a risk of death during the first 24 hours after a heart attack.
113. Cardiac arrest occurs when the heart suddenly stops pumping blood because its electrical system malfunctions. Cardiac arrest can cause death quickly if proper steps such as CPR are not taken immediately.
114. Heart failure occurs when the heart cannot pump blood as well as it should.
The heart cannot keep up with its workload.
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TIMI Score and HEART Score
115. A TIMI Risk Score and a HEART Score each predicts the risks of heart attack and death in patients who arrive at the ER with chest pain.
116. A TIMI Risk Score predicts the chances the patient will experience one or more of these “heart events” within 14 days: (a) coronary ischemia requiring urgent revascularization, (b) a new or recurrent heart attack, (c) death.
117. Revascularization is a therapy that restores blood-flow to an ischemic part of the body. Revascularization of a coronary artery may be accomplished through
(a) angioplasty, (b) bypass surgery, or (c) clot-dissolving agents.
118. To calculate the TIMI Score, doctors give one point for each of the following seven factors:
• being older than 65
• using aspirin within the last week
• having at least two angina episodes in the last 24 hours
• having elevated serum cardiac biomarkers
• having an ST-segment deviation
• having known coronary artery disease
• having at least three risk factors for heart disease, including:
o high blood pressure (greater than 140/90) o smoking (being a current smoker) o low HDL cholesterol (less than 40 mg/dL) o diabetes o a family history of heart disease
119. A patient’s score predicts the patient’s risk of a “heart event.”
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120. Accordingly, a patient with TIMI Risk Score of 6 has a 40.9% or greater chance of experiencing at least one “heart event” within 14 days.
121. A HEART Score predicts the chances that a patient will experience one or more of these “heart events” within six weeks: (a) an angioplasty, (b) a heart attack, (b) bypass surgery, (d) death.
122. To calculate a HEART Score, doctors give 0 to 2 points for each of five factors, according to the following table.
123. A patient’s HEART Score predicts the patient’s risk of a “heart event.”
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124. Accordingly, a patient with a score of 7-10, has a 72.7% chance of experiencing an angioplasty, a heart attack, bypass surgery, and/or death, within six weeks.
125. A physician must accurately compute a patient’s TIMI Risk Score or HEART Score when the patient presents at the ED with chest pain. The physician must then provide for treatment suitable to the risks reflected in the score. If a patient has a HEART Score of 7 or more, for example, the physician must provide for an early invasive strategy, such as angioplasty or bypass surgery.
Electrocardiogram (EKG or ECG)
126. The heart’s pumping action is regulated by an electrical system that coordinates the contractions of the heart’s chambers.
127. An EKG is a medical test that reads and records the heart’s electrical signal as it travels through the heart. The test is also referred to as an ECG.
128. During the test, an EKG machine picks up the signal through electrode patches attached to the patient’s chest, arms, and legs.
129. The machine traces the signal as lines on a screen or on paper. This tracing is also called an EKG or ECG.
130. An EKG thus graphs the heart’s electrical signal as it travels through the heart causing the heart’s chambers to contract and pump blood.
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131. An EKG consists of waves, segments, and intervals.
132. These elements may be crucial in diagnosing heart problems.
133. Certain changes (deflections) in an EKG indicate myocardial infarction.
• ST-segment depressions and T-wave inversions indicate an NSTEMI.
• ST-segment elevations indicate a STEMI.
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134. The PR-segment serves as the baseline (also called a reference line or isoelectric line) of the EKG curve. Elevations and depressions are therefore measured against the level of the PR-segment.
135. A physician must take into account the patient’s EKGs in determining whether the patient is having a heart attack. When an EKG indicates a STEMI, a physician must promptly take steps to confirm or rule out MI.
Cardiac Biomarkers
136. Biomarkers are another essential tool in heart-attack diagnosis.
137. Biomarkers are proteins that the muscles release into the bloodstream when stressed, injured, or damaged.
138. The heart muscle releases cardiac biomarkers into the bloodstream during myocardial infarction.
139. The more damage the heart has suffered, the greater the concentration of cardiac biomarkers in the bloodstream.
140. Blood tests that measure cardiac biomarkers are thus important tools in identifying the occurrence and extent of a heart attack.
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141. Today, Troponin-I and Troponin-T are the preferred biomarkers for evaluating a patient with suspected acute myocardial infarction.
142. This table identifies the normal range for three biomarkers relevant here.
Cardiac Biomarker
Normal Range
Troponin-I 0.0 to 0.03 CK-MB 0.5 to 5.0 BNP 0 to 100
143. Levels above the normal range suggest recent or ongoing damage to the heart, including possible myocardial infarction.
144. A physician must take into account a patient’s cardiac biomarkers in confirming or ruling out NSTEMI or STEMI.
Echocardiogram
145. An echocardiogram is an ultrasound of the heart. An echocardiogram is often called an echo for short. During an echo, a technician scans the heart with a hand-held device called a transducer.
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146. The transducer sends high-frequency sound waves (ultrasound) that bounce off the heart’s structures. The waves produce moving images and sounds of the beating heart that are captured on a monitor.
147. Doctors use the images and sounds to detect heart damage and disease, including problems with the chambers and valves of the heart.
148. An echo provides key information about the heart, including its size and shape, its ability to pump blood, and the location and extent of any tissue damage.
149. An echo is a reliable tool for detecting motion abnormalities in the walls of the heart, including their ability to contract (in order to pump blood).
150. An echo is also specifically used to estimate the amount of blood pumped out of the left ventricle with each heartbeat (the LVEF), as explained below.
151. A transthoracic echocardiogram (TTE) is the standard and most-common echo.
In a TTE, the transducer is aimed at the heart through thorax (chest).
Myocardial Perfusion Test
152. A myocardial perfusion stress test is an imaging test that shows how well blood is flowing through the heart muscle during stress.
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153. For the test, the patient is injected with a tiny amount of a radioactive substance called a tracer. The tracer travels through the bloodstream to the heart muscle. A special camera that picks up radioactivity is then used to scan the heart and take images.
154. These images range from red (hot) for the portions of the heart that best absorb the tracer, to blue (cold) for the portions that absorb little or no tracer.
155. Because it has good blood-flow, healthy heart muscle absorbs the tracer. In contrast, because it has poor blood-flow, heart muscle that is damaged, or that is in danger of being damaged, absorbs little to no tracer.
156. The better the blood-flow, the closer the color will be to red. The poorer the blood-flow, the closer the color will be to blue.
157. Images are taken when the heart is in stress and at rest. A comparison of the two sets helps doctors identify areas of damage and poor blood-flow.
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158. Myocardial perfusion imaging identifies, more precisely than cardiac catheterization, the myocardial territories with a perfusion defect. 2
159. A myocardial perfusion test also assesses left-ventricular function more precisely than cardiac catheterization.
160. There are two myocardial perfusion stress tests: exercise and pharmacological.
In the exercise test, the patient walks or runs on a treadmill, to put stress on the heart. In the pharmacological test, the patient takes medicine that simulates the effects of exercise by raising heartrate or widening blood vessels.
Cardiac Catheterization and Coronary Angiography
161. Cardiac catheterization is a medical procedure in which a catheter is moved through a blood vessel to the heart to better diagnose heart conditions.
162. Cardiac catheterization is also called cardiac cath, angiogram, or angio.
163. In a cardiac catheterization, a doctor inserts a small, flexible, hollow tube (a catheter) into a blood vessel in the groin, arm, or neck. Guided by x-ray, the doctor threads the catheter to the coronary arteries. There, the doctor may perform diagnostic tests, including coronary angiography.
Myocardial perfusion imaging also helps doctors determine whether a perfusion defect is fixed or reversible. A perfusion defect is fixed if the affected myocardium is scarred and no longer viable. A perfusion defect is reversible if the affected myocardium remains viable despite the defect.
2
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164. Coronary angiography is a test to obtain x-ray images of the coronary arteries.
A doctor uses the catheter to inject a contrast dye into the coronary arteries so that they become visible and can be captured on x-ray imaging.
165. Coronary angiography shows if, where, and how much the arteries are blocked.
166. A cardiac catheterization helps doctors decide if and where a patient’s heart needs treatment, such as angioplasty, stenting, or bypass surgery.
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TIMI Flow Grade
167. With angiography, doctors can grade blood-flow through a blockage using a scale known as the Thrombolysis in Myocardial Infarct (TIMI) Flow Grade.
168. The TIMI Flow Grade is a widely used method for assessing coronary artery blood-flow in acute coronary syndromes.
169. The TIMI Flow Grade ranges from 0 to 3.
170. A TIMI 3 means complete perfusion: the artery has normal blood-flow that fills even the far coronary bed supplied by the artery, without slowing down.
171. A TIMI 2 means there is partial perfusion.
172. A TIMI 1 means there is penetration without perfusion.
173. A TIMI 0 means that there is no flow—the artery is completely blocked.
ACC/AHA Occlusion Types
174. The American College of Cardiology (“ACC”) and the American Heart Association (“AHA”) have a classification system that estimates the likelihood that an occlusion will be treated successfully with angioplasty.
175. The ACC/AHA system also estimates the likelihood of abrupt vessel closure during a cardiac catheterization—a sudden drop in TIMI Flow Grade from 3 or 2 to 1 or 0, at 5 mm or less downstream from the blockage.
176. Type A occlusions are associated with a high angioplasty success rate (>85%) and a low risk of abrupt closure; Type B occlusions, with a moderate success rate (60-85%) and/or a moderate risk of abrupt closure; Type C occlusions, with a low success rate (<60%) and/or a high risk of abrupt closure.
177. An angioplasty is deemed successful if it (a) achieves a 20% or greater change in luminal diameter, with a final blockage diameter of less than 50%, and (b) achieves those results without the occurrence of death, acute myocardial infarction, or the need for emergency bypass surgery.
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Angioplasty
178. Doctors use cardiac catheterization to both find and fix problems.
179. After doctors find and grade a blocked artery, doctors can perform treatment procedures – angioplasty and stenting – to open the blockage.
180. Angioplasty is a procedure that widens a coronary artery by inflating a tiny balloon at the site of a blockage.
181. Another name for angioplasty is percutaneous coronary intervention, or PCI.
182. Angioplasty is often used during a heart attack to quickly open a blocked artery and limit damage to the heart.
183. Angioplasty is often combined with stenting. Most people who have angioplasty also have stenting during the same catheterization.
184. A stenting is a procedure to place a stent at the site of a blockage after an angioplasty, in order to keep the artery open.
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185. A stent is a wire-mesh tube that props up the artery, like scaffolding inside a tunnel, decreasing the odds that the artery will narrow again.
186. In a stenting, the stent is guided to the occluded artery wrapped around a balloon at the tip of the catheter.
187. When the balloon is inflated at the site of the blockage, the stent expands spring-like and locks into place.
Left-Ventricular Function and LVEF
188. A prognosis predicts (a) whether signs and symptoms will improve, worsen, or remain stable; (b) expectations of quality of life, such as the ability to carry out daily activities; (c) the potential for complications and associated health issues; and (d) the likelihood of survival, including life-expectancy.
189. How well the left ventricle functions is significant in the prognosis of patients with coronary artery disease. Left-ventricular function is also a major determinant in a patient’s prognosis after a heart attack.
190. The key measure of left-ventricular function is the left-ventricular ejection fraction (LVEF).
191. With each heartbeat, the left ventricle pumps out a fraction of the blood it contains. The LVEF is the percentage of blood the left ventricle pumps out to the body with each heartbeat (contraction).
192. The LVEF thus tells doctors how well a patient’s heart is pumping blood out with each heartbeat.
193. An LVEF of 55-70% is normal. In other words, a patient with normal leftventricular function pumps out 55% to 70% of the blood in the left ventricle with each heartbeat.
194. An LVEF of 40-54% is slightly below normal. An LVEF of 35-39% is moderately below normal. An LVEF below 35% is severely below normal.
195. A low LVEF represents the left-ventricle’s reduced ability to pump blood. A low LVEF may be accompanied by wall-motion abnormalities, such as those
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caused by active ischemia, myocardial necrosis, and/or scar-tissue formation. As the LVEF goes down, the patient’s risk of death goes up.
Bypass Surgery
196. Coronary artery bypass grafting (CABG) is a surgery that uses a healthy vessel (a graft) to redirect blood around a blocked coronary artery.
197. The graft creates a new pathway for blood to flow directly to a part of the heart cut off from blood-flow by the blockage.
198. A graft may be a healthy vein or artery, or a manmade vessel.
199. Doctors often call a CABG “bypass surgery” or “bypass” for short. Doctors also use the acronym CABG, pronouncing it like the vegetable “cabbage.”
200. CABG is generally recommended when a patient has a high-grade blockage in any of the major coronary arteries.
201. CABG is also generally recommended when a PCI (angioplasty) fails. 3
3
See Netter’s Cardiology, Third Edition, Elservier, Inc., 2019, at 156.
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202. After a failed PCI, an emergency CABG is recommended if the patient has either ongoing ischemia or a threatened occlusion that puts substantial myocardium at risk.
203. CABG is also recommended when the patient has post-MI angina.
Informed Consent
204. When a physician finds or diagnoses an illness, disease, or condition in a patient, the physician must (a) inform the patient of the finding or diagnosis, and (b) present available treatment options to the patient.
205. Having made these disclosures, the physician must then obtain the patient’s informed consent to the proposed treatment-plan.
Hospital Admission
206. If a patient arrives at a hospital with a STEMI, a hospitalist must not admit the patient to the hospital unless it has the capability to provide definitive care for the STEMI, such as angioplasty or bypass surgery.
207. If the hospital cannot provide definitive care to the patient, the hospitalist must refer and transfer the patient emergently to a hospital that can.
208. If the hospitalist nevertheless admits the patient, the hospitalist must then refer and transfer the patient emergently to a hospital with the capability to provide definitive care. In fact, the Emergency Medical Treatment and Labor Act (“EMTALA”) requires such transfer. See 42 U.S.C. § 1395dd(b)(1).
Record Keeping
209. A physician must promptly enter accurate medical records, so that other providers can rely on the records in providing appropriate medical care to the patient downstream. These requirements apply with special force where the records concern life-threatening conditions, such as STEMI.
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Medical Chronology
210. To make it as easy as possible for Defendants to confirm and answer the numerated allegations, this section has screenshots of Charlene’s medical records. Defendants need not answer the statements in the screenshots.
Prologue
211. In 2013, Charlene Doggett was hospitalized with a heart attack at Phoebe Putney Memorial Hospital, in Albany, Georgia. TRH 178, TRH 213, TRH 38.
212. At that time, she underwent an angioplasty and received two stents. TRH 178, TRH 213.
TRH 178.
TRH 213.
213. By early 2020, Charlene “had chest pain on and off.” TRH 212. On or about February 12, 2020, the pain became “constant,” and then “worsened” over the subsequent few days. TRH 212. On February 19, 2020, Charlene sought treatment for her chest pain at an urgent-care facility, where she was diagnosed with an upper-respiratory infection. TRH 212, TRH 176.
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TRH 212.
First Tift Hospitalization – February 20-23, 2020
Charlene takes ambulance to Tift ER with severe chest pain
Thursday, February 20, 2020
214. On February 20, 2020, after she awoke “feeling worse,” Charlene took an ambulance to Tift Regional Medical Center (“Tift”), in Tifton, Georgia. TRH 176, TRH 178, TRH 193, TRH 212. On route, EMS gave her aspirin and nitroglycerin, relieving her pain. TRH 176, TRH 178, TRH 193, TRH 212.
TRH 176.
215. At 07:27, Charlene arrived and checked into the ER. TRH 188, TRH 187.
Charlene was registered as an uninsured, “Self Pay” patient. TRH 167.
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TRH 167.
216. Charlene’s chief complaint was chest pain. TRH 176, TRH 414.
TRH 176.
Dr. Moorman recommends admission to investigate “high risk of cardiac etiology”
217. At 07:29, Nurse Laurajean Smith triaged Charlene. Nurse Smith assigned Charlene’s condition an acuity level of “3 - Urgent.” TRH 176, TRH 410.
218. Between 07:28 and 07:35, Charlene underwent a stat EKG and a stat chest x-ray, for chest pain. TRH 186.
219. The EKG was “abnormal.” TRH 331. It showed “sinus bradycardia” and a “nonspecific T-wave abnormality.” TRH 331.
TRH 331.
220. The abnormality was a “T wave inversion.” TRH 207, TRH 331, TRH 212-13.
TRH 207.
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221. The chest x-ray revealed clear lung-fields, no evidence of pleural effusions, and “no significant abnormality.” TRH 339, TRH 180, TRH 194. The x-ray also “showed no acute cardiopulmonary abnormality,” and was “negative” for bronchitis. TRH 193, TRH 210.
222. By 07:35, Charlene had stat cardiac-biomarker tests: Troponin-I, CK, and BNP. TRH 186.
223. At 07:43, Charlene’s Troponin-I level was 0.03—the high-end of normal. TRH
336. Charlene’s BNP level was 97, near the high-end of normal. TRH 336.
TRH 336.
224. At 07:44, Charlene rated her pain a 10 out of 10, meaning that it was the “worst possible pain.” TRH 368.
TRH 368.
225. At 09:16, she was “still in pain,” and medication had “not helped.” TRH 409.
TRH 409.
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226. At 09:54, Dr. Ross Moorman examined Charlene. TRH 178-81. Her chest pain continued to be a 10 of 10. TRH 178, TRH 368.
TRH 178.
227. Because the EKG revealed “sinus bradycardia at 58 bpm with some nonspecific ST and T wave changes and mild ST depression” and the biomarkers were “relatively benign with a troponin which is at high end of normal at 0.03,” Dr. Moorman concluded there was “no evidence of acute STEMI.” TRH 179.
228. Still, Dr. Moorman diagnosed Charlene with “chest pain, with a high risk of cardiac etiology.” TRH 179.
229. Accordingly, he decided to “ask hospitalist service to evaluate for admission on basis of known coronary artery disease,” noting that Charlene would “most likely require sequential cardiac enzymes and further work-up.” TRH 179.
TRH 179.
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TRH 179.
Dr. Eric Afari diagnoses pain as “pleuritic”
230. At 10:24, Dr. Afari examined Charlene. TRH 193-97. She had a “burning pain located on upper chest” radiating “to left arm.” TRH 193. The pain was “triggered by cough” and “associated with exertion or rest.” TRH 193.
TRH 193.
231. Noting that Charlene’s “EKG showed nonspecific T wave abnormalities,” her initial Troponin was normal, and her HEART Score was 5, Dr. Afari concluded that the chest pain was “likely due to cough from bronchitis.” TRH 194. (In fact, Charlene’s Heart Score was at a least a 7.)
232. Dr. Afari thus diagnosed Charlene with “atypical pleuritic chest plain,” with a differential diagnosis including “MI” (myocardial infarction). TRH 194.
TRH 194.
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233. Dr. Afari consulted the hospitalist team “to admit patient for further management.” TRH 193. At 10:50, Dr. Afari ordered observation care for acute bronchitis and chest pain. TRH 254.
TRH 193.
TRH 254.
After Troponin rises, Charlene is admitted with NSTEMI
234. At 13:19, Charlene’s Troponin-I level was 1.30—above the normal range. TRH
336.
TRH 336.
235. At about 13:41, Charlene was discharged from the ED and admitted to the hospital floor. 4 TRH 187, TRH 370, TRH 416, TRH 192.
236. Notwithstanding Dr. Afari’s diagnosis of “pleuritic chest pain,” the admitting diagnosis was now: “Chest pain and NSTEMI.” TRH 172, TRH 9, TRH 36.
4
Charlene was not placed in intensive care at Tift during either hospitalization.
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TRH 172.
TRH 36.
237. At 14:21, LPN Tangla Reynolds reported the 1.30 Troponin-I level as a “critical value” to Dr. Afari at bedside. TRH 412-13. Dr. Afari then ordered a cardiology consult. TRH 413.
Dr. Afari consults with Dr. Murray, as Troponin climbs
238. Between 14:23 and 15:01, Dr. Afari consulted with Cardiologist Paul Murray about the increase in Charlene’s Troponin-I “from 0.03 to 1.30.” TRH 252.
TRH 252.
239. At 17:27, Dr. Murray ordered a cardiovascular (“CV”) transthoracic echocardiogram (“TTE”) for “Chest Pain,” ASAP. TRH 250.
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TRH 250.
240. At 17:53, Charlene’s Troponin-I climbed to 5.03. TRH 335. At 19:46, Nurse Whitney Prater reported the Troponin-I level as a “critical value” to Family Nurse Practitioner Jessica Ashley at beside. TRH 412.
TRH 335.
TRH 412.
241. At 18:30, Dr. James Darling performed a chest CT scan on Charlene (CT Chest Pulmonary Embolism Protocol). TRH 337-38. The CT scan found COPD, “mild coronary artery calcifications with no mediastinal mass or adenopathy,” and “no evidence of pulmonary embolus.” TRH 338.
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TRH 338.
242. At 21:48, Charlene’s Troponin-I climbed to 9.93. TRH 335. At 22:27, Nurse Whitney Prater reported this as a “critical value” to FNP-C Ashley. TRH 412.
Friday, February 21, 2020
243. At 02:19, Charlene’s Troponin-I was 12.76. TRH 335. At 03:02, Nurse Prater reported this as a “critical value” to Dr. Barbara Crawford. TRH 412.
TRH 335.
TRH 412.
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Dr. Murray performs cardiac catheterization
244. At 06:43, Dr. Murray ordered a left-heart catheterization for “Chest Pain,” ASAP. TRH 249.
TRH 249.
245. At 06:48, Charlene’s Troponin-I was 18.69. TRH 335. At 07:39, LPN Holly Taylor reported the Troponin-I level as a “critical value” to Physician’s Assistant Kristin Davis Campbell. TRH 412.
TRH 335.
TRH 412.
246. At about 07:40, the catheterization got underway. TRH 321.
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TRH 321.
247. By 09:08, the procedure ended, and Charlene was in the post-anesthesia care unit (PACU). At 10:01, she was discharged from the PACU. TRH 217. At 10:03, Dr. Murray completed and signed his procedure note for the catheterization. TRH 325-26.
The catherization reveals 100% occlusion in mid-RCA
248. The catheterization revealed the following about Charlene’s heart condition.
249. She had a “diffuse, (20 mm (L)) 100% occlusion in the previous stent” in her mid-RCA. TRH 326, TRH 325.
250. The occlusion was “consistent with atherosclerotic disease” and had “a filling defect consistent with thrombus.” TRH 326, TRH 325.
251. The occlusion had a TIMI Flow Grade of 0, meaning that there was “no flow across the lesion.” TRH 326, TRH 325.
252. The occlusion, moreover, presented “an ACC/AHA type C ‘high risk’ lesion for intervention.” TRH 326, TRH 325.
253. The blocked portion of the RCA supplied “a moderate-sized vascular territory” in Charlene’s heart. TRH 326, TRH 325.
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TRH 326.
254. The lesion was “a likely culprit for the patient’s clinical presentation”“NSTEMI presentation with recent return of chest pain.” TRH 325.
TRH 325.
255. Dr. Murray thus recognized that the occlusion was the cause of Charlene’s presentation—both her “NSTEMI” and her “chest pain.” TRH 325.
After angioplasty fails, Charlene’s RCA remains blocked—with no collateral circulation
256. Dr. Murray tried to open the occlusion with angioplasty, but stopped after several inflations “to prevent coronary artery perforation.” TRH 325, TRH 326.
257. As a result, the angioplasty was an “unsuccessful attempt at opening occluded mid RCA.” TRH 325. Thus: “Vessel remains occluded.” TRH 325.
TRH 325.
258. “Following the intervention,” there was still “a residual 100% stenosis with TIMI grade 0 flow (no flow).” TRH 325, TRH 326.
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259. The catherization thus resulted “in no improvement in angiographic appearance[.]” TRH 325, TRH 326.
TRH 325.
TRH 326.
260. The angioplasty was an “unsuccessful PCI attempt” and a “failed attempt to open mid RCA.” TRH 325, TRH 207.
TRH 325.
TRH 207.
261. Charlene’s heart was “right dominant,” TRH 325, meaning that her RCA gave rise to her posterior descending artery (“PDA”). The occlusion thus also jeopardized the region of her heart supplied by the PDA.
262. Critically, Charlene’s heart had “no collaterals” “from the left coronary system to the right PDA.” TRH 325. Her PDA, therefore, was cut off.
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TRH 325.
263. Nevertheless, Dr. Murray assigned Charlene “medical therapy.” TRH 325.
The TTE shows Charlene’s heart is otherwise healthy
264. By 11:44, Charlene had the TTE Dr. Murray had ordered the night before.
TRH 328-29, TRH 250. The TTE demonstrated that, other than mild mitral-valve regurgitation, all the structures of Charlene’s heart were normal, including the four chambers and four valves. TRH 328-29, TRH 37.
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TRH 328.
265. Notably, the function of Charlene’s left ventricle was well preserved.
266. Her left-ventricle’s wall motion was “normal,” with “no regional wall motion abnormalities.” TRH 328.
267. Her left-ventricle’s cavity was “normal,” and its systolic (squeezing) function was also “normal.” TRH 328.
268. Notably, her ejection fraction was also normal: “55-60%.” TRH 328, TRH 37.
TRH 328.
269. In sum, Charlene’s heart had “an EF of 55 to 60%, no wall motion abnormality and mild mitral regurgitation.” TRH 37.
TRH 37.
Despite blocked RCA, Charlene is placed under observation
270. At 13:53 and 14:44, respectively, PA Campbell and Dr. Vince Faridani documented cardiology’s treatment plan post-catheterization. TRH 207-11.
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TRH 211.
271. Though the angioplasty “failed” to “open mid RCA,” the plan consisted of lowseverity “observation care” and “serial” Troponin tests. TRH 210, TRH 207.
TRH 210.
TRH 210.
272. Dr. Murray was “following and managing” this treatment plan. TRH 211.
TRH 211.
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273. At 18:58, telemetry demonstrated sinus rhythm with an inverted T-wave. TRH
222. 5
TRH 222.
TRH 222.
Despite blocked RCA, Dr. Tronolone clears Charlene for discharge pending drop in Troponin
Saturday, February 22, 2020
274. At 05:47, Charlene’s Troponin-I peaked at 43.27. TRH 335. At 07:14, LPN Taylor reported this level as a “critical value” to Dr. Harris. TRH 412.
TRH 335.
5
Telemetry is a tool that continuously monitors a patient’s EKG, respiratory rate, and oxygen.
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TRH 412.
275. At 11:19, Cardiologist Jonathan Tronolone saw Charlene. TRH 203-05.
276. Charlene’s present illness was “Chest pain-NSTEMI.” TRH 203.
277. Charlene’s RCA remained “occluded at the distal stent edge.” TRH 204.
278. Nevertheless, Dr. Tronolone approved Charlene’s discharge, pending a drop in her Troponin levels. TRH 204.
279. Although her Troponin had just risen to its highest level, Dr. Tronolone concluded that the “elevation” was “from washout.” TRH 203-04.
280. Charlene’s NSTEMI was “stable” and she was not having “any further” chest pain. TRH 203-204. “Given no pain,” Dr. Tronolone cleared Charlene for discharge “later today,” if her “trop is trending down.” TRH 204.
TRH 203.
TRH 204.
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281. At 12:13, Hospitalist Erinn Harris examined Charlene. TRH 205-07.
Charlene’s chest pain was “resolved” after “[left-heart catheterization] with NSTEMI.” TRH 207.
282. Although Charlene’s Troponin had not yet dropped, Dr. Harris resolved to “continue to monitor [ ] downtrend of troponin today,” and ordered Charlene’s discharge “today or tomorrow as troponin trend[s] down.” TRH 207.
283. Dr. Harris anticipated discharging Charlene even though her RCA “was occluded from prox[imal] to mid RCA.” TRH 207.
284. Dr. Harris planned Charlene’s discharge based on two erroneous beliefs: (a) that a “stent was placed” in an occlusion from the proximal to mid RCA, and (b) that the untreated occlusion was a “distal occlusion of RCA,” which was “most like[ly]” the “cause of elevated Tropon[in].” TRH 207.
TRH 207.
285. By 18:34, Charlene’s Troponin-I level had dropped to 27.81—still a critical value far above the normal range. TRH 335.
TRH 335.
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Despite blocked RCA, Dr. Harris discharges Charlene
Sunday, February 23, 2020
286. At 07:06, Charlene’s Troponin-I level was 20.90. TRH 335. At 08:15, LPN Taylor reported this as a “critical value” to Dr. Harris at bedside. TRH 412.
TRH 412.
287. At 12:40, Charlene had “improved” and was “pain free,” with “troponin trending down.” TRH 172. At that time, Dr. Harris entered Charlene’s discharge summary. TRH 172.
288. Dr. Harris discharged Charlene even though her RCA remained “occluded from prox to mid RCA,” and the “distal occlusion of RCA was not treated.”
TRH 172.
289. Dr. Harris based her discharge order on the same two erroneous beliefs: (a) that a “stent was placed” in an occlusion from the proximal to mid RCA, and (b) that the untreated occlusion was a “Distal occlusion of RCA.” TRH 207.
TRH 172.
TRH 172.
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290. Dr. Harris’s misinterpretation and misstatement of Charlene’s medical condition exemplify broader systemic failures: Tift lacked or did not effectively disseminate or enforce (a) policies requiring medical providers to read and communicate clinical information carefully, and (b) protocols for the effective hand-off of patients and of clinical information among providers.
Charlene leaves Tift unaware of her blocked RCA
291. At 14:12, Charlene was discharged from Tift. TRH 167. At that time, hospital staff informed Charlene for the first time that she had had a heart attack.
292. Neither Dr. Murray, nor Dr. Harris, nor anyone else informed Charlene or her family about the complete occlusion in her mid-RCA. Charlene thus went home unaware that a major artery in her heart was completely blocked.
293. That night, because she was “not feeling right” and was “afraid to be alone,” Charlene slept at her son’s house, instead of her own home.
Second Tift Hospitalization – February 24, 2020
Charlene returns to Tift ED at daybreak
Monday, February 24, 2020
294. At about 02:00, Charlene’s chest pain returned. She later described that pain as a 10 and “like an elephant sitting on my chest.” TRH 37.
TRH 37.
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TRH 15.
295. At daybreak, Charlene woke Jason (her son) and Carrie (his wife). Carrie immediately drove Charlene to the Tift ER. On the way, Charlene repeatedly gripped her chest, rocked with distress, and begged Carrie to hurry.
296. From this time forward, Charlene’s chest pain was constant, relentless, and obvious. Each time a provider asked about her pain, she said that medications were “not helping.”
297. At Tift, because Charlene was unable to get out of the car, Carrie ran into the ER to get help. Tift staff then transported Charlene into the hospital on a wheelchair, while Carrie went to park the car.
ED immediately recognizes STEMI, confirmed by EKG
298. When Carrie walked into the ER, a nurse immediately told her that an EKG showed that Charlene was having “an acute heart attack.” The nurse praised Carrie for doing “a great job getting her here in time.”
299. At 08:30, Charlene checked into the Tift ED. TRH 30.
300. Upon Charlene’s arrival, the ED mobilized to diagnose and treat an acute STEMI.
301. At 08:30, Dr. Justin Harrell, a family-medicine specialist, ordered stat cardiac biomarkers. TRH 27, TRH 82-85.
302. At 08:31, Nurse Kimberly Tapp triaged Charlene. Nurse Tapp assigned Charlene’s condition an acuity level of “2 - Emergent.” TRH 13, TRH 161.
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TRH 13.
303. At 08:31, Dr. Harrell ordered a stat EKG and a stat x-ray, for chest pain. TRH 73, TRH 108.
TRH 73.
TRH 108.
304. Nurse Tapp immediately notified Dr. Harrell of the EKG results. TRH 142.
305. At 8:31, an EKG showed that Charlene was having an “ACUTE MI”— acute myocardial infarction. 6 TRH 114.
306. The EKG detected a marked ST-segment elevation without a normally inflected T-wave in leads II and aVF. TRH 114.
307. The EKG also detected a lateral wall ST-segment depression. TRH 114.
As explained below, Dr. Murray confirmed this and two other similar EKGs the next morning, after Charlene had died. TRH 114.
6
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TRH 114.
TRH 114.
ED activates catheterization team
308. At 08:33, EMT Samuel Haag reported to Dr. Harrell that the EKG was “critical” and indicated an “inferior STEMI.” TRH 34.
309. Dr. Harrell “confirmed stemi” and activated the catheterization team. TRH 34.
TRH 34.
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310. At 08:34, the catheterization team was “activated,” and started to prepare Charlene for the procedure. TRH 33.
TRH 33.
311. At 08:40, Charlene’s pain remained a 10. TRH 135.
TRH 135.
312. By 08:43, Dr. Harrell reviewed the EKG. It showed “sinus rhythm at 71 bpm with ST elevation in anterior leads,” indicating “an inferior MI.” TRH 17.
TRH 17.
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Dr. Murray overrules STEMI diagnosis
313. At about 08:43, without examining Charlene, Dr. Murray disagreed with the diagnosis of a STEMI. As a result, Dr. Murray “canceled the cath team at this time,” pending the results of Charlene’s cardiac biomarkers (“labs”). TRH 17.
TRH 17.
314. Shortly after that, Hospitalist Cynthia Phillips arrived and directed the team to stop preparing Charlene for the catheterization. Dr. Phillips looked puzzled and unsettled. She explained that she had just spoken to Dr. Murray by telephone and that he did not want to perform another catheterization because the last one was unsuccessful.
315. Dr. Phillips also informed Charlene and Carrie that the catheterization had revealed a complete RCA occlusion that Dr. Murray “was unable to fix.” This was the first time Charlene or her family learned of the occlusion.
Dr. Phillips orders admission to SDU
316. At 08:35, Charlene’s cardiac biomarkers all remained far above the reference range. TRH 118.
TRH 118.
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317. At 09:12, Nurse Julia Delaney Dasher reported the Troponin-I level as a “critical value” to Family Nurse Practitioner Dawn Glisson. TRH 162.
TRH 162.
318. Between 08:43 and 09:18, FNP-C Glisson reviewed Charlene’s chest x-ray, which revealed “no acute findings.” TRH 17. FNP-C Glisson also reviewed Charlene’s cardiac biomarkers. THR 17.
319. By 09:18, FNP-C Glisson “discussed these results with Dr. Murray.” TRH 17.
320. Although he had cancelled the catheterization pending the lab results, and although Charlene’s biomarkers remained “elevated” and were “critical values,” Dr. Murray recommended “medical management.” TRH 17.
321. In addition, although Charlene’s chest x-ray revealed “no acute chest findings,” and although the chest pain during her first hospitalization was from the NSTEMI, Dr. Murray now cited Charlene’s “pleuritic type chest pain” of “last week” as the basis for his recommendation. TRH 119, TRH 17.
322. At 09:18, while recognizing that the chest CT scan of February 20 had ruled out pulmonary embolism, FNC-C Glisson and Dr. Harrell followed Dr. Murray’s recommendation and “presented” Charlene “to hospital medicine for admission, further evaluation, and management.” TRH 17.
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TRH 17.
323. By 09:21, Charlene’s chest x-ray demonstrated “no interval change,” “no acute chest findings,” and “continued normal heart size with clear lungs and pleural spaces.” TRH 119.
324. At 09:24, FNP-C Glisson entered a request to admit Charlene for medical observation. TRH 70.
TRH 70.
325. At 09:26, Dr. Phillips ordered Charlene’s admission to the step-down unit (SDU). TRH 70.
TRH 70.
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ED waits for Dr. Murray to see patient; Dr. Phillips keeps catheterization order active
326. At 09:27 and 09:31, Nurse Dasher attempted unspecified telephone consults.
TRH 35-36. At 09:30, Dr. Phillips requested a consult with Dr. Murray about “nstemi.” TRH 74.
TRH 74.
327. At 09:33, FNP-C Glisson also recognized that the EKG showed “sinus rhythm at 71 bpm with ST elevation in anterior leads,” indicating “an inferior MI.” TRH 18. (At 18:39, Dr. Harrell confirmed that reading. TRH 19.)
TRH 18.
328. At 09:33, Charlene’s pain was “a pressure” and “constant.” TRH 16.
329. At 09:35, Dr. Phillips updated Dr. Harrell’s catheterization order, which therefore remained “active.” TRH 58.
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TRH 58.
330. At 10:23, Dr. Phillips ordered another stat EKG, expressly for “Chest Pain” and “STEMI (ST elevation myocardial infarction).” TRH 72, TRH 24-26.
TRH 72.
331. At 11:08, Dr. Phillips again updated Dr. Harrell’s catheterization order, which therefore remained “active.” TRH 57.
TRH 57.
Dr. Phillips diagnosis STEMI, yet orders hospital care in SDU
332. At 11:08, the latest EKG confirmed that Charlene’s heart was suffering an ongoing, evolving inferior STEMI. TRH 113.
333. The EKG revealed a “nonspecific ST & T-wave abnormality,” “evolving changes of inferior myocardial infarction,” and “lateral wall ST depression.” TRH 113.
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TRH 113.
334. At 11:10, Nurse Dasher notified Dr. Murray of the latest EKG. TRH 142.
TRH 142.
335. At 11:10, Dr. Phillips also diagnosed Charlene with “STEMI (ST elevation myocardial infarction) – based on EKG.” TRH 36, TRH 38.
336. Nevertheless, Dr. Phillips planned to “admit [Charlene] to SDU,” noting that Dr. Murray was “coming to see patient.” TRH 38.
TRH 38.
337. At 11:12, Dr. Phillips ordered initial hospital care incident to “STEMI (ST elevation myocardial infarction).” TRH 75.
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TRH 75.
Though EKG and biomarkers are “consistent with STEMI,” Dr. Murray insists Charlene is not having a STEMI
338. At about 12:38, Dr. Murray “reviewed the EKG” and finally “examined the patient,” in consultation with Nurse Practitioner Radha Patel. TRH 44-47.
339. Dr. Murray acknowledged that the EKG had “inferior leads ST elevation” and that the “findings on cardiac enzymes and EKG were consistent with STEMI.” TRH 45. Nevertheless, Dr. Murray insisted that the “Patient is not having acute heart attack.” TRH 45.
340. The basis for his conclusion now shifted from the “pleuritic type pain” of “last week” to “the recent cath.” TRH 45.
TRH 45.
341. Accordingly, Dr. Murray informed NPC Patel that there was “no plan for repeating any ischemic evaluation at this time.” TRH 45.
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342. Accordingly, NPC Patel decided to “continue to monitor patient,” “trend cardiac enzymes,” and “repeat EKG x4 every 6 hours.” TRH 45.
TRH 45.
Dr. Murray tells family that pain is carryover, blood-flow will bypass occlusion, and Charlene just has to “push through” pain
343. At the time of his consult, Dr. Murray told Jason and Carrie that Charlene’s chest pain was a “carryover” from the recent NSTEMI.
344. When Carrie asked if the occlusion could cause further harm to Charlene, Dr.
Murray said “no.”
345. Then, implying that collateral circulation could form overnight, Dr. Murray explained that blood-flow would bypass the blockage on its own.
346. Dr. Murray added that nothing else could be done for Charlene and that she was “just going to have to push through the pain.”
347. A few hours later, a nurse repeated that statement to Charlene and her family as she was writhing in pain on the brink of death.
348. When Carrie observed that the pain seemed to be from a new heart attack, Dr.
Murray stared blankly at her without response.
349. Dr. Murray’s meeting with Charlene’s family lasted less than 10 minutes and was his only contact with her or her family on this, the day of her death.
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Charlene is discharged to SDU, with instructions to seek immediate medical attention for chest discomfort, because “MINUTES DO MATTER”
350. At 14:14, Charlene’s Troponin-I was still high, at 5.93. At 15:03, it rose to 6.06.
TRH 118.
TRH 118.
351. At 15:25, Charlene was discharged from the ED and admitted to the SDU in serious condition on a stretcher. TRH 128, TRH 30.
352. At 15:25, her diagnosis continued to be “STEMI (ST elevation myocardial infarction).” TRH 26.
TRH 26.
353. Charlene’s ED-discharge papers instructed her to seek “immediate medical attention” if she experienced “warning signs” of a heart attack, such as chest discomfort lasting “more than a few minutes.” TRH 22. “MINUTES DO MATTER,” the instructions warned. TRH 22.
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TRH 22.
354. At 15:37, in the SDU, Nurse Candice Smith reported the most-recent Troponin-I level as a “critical value” to Dr. Phillips at bedside. TRH 162.
355. Dr. Phillips ordered continued monitoring, not any referral, therapy, or intervention. TRH 162.
TRH 162.
EKG reconfirms STEMI in progress, telemetry shows cardiac arrest
356. At 19:38, an EKG was “abnormal.” TRH 112.
357. This EKG confirmed yet again that Charlene was having an ongoing inferior STEMI. TRH 112.
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358. The EKG showed “ST elevation” without a normally inflected T-wave in leads II and aVF, and “evolving changes of inferior infarction,” indicative of “inferior injury.” TRH 112.
TRH 112.
TRH 112.
359. At 19:41, telemetry reported to Dr. Phillips continued to demonstrate a STEMI in progress. TRH 50.
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TRH 50.
360. At 19:42, Nurse Practitioner Billie Joe Pitts notified an unnamed provider of Charlene’s chest pain. TRH 162. At 19:46, the provider responded with unspecified orders. TRH 162.
361. At 20:52, telemetry reported to Dr. Phillips showed cardiac arrest. TRH 51-52.
TRH 51.
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TRH 52.
Charlene Doggett dies
362. At about 20:45, Jason Doggett left his mother’s room for a few minutes to get a snack at a hospital vending machine. Since Carrie had gone home to clean up after a long day at Tift, Charlene was left alone in her room.
363. At about 20:53, Charlene suffered cardiopulmonary arrest, code blue was called, and the response team initiated resuscitation (ACLS) efforts. TRH 42.
364. Jason sprinted to his mother’s room, to find her dead.
365. Despite “aggressive measures” to revive her, “including chest compressions,” the response team was “unable to obtain a sustainable pulse.” TRH 42.
TRH 42.
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366. At 21:07, Hospitalist Craig Smith pronounced Charlene Doggett officially dead, referring the case to the medical examiner. TRH 2, TRH 42.
TRH 2.
367. At 21:22, telemetry confirmed asystole—flatlining. TRH 53.
368. At 21:45, Dr. Smith listed “cardiopulmonary failure” as the preliminary cause of death. TRH 42. Among other pertinent diagnoses, Dr. Smith listed “ST elevation (STEMI) myocardial infarction.” TRH 42.
TRH 42.
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369. Charlene’s official cause of death was acute myocardial infarction and/or arrhythmia. TRH 2.
TRH 2.
370. At 23:33, Nurse Lacey Powell notified Dr. Murray that “patient expired.” TRH
162.
371. After Charlene died, Charlene’s family asked to see Dr. Murray, hoping he could explain her death, but he never came to see them.
372. Instead, Dr. Smith stopped by and told Charlene’s siblings that Tift “does not crack the chest open for just one blockage” and that “sometimes your loved ones just die.”
Dr. Murray relabels Charlene’s chest pain as “clearly pleuritic,” yet belatedly confirms EKGs showing STEMI
Tuesday, February 25, 2020
373. At 06:34, Dr. Murray accessed the Tift records system and entered an “Addendum” to his consultation note of 12:38 the previous day. TRH 47.
374. Dr. Murray now relabeled Charlene’s pain as “clearly pleuritic.” TRH 47.
TRH 47.
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375. Even though Charlene’s pain during her first visit to Tift four days earlier was angina from the NSTEMI, TRH 172, TRH 36, Dr. Murray now explained that this “pleuritic pain” was “similar pain as prior admission.” TRH 47.
376. Dr. Murray’s same addendum thus contradicts his after-the-fact attempt to relabel Charlene’s angina as “clearly pleuritic.”
377. At 06:37 and 06:38, Dr. Murray belatedly confirmed three of Charlene’s EKGs of the prior day. TRH 112-14. Each showed she was having a STEMI.
TRH 114.
Professional Negligence: Standard-of-Care Violations
378. This Complaint next identifies requirements of the standard of care that apply under the following circumstances present in this case:
a. a cardiologist (here, Dr. Paul Murray) is caring for patient (here, Charlene Doggett) with an NSTEMI, at a hospital (here, Tift) without the capability to perform bypass surgery;
b. the cardiologist finds a 100% in-stent occlusion in the patient’s mid-RCA, through a catheterization study;
c. the cardiologist also finds no collateral circulation around the occlusion, during the same catheterization study;
d. the cardiologist is unable to clear the occlusion with angioplasty; and
e. the patient is discharged from the hospital two days later, with a completely occluded RCA and without further investigation of the adequacy of collateral blood-flow or myocardial perfusion.
379. This Complaint then also outlines how each requirement was violated here.
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Count 1: Failure to Refer for Angioplasty – Against Dr. Murray and the Southwell Defendants
380. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
381. In the circumstances summarized in Paragraph 378, the standard of care requires the cardiologist to refer the patient to a hospital capable of performing bypass surgery, where the patient can undergo another angioplasty, with bypass surgery as a backup in case of complications.
382. On February 21, 22, and 23, 2020, Dr. Paul Murray violated this requirement by failing to refer Charlene Doggett to another hospital for an angioplasty. Dr. Murray’s violation was all the more egregious because Charlene was having, or had just had, an NSTEMI.
383. At a hospital capable of performing bypass surgery, an interventional cardiologist could have performed an angioplasty more aggressively, knowing that bypass surgery was available as a backup in case of complications. Also, a referral hospital would have had greater clinical capabilities than Tift.
384. On February 21, 22, and 23, 2020, Charlene was eligible for an angioplasty at a referral hospital.
385. Because Charlene’s heart was otherwise fundamentally healthy, an angioplasty at a referral hospital likely would have been successful.
386. A successful angioplasty would have restored normal blood-flow to Charlene’s heart, and thus would have prevented or resolved her STEMI.
387. Had Dr. Murray referred Charlene for an angioplasty at another hospital, she would have survived and resumed her life.
388. Dr. Murray’s failure to refer Charlene to another hospital for an angioplasty thus caused her pain, suffering, injury, and death.
389. As alleged below, even if another angioplasty had proved unsuccessful, Charlene then would have undergone a successful bypass surgery.
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390. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence, because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
Count 2: Failure to Refer for Bypass Surgery - Against Dr. Murray and the Southwell Defendants
391. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
392. In the circumstances summarized in Paragraph 378, the standard of care requires the cardiologist to refer the patient to a heart surgeon for bypass surgery.
393. On February 21, 22, and 23, 2020, Dr. Murray violated this requirement by failing to refer Charlene Doggett to a heart surgeon for bypass surgery. In fact, Dr. Murray did not even consult a heart surgeon.
394. Dr. Murray’s violation was all the more egregious because (a) Charlene was having, or had just had, an NSTEMI, and (b) she had a Type A, high-risk occlusion with a 0 TIMI Flow Grade in a major coronary artery.
395. On February 21, 22, and 23, 2020, Charlene was eligible for bypass surgery.
396. Bypass surgery would have restored normal blood-flow around the occlusion, and thus would have prevented or resolved Charlene’s STEMI.
397. Had Dr. Murray referred Charlene for bypass surgery, she would have survived and resumed her life.
398. The failure to refer Charlene for bypass surgery thus caused her pain, suffering, injury, and death.
399. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence, because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
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Count 3: Failure to Obtain Informed Consent - Against Dr. Murray and the Southwell Defendants, and Against Dr. Tronolone, Tronolone Cardiology, and Tronolone Medical
400. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
401. In the circumstances summarized in Paragraph 378, the standard of care requires a cardiologist to obtain the patient’s informed consent to a course of treatment that excludes bypass surgery and another angioplasty at another hospital.
402. Dr. Murray (on February 21, 22, and 23, 2020) and Dr. Tronolone (on February 23, 2020) each violated this requirement by:
a. failing to inform Charlene of the occlusion;
b. failing to inform Charlene that bypass surgery and another angioplasty were definitive-care options available at other hospitals; and
c. failing to obtain Charlene’s consent to a course of treatment that excluded bypass surgery and another angioplasty.
403. Had Dr. Murray or Dr. Tronolone sought Charlene’s informed consent, Charlene would have requested and sought an angioplasty and/or bypass surgery at another hospital. As a result, her STEMI would have been prevented or resolved, and her death averted.
404. Each failure to obtain Charlene’s informed consent thus caused her pain, suffering, injury, and death.
405. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence, because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
406. As Dr. Tronolone’s employer or other principal at the time of his negligence, Tronolone Cardiology and/or Tronolone Medical are/is vicariously liable for his negligence, because Dr. Tronolone was acting within the scope of his employment or agency with either or both of those entities at that time.
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Count 4: Failure to Administer Myocardial Perfusion Test Against Dr. Murray and the Southwell Defendants, and Against Dr. Tronolone, Tronolone Cardiology, and Tronolone Medical
407. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
408. In the circumstances summarized in Paragraph 378, the standard of care requires a cardiologist to give the patient a myocardial perfusion test.
409. Dr. Murray (on February 21, 22, and 23, 2020) and Dr. Tronolone (on February 23, 2020) each violated this requirement, by failing to give Charlene Doggett a myocardial perfusion test.
410. Such further investigation of the adequacy of collateral blood-flow and myocardial perfusion would have shed light on where and to what extent Charlene’s heart-muscle was in jeopardy. The test thus would have confirmed the deadly threat posed by the unresolved occlusion in Charlene’s RCA, highlighting the importance of providing her definitive and emergent care.
411. Each failure to give Charlene a myocardial perfusion test thus led to her pain, suffering, injury, and death.
412. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence, because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
413. As Dr. Tronolone’s employer or other principal at the time of his negligence, Tronolone Cardiology and/or Tronolone Medical are/is vicariously liable for his negligence, because Dr. Tronolone was acting within the scope of his employment or agency with either or both of those entities at that time.
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Count 5: Premature Closure and Discharge - Against Dr. Murray and the Southwell Defendants, and Against Dr. Tronolone, Tronolone Cardiology, and Tronolone Medical
414. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
415. In the circumstances summarized in Paragraph 378, the standard of care requires a cardiologist to keep the patient hospitalized while the occlusion remains unresolved.
416. On February 23, 2020, Dr. Murray and Dr. Tronolone each violated this requirement by failing to order Charlene Doggett’s continued hospitalization, permitting instead the premature closure of her case and her premature discharge from Tift.
417. These violations were all the more egregious because:
a. Charlene had a 100% occlusion with a TIMI Flow Grade of 0 and no collateral circulation; and
b. Dr. Murray and Dr. Tronolone did not order or perform a myocardial perfusion test or any other further investigation of the adequacy of myocardial perfusion or collateral blood-flow around the occlusion.
418. Had Charlene remained hospitalized, providers at Tift would have had additional encounters with her, each an additional opportunity to recognize, diagnose, and respond properly to her myocardial infarction.
419. The premature closure and discharge thus deprived Charlene of vital opportunities to prevent or resolve her STEMI and avert her death.
420. Each failure to keep Charlene hospitalized thus led to her pain, suffering, injury, and death.
421. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence, because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
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422. As Dr. Tronolone’s employer or other principal at the time of his negligence, Tronolone Cardiology and/or Tronolone Medical are/is vicariously liable for his negligence, because Dr. Tronolone was acting within the scope of his employment or agency with either or both of those entities at that time.
423. Dr. Tronolone’s failure to keep Charlene hospitalized (and to order myocardial imaging) exemplifies a systemic failure: Tift was understaffed on weekends.
Count 6: Failure to Diagnose STEMI - Against Dr. Murray and the Southwell Defendants
424. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
425. When a patient develops a STEMI, the standard of care requires a cardiologist to recognize and diagnose the STEMI. These requirements apply with special force in the circumstances summarized in Paragraph 378.
426. On February 24, 2020, Dr. Murray violated these requirements by:
a. failing to recognize and diagnose Charlene Doggett’s STEMI;
b. ruling out STEMI as the diagnosis, overruling other providers;
c. making his misdiagnosis without first examining Charlene; and
d. failing to correct his misdiagnosis in the face of additional evidence (chestpain, biomarkers, EKGs) confirming that Charlene was actively infarcting and gradually and painfully dying from a STEMI in progress.
427. Dr. Murray’s violations were all the more egregious because:
a. Charlene had just had an NSTEMI;
b. the attending physician at the ER diagnosed Charlene with a STEMI immediately upon her return to Tift that morning;
c. Charlene’s medical history, clinical presentation, and test results made it clear that she was having an acute inferior STEMI;
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d. the inferior STEMI was consistent with the complete occlusion in the midRCA that Dr. Murray himself found; and
e. Dr. Murray himself recognized that Charlene’s biomarkers and EKG indicated she was having an acute inferior STEMI.
428. Because Dr. Murray’s failure to diagnose the STEMI provided a rationale for the failure to refer or transfer Charlene to another hospital for definitive care, his failure to diagnose caused her pain, suffering, injury, and death.
429. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence, because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
430. In addition, Dr. Murray’s failures exemplify broader institutional failures.
431. First, Dr. Murray’s wanton delay in examining Charlene exemplifies the failure to have, or disseminate or enforce, policies and protocols for the rapid evaluation and treatment of heart-attack patients.
432. Second, his failure to diagnose an obvious STEMI exemplifies Tift’s failure to hire, contract, or privilege qualified and competent medical providers.
433. Third, Dr. Murray’s failure to diagnose the STEMI exemplifies Tift’s failure to train, review, and evaluate medical providers for basic competence.
434. In addition, upon information and belief, Dr. Murray’s failures in this case reflect a professional and/or personal history that the Southwell Defendants knew about or should have known about in hiring or credentialing him.
Count 7: Failure to Diagnose and Treat Angina - Against Dr. Murray and the Southwell Defendants
435. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
436. In the circumstances summarized in Paragraph 378, when the patient has angina, the standard of care requires the cardiologist to diagnose and treat the angina.
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437. On February 24, 2020, Dr. Murray violated these requirements by failing to diagnose and treat Charlene Doggett’s angina.
438. Dr. Murray’s violations were all the more egregious because:
a. the attending physician in the ER diagnosed Charlene with a STEMI immediately upon her return to Tift that morning;
b. Charlene’s medical history, clinical presentation, and test results made it clear that she was having an acute STEMI;
c. Dr. Murray himself recognized that Charlene’s biomarkers and EKG indicated she was having a STEMI;
d. Charlene rated her chest pain a 10, and described it as “an elephant sitting” on her chest;
e. the angina was a symptom of a STEMI in progress that gradually and painfully took Charlene’s life; and
f. Dr. Murray misinformed Charlene that her chest pain was normal and that she just had to “push through the pain.”
439. Dr. Murray also violated these requirements by failing to correct his misdiagnosis even in the face of additional evidence (chest-pain, biomarkers, EKGs) confirming STEMI.
440. Because Dr. Murray’s failure to diagnose the angina served as a rationale for the failure to refer or transfer Charlene to another hospital for definitive care, his failure to diagnose caused her pain, suffering, injury, and death.
441. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence, because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
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Count 8: Second Failure to Refer for Angioplasty – Against Dr. Murray and the Southwell Defendants
442. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
443. In the circumstances summarized in Paragraph 378, when the patient has a STEMI within a few days after the onset of the NSTEMI, the standard of care requires the cardiologist emergently to refer the patient to a hospital capable of performing bypass surgery, where the patient can undergo another angioplasty, with bypass surgery as a backup in the event of complications.
444. On February 24, 2020, Dr. Murray violated this requirement, by failing to refer Charlene Doggett to another hospital for angioplasty.
445. On February 24, 2020, Charlene remained eligible for an angioplasty at a referral hospital.
446. At a hospital capable of performing bypass surgery, an interventional cardiologist could have performed angioplasty more aggressively, knowing that bypass surgery was available as a backup in case of complications. Also, a referral hospital would have had greater clinical capabilities than Tift.
447. Because Charlene’s heart was otherwise fundamentally healthy, an angioplasty at a referral hospital likely would have been successful.
448. A successful angioplasty would have restored normal blood-flow to Charlene’s heart, and thus would have resolved her STEMI.
449. Had Dr. Murray referred Charlene for an angioplasty at another hospital, she would have survived and resumed her life.
450. Dr. Murray’s additional failure to refer Charlene for an angioplasty thus caused her pain, suffering, injury, and death.
451. As alleged below, even if another angioplasty had proved unsuccessful, Charlene then would have undergone a successful bypass surgery.
452. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence,
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because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
Count 9: Second Failure to Refer for Bypass Surgery - Against Dr. Murray and the Southwell Defendants
453. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
454. In the circumstances summarized in Paragraph 378, when the patient has a STEMI within a few days after the onset of the NSTEMI, the standard of care requires the cardiologist to refer the patient emergently to a heart surgeon for bypass surgery.
455. On February 24, 2020, when Charlene returned to Tift with a STEMI, Dr.
Murray violated this requirement, by failing to refer her to a heart surgeon for bypass surgery. Dr. Murray did not even consult a heart surgeon.
456. Dr. Murray’s violation was all the more egregious because (a) Charlene was having, or had just had, an NSTEMI, and (b) she had a Type A, high-risk occlusion with a 0 TIMI Flow Grade in a major coronary artery.
457. On February 24, 2020, Charlene remained eligible for bypass surgery.
458. Bypass surgery would have restored normal blood-flow around the occlusion, and thus would have resolved Charlene’s STEMI.
459. Had Dr. Murray referred Charlene for bypass surgery, she would have survived and resumed her life.
460. This additional failure to refer Charlene for bypass surgery thus caused her pain, suffering, injury, and death.
461. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence, because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
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Count 10: Second Failure to Obtain Informed Consent - Against Dr. Murray and the Southwell Defendants
462. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
463. In the circumstances summarized in Paragraph 378, when the patient has a STEMI within a few days after the onset of the NSTEMI, the standard of care requires the cardiologist to obtain the patient’s informed consent to a course of treatment that excludes bypass surgery and another angioplasty.
464. On February 24, 2020, Dr. Murray violated this requirement by:
a. failing to inform Charlene Doggett that she was having a STEMI;
b. failing to inform Charlene that bypass surgery and another angioplasty were definitive-care options available at other hospitals;
c. failing to obtain Charlene’s consent to a course of treatment that excluded bypass surgery and another angioplasty;
d. misinforming Charlene that her angina was “carryover” from the NSTEMI; and
e. misinforming Charlene that her heart would self-correct—that is, bypass the occlusion on its own.
465. Had Dr. Murray sought Charlene’s informed consent on this date, Charlene would have requested and sought an angioplasty and/or bypass surgery at another hospital.
466. As a result, her heart would have been revascularized, her STEMI resolved, and her death averted.
467. This additional failure to obtain Charlene’s informed consent thus caused her pain, suffering, injury, and death.
468. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence,
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because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
Count 11: Failure to Maintain Records - Against Dr. Murray and the Southwell Defendants
469. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
470. In the circumstances summarized in Paragraph 378, the standard of care requires the cardiologist to maintain accurate and timely medical records concerning the patient.
471. On February 25, 2020, the morning after Charlene died from an untreated STEMI, Dr. Murray violated this requirement, by amending his diagnosis of February 24, 2020, to relabel Charlene’s chest pain as “clearly pleuritic.”
472. In the same amendment, Dr. Murray himself contradicted that label, by acknowledging that Charlene’s chest pain was in fact “similar pain as prior admission,” when she had angina from the NSTEMI.
473. That same morning, Dr. Murray also belatedly confirmed that the EKGs of the prior day showed that Charlene was having an acute STEMI.
474. These failures painted an incomplete, inaccurate, and misleading picture of Charlene’s medical condition, further contributing to the repeated failures to recognize, diagnose, and treat her STEMI and angina.
475. Dr. Murray’s failures to maintain accurate and timely records thus contributed to Charlene’s pain, suffering, injury, and death.
476. As Dr. Murray’s employer or other principal at the time of his negligence, one or more of the Southwell Defendants are vicariously liable for his negligence, because Dr. Murray was acting within the scope of his employment or agency with one or more of the Southwell Defendants at that time.
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Count 12: Improper Admission to Tift - Against Dr. Phillips and the Southwell Defendants
477. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
478. In the circumstances summarized in Paragraph 378, when the patient returns the next day with a STEMI and the cardiologist refuses to perform another catheterization, the standard of care requires a hospitalist to deny the patient’s admission, so that the patient may be transferred to a hospital capable of providing her definitive care—angioplasty and bypass surgery.
479. On February 24, 2020, Hospitalist Cynthia Phillips violated this requirement by admitting Charlene Doggett to Tift, even though Tift lacked both the capability and a plan to provide definitive care for her STEMI.
480. This violation was all the more egregious because:
a. Charlene had just had an NSTEMI;
b. the attending physician in the ER diagnosed Charlene with a STEMI immediately upon her return that morning;
c. Charlene’s medical history, clinical presentation, and EKGs made it clear that she was having an acute inferior STEMI;
d. the inferior STEMI was consistent with an occlusion in the mid-RCA; and
e. Dr. Phillips admitted Charlene to the step-down unit (SDU) for medical management and hospital care.
481. Had Dr. Phillips denied Charlene’s admission to Tift, Charlene would have been transferred to a hospital capable of providing her definitive care. There, an angioplasty or bypass surgery would have restored normal blood-flow to Charlene’s heart, resolving her STEMI and averting her death.
482. Dr. Phillips’s admission thus caused Charlene pain, suffering, injury, and death.
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483. As Dr. Phillips’s employer or other principal at the time of her negligence, one or more of the Southwell Defendants are vicariously liable for her negligence, because Dr. Phillips was acting within the scope of her employment or agency with one or more of those entities at that time.
Count 13: Failure to Transfer to Another Hospital - Against Dr. Phillips and the Southwell Defendants
484. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
485. If the hospitalist nevertheless admits the patient, the standard of care then requires the hospitalist to transfer the patient emergently to a hospital capable of providing definitive care for the STEMI. In fact, the Emergency Medical Treatment and Labor Act (“EMTALA”) requires such transfer. See 42 U.S.C. § 1395dd(b)(1).
486. This requirement applies with even greater force where the hospitalist herself has confirmed and documented the STEMI.
487. On February 24, 2020, Dr. Phillips violated this requirement by failing to transfer Charlene to a hospital capable of performing bypass surgery, so that Charlene could there undergo either bypass surgery, or another angioplasty with bypass as a backup, or both.
488. Because it violated EMTALA, Dr. Phillips’s failure to transfer Charlene was negligence per se.
489. This violation is all the more egregious because:
a. Charlene’s medical history, clinical presentation, and EKGs confirmed an acute inferior STEMI in progress;
b. the inferior STEMI was consistent with an occlusion in the mid-RCA;
c. the attending physician in the ER confirmed his initial diagnosis;
d. Dr. Phillips herself ordered a second EKG, which confirmed the STEMI;
e. Dr. Phillips herself noted that Charlene was having a STEMI;
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f. Troponin levels, telemetry, and a third EKG repeatedly reconfirmed a STEMI in progress while Charlene was in the SDU; and
g. Charlene spent the last hours of her life dying painfully of an untreated STEMI as an admitted patient in the SDU.
490. At a referral hospital, an angioplasty or bypass surgery would have restored normal blood-flow to Charlene’s heart, resolving her STEMI and averting her death.
491. Dr. Phillips’s failure to transfer Charlene to another hospital thus caused her pain, suffering, injury, and death.
492. As Dr. Phillips’s employer or other principal at the time of her negligence, one or more of the Southwell Defendants are vicariously liable for her negligence, because Dr. Phillips was acting within the scope of her employment or agency with one or more of those entities at that time.
Count 14: Third Failure to Obtain Informed Consent – Against Dr. Phillips and the Southwell Defendants
493. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
494. The standard of care requires the hospitalist to obtain the patient’s informed consent to the patient’s admission to a hospital that cannot provide definitive care for the STEMI, in lieu of transfer to a hospital that can.
495. On February 24, 2020, Dr. Phillips violated this requirement by:
a. failing to inform Charlene Doggett that she was having a STEMI;
b. failing to inform Charlene that Tift lacked the capability to provide definitive care for her STEMI;
c. failing to inform Charlene that bypass surgery and another angioplasty were definitive-care options available at other hospitals;
d. failing to obtain Charlene’s informed consent to remaining at a hospital that lacked the capability to provide definitive care for her STEMI; and
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e. failing to obtain Charlene’s informed consent to a course of treatment that excluded the definitive care available at other hospitals.
496. Had Dr. Phillips sought Charlene’s informed consent, Charlene would have requested and sought a transfer to a hospital capable of providing her definitive care—another angioplasty and bypass surgery.
497. There, an angioplasty or bypass surgery would have restored normal bloodflow to Charlene’s heart, resolving her STEMI and averting her death.
498. Dr. Phillips’s failure to obtain Charlene’s informed consent thus caused her pain, suffering, injury, and death.
499. As Dr. Phillips’s employer or other principal at the time of her negligence, one or more of the Southwell Defendants are vicariously liable for her negligence, because Dr. Phillips was acting within the scope of her employment or agency with one or more of those entities at that time.
500. The failures by Dr. Murray, Dr. Tronolone, and Dr. Phillips to obtain Charlene’s informed consent exemplify a systemic failure: Tift lacked or did not sufficiently disseminate or enforce policies for obtaining such consent.
Count 15: Ordinary Negligence – Against the Southwell Defendants7
501. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
502. Each of the Southwell Defendants owed patients an ordinary duty to safeguard their safety when hospitalized at Tift.
503. Upon information and belief, the Southwell Defendants, through their management and administrators, breached that duty by failing to implement policies, procedures, and practices sufficient to safeguard patient safety.
Because this Count is for ordinary negligence by the Southwell Defendants through their managers and administrators (as opposed to a claim for professional negligence, based on the conduct of licensed healthcare professionals), it is not subject to O.C.G.A. § 9-11-9.1.
7
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504. The repeated confounding failures by the individual Defendants reveal and exemplify those systemic failures.
505. Dr. Harris’s obvious misinterpretation and misstatement of Charlene’s medical condition, for example, suggests that Tift lacked or did not sufficiently disseminate or enforce (a) policies requiring medical providers to read and communicate clinical information carefully, and (b) protocols for the effective hand-off of patients and of clinical information among providers.
506. Dr. Tronolone’s failures to order a myocardial-perfusion test and to keep Charlene hospitalized suggest (among other problems) that the Southwell Defendants failed to staff Tift sufficiently on weekends.
507. The failures by Dr. Murray, Dr. Tronolone, and Dr. Phillips to obtain Charlene’s informed consent suggest that the Southwell Defendants lacked or did not sufficiently disseminate or enforce policies for obtaining such consent.
508. Dr. Murray’s wanton delay in examining Charlene suggests that the Southwell Defendants failed to have, disseminate, and/or enforce protocols for the rapid evaluation and treatment of heart-attack patients.
509. Dr. Murray’s failure to diagnose an obvious STEMI shows that the Southwell Defendants failed to hire or contract qualified and competent medical providers, even in a specialty as critical as cardiology.
510. Dr. Phillips’s failure to transfer Charlene to another hospital suggests that the Southwell Defendants lacked or did not enforce a sound policy for the transfer of patients, even when required by federal law (EMTALA).
511. Dr. Smith’s quips that Tift “does not crack the chest open for just one blockage” and that “sometimes your loved ones just die” reveal that Tift lacked proper training and protocols for providing definitive care to heart-attack patients.
512. Such institutional failures, moreover, are widespread among hospitals—a fact that reinforces the systemic breaches inferred from individual failures here.
513. As one article explains, for example: “Clinical Handover has been identified as one of the most high-risk processes within medicine. Inadequate handover is a significant cause of avoidable adverse events across many hospitals.” Annals of Medicine and Surgery, Vol. 56, August 2020, at 77-81.
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514. The failures by individual Defendants thus reflect and exemplify the Southwell Defendants’ breaches of their duty to safeguard patient safety.
515. The Southwell Defendants’ systemic breaches were thus a cause of the harm Charlene suffered at Tift, including her pain, suffering, injury, and death.
Causation: All Counts
516. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
517. During both of Charlene’s hospitalizations at Tift, there were at least two definitive options for revascularizing her heart, at hospitals capable of performing bypass surgery: (a) another angioplasty with bypass surgery as backup in the event of complications, and (b) bypass surgery itself.
518. After Dr. Murray documented a 100% in-stent occlusion without collateral circulation in Charlene’s mid-RCA, both procedures were indicated.
519. Charlene was eligible for both procedures during both Tift hospitalizations.
520. Charlene was eligible for angioplasty.
521. A successful angioplasty would have restored normal blood-flow and would have prevented or resolved Charlene’s STEMI.
522. At a hospital capable of performing bypass surgery, an interventional cardiologist could have performed angioplasty more aggressively, knowing that bypass surgery was available as a backup in case of complications. Also, a referral hospital would have had greater clinical capabilities than Tift.
523. Thus, if the referral hospital decided to try angioplasty first, and even if angioplasty then proved unsuccessful, Charlene then would have undergone a successful bypass surgery, as explained below.
524. Charlene was also eligible for bypass surgery, for the following reasons:
a. She had a single-vessel disease (in her RCA).
b. She did not have any clinically significant LAD stenosis.
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c. She had well preserved ventricular function—a major determinant of prognosis after a heart attack.
d. Her heart was fundamentally normal except for the occlusion itself.
e. She had no comorbidities that increased the risk of the surgery.
f. Her functional status prior to the Tift hospitalizations was normal.
525. Even when Charlene returned to Tift with a STEMI on February 24, 2020, bypass surgery would have been a brief, straightforward, and low-risk procedure, lasting approximately 30 minutes.
526. Charlene’s eligibility for bypass surgery was all the more clear during her first Tift hospitalization, before the onset of the STEMI.
527. Bypass surgery would have restored normal blood-flow around the occlusion, and thus would have prevented or resolved Charlene’s STEMI.
528. Charlene’s risk of death from bypass surgery was less than 1%. That is, her chances of survival were over 99%.
529. After bypass surgery, given her age and medical history, Charlene would have gone on to lead a long, healthy, high-quality life.
530. After bypass surgery, Charlene would have resumed all activities of daily living with substantially the same functionality as before the NSTEMI that led to her first Tift hospitalization.
531. In light of the definitive treatments available at a referral hospital during the course of her two Tift hospitalizations, Charlene’s STEMI would have been prevented or resolved, and her death averted, had a provider at Tift referred or transferred Charlene.
532. Providers at Tift thus wasted repeated opportunities to prevent or resolve Charlene’s STEMI and avert her death.
533. But-for each failure to refer or transfer Charlene, she would have survived and resumed her life.
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534. Each such failure thus led directly to Charlene’s coronary ischemia, myocardial infarction, malignant arrhythmias, cardiac arrest, and death.
535. Each such failure thus caused Charlene pain, suffering, injury, and death.
536. Insofar as misdiagnosis of her condition was a rationale for a failure to refer or transfer Charlene, each instance of misdiagnosis was also a cause of her pain, suffering, injury, and death.
537. Because further investigation of the adequacy of collateral blood-flow and myocardial perfusion would have shed light on where and to what extent Charlene’s heart-muscle was in jeopardy, the failure to perform a myocardial perfusion test or otherwise conduct such further investigation was also a cause of Charlene’s pain, suffering, injury, and death.
538. Had Charlene been informed that she needed and was eligible to undergo bypass surgery or another angioplasty at another hospital, it stands to reason that she would have pursued those options. As a result, any failure to so inform Charlene was also a cause of her pain, suffering, injury, and death.
Damages
539. Pursuant to OCGA Title 51, Chapter 4, Plaintiff is entitled to recover from all Defendants for all damages caused by their negligence.
Survival Action: Estate Claim
540. Plaintiff incorporates by reference all paragraphs of this Complaint as though fully set forth herein.
541. Plaintiff is entitled to damages for Charlene Doggett’s conscious pain and suffering resulting from the untreated occlusion in her mid-RCA.
542. As early as February 20, 2020, the date of her first Tift hospitalization, Charlene rated her pain a 10 out of 10—the “worst possible pain.” TRH 368.
543. Plaintiff is also entitled to damages for Charlene’s conscious pain and suffering over the hours she endured an untreated STEMI.
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544. After her discharge from Tift, Charlene spent the night at her son’s home, in pain and fear. At the Tift ER the following morning, she described the pain as a 10 and “like an elephant sitting on my chest.” TRH 37.
545. From that point until her death that night, Charlene’s chest pain remained constant, relentless, and obvious. See, e.g., TRH 16. She continually hunched over, gripping her chest and rocking. Each time a doctor or nurse asked about her pain, she said that medications were “not helping.”
546. Plaintiff is also entitled to damages for Charlene’s conscious pain and suffering when she endured coronary ischemia, myocardial infarction, malignant arrhythmias, cardiac arrest, and death.
547. Plaintiff is also entitled to damages for the existential terror Charlene faced during the hours she died gradually and painfully, unattended, because Defendants failed to provide definitive care for a fatal STEMI.
548. What’s worse, providers at Tift told Charlene that her pain was just a “carryover” from the NSTEMI, that her occlusion was self-correcting, and that she just had to “push through the pain”—all medical distortions that confounded her final hours, deepening her dread and suffering.
Wrongful-Death Claim
549. Prior to her Tift hospitalizations, Charlene Doggett was independent and self-sufficient. She often proclaimed she was happy living alone in her house.
550. Charlene performed all the activities of daily living by herself. She managed and cared for her home, and did her household errands and chores. In fact, Charlene often drove her grandkids and others to run their errands. For example, she often took her granddaughters to do their nails.
551. Charlene cleaned houses for income. Before that, she worked as a caretaker for several families. She would declare that she was going to keep working all her life. She usually punctuated that declaration with: “and that’s that.”
552. Charlene was active in her church—New Bethel Freewill Baptist Church, in Sylvester, Georgia. She liked helping others and often helped them—family, friends, neighbors.
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553. Charlene loved her family. She attended most family gatherings, bringing food, usually a cake or pie she made. Her last Christmas, she was thrilled to host her siblings and their families at her home.
554. Charlene was generous with her time and money.
555. Charlene sometimes joined Jason, Carrie, and their kids on vacations. She sometimes paid for the kids’ “share.” Sometimes she would step in and give Jason and Carrie money for no particular reason—just “to help out,” she said.
556. Whenever Jason and Carrie traveled, Charlene babysat their minor kids.
557. During the school year, her grandkids would sleep over at her house at least once a month. Over the summer, they would sleep over at her house several nights at a time. Charlene said she was “all about the grandkids.”
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558. Charlene treasured her friendships and associations. Her friend Linda would come visit and stay for several days. After Charlene passed away, her friends posted kind comments on her Facebook profile. The funeral home had an online page, where people posted similar comments.
559. Over 100 people attended her viewing, which was held on February 28, 2020.
560. After Charlene’s death, a local restaurant commemorated her birthday. This is how a local newspaper covered the event:
“Friday, August 15th was Ms. Charlene Doggett’s birthday and Ed’s Truckstop presented her family with a Memorial Bench to honor her passing on February 24th. The bench was also to commemorate her time spent at Ed’s, where she worked for Mr. Ed as a waitress, for many years.
“She fit right in at Ed’s. She loved to talk and most customers did too, between mouthfuls. New customers at Ed’s would find a friend in Charlene and the old timers enjoyed the conversations about her four grandbabies and other local subjects.”
561. Charlene’s photograph hangs in memoriam, inside Ed’s.
___________________
562. As a direct and proximate result of Defendants’ conduct, Plaintiff is entitled to recover from Defendants reasonable compensatory damages in an amount exceeding $10,000.00 to be determined by a fair and impartial jury, for all damages Charlene Doggett and Plaintiff suffered.
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WHEREFORE, Plaintiff demands a trial by jury, and judgment against the Defendants as follows:
a.
b.
c.
d.
e.
Compensatory damages in an amount exceeding $10,000.00 to be determined by a fair and impartial jury;
All costs of this action;
Expenses of litigation pursuant to OCGA 13-6-11, including attorneys fees;
Punitive damages; and
Such other and further relief as the Court deems just and proper.
August 13, 2021
Respectfully submitted,
/s/ Lloyd N. Bell Lloyd N. Bell Georgia Bar No. 048800 Daniel E. Holloway Georgia Bar No. 658026
BELL LAW FIRM 1201 Peachtree St. N.E., Suite 2000 Atlanta, GA 30361 (404) 249-6767 (tel) bell@BellLawFirm.com dan@BellLawFirm.com