IN THE STATE COURT OF DEKALB COUNTY

STATE OF GEORGIA

Yolanda Ratchford,

Plaintiff,

— versus —

Emory University,

Emory Healthcare, Inc,

The Emory Clinic, Inc,

Olamide Alabi, MD,

Galimat Khaidakova, MD,

Ronald Chang, MD,

Milad Sharifpour, MD,

Paula Lay, NP,

Alexander Kosiak, MD,

Tyler Hall, RN,

Shaquira Hall, RN,

Keera Price, RN,

AMN Healthcare, Inc,

Veronica Harsany, RN,

and

John/Jane Does 1-10,

                                             Defendants

CIVIL ACTION

FILE NO. ___________

JURY TRIAL DEMANDED

PLAINTIFF’S COMPLAINT FOR DAMAGES

Nature of this Action

1.             This medical malpractice action arises out of medical and nursing care negligently provided to Yolanda Ratchford on March 26 and 27, 2021.

2.             Plaintiff hereby asserts claims of professional negligence against each of the Defendants, either directly or variously. In addition, this Complaint asserts claims of ordinary negligence against each of the corporate Defendants.

3.             As used here, “standard of care” means that degree of care and skill ordinarily employed by the medical profession generally under similar conditions and like circumstances as pertained to the Defendants’ actions here.

4.             Pursuant to OCGA § 9-11-9.1, the affidavits of Tejas Shah, MD, Eric Gluck, MD, and Judith Climenson, RN, are attached as Exhibits 1-3, respectively.

5.             This Complaint incorporates the opinions and allegations found in those affidavits. Plaintiff also stipulates that Defendants need not respond to:

·      anything contained in the exhibits or attachments to this Complaint,

·      statements that are not made in numbered allegations, including footnotes, except where a numbered allegation explicitly incorporates accompanying matter that is not in a numbered paragraph, and

·      citations to Bates-stamped pages of records or to graphics or screenshots that accompany allegations (which are included to make it easy to respond to the allegations, but are not part of the allegations).  

Parties, Jurisdiction, and Venue

6.             Plaintiff YOLANDA RATCHFORD is a citizen and resident of Alabama.  Plaintiff submits to the personal jurisdiction and venue of this Court.

7.             EMORY UNIVERSITY (“EU”) is a Georgia nonprofit corporation. Its Registered Agent is Amy Adelman. Its physical address is 201 Dowman Drive, 312 Administration Building, Atlanta, GA, 30322, in DeKalb County. Its principal office address is 505 Kilgo Circle NE, 300 Convocation Hall, Atlanta, GA 30322, in DeKalb County.

8.             EU is subject to the personal jurisdiction of this Court.

9.             EU is subject to the subject matter jurisdiction of this Court in this case.

10.          EU is directly subject to venue[1] in this Court because its principal office is in DeKalb County.

11.          EU has been properly served with this Complaint.

12.          EU has no defense to this lawsuit based on undue delay — whether based on the statute of limitations, the statute of repose, laches, or any other similar theory.

13.          At all times relevant to this Complaint, EU was the parent corporation of Emory University Hospital. EU thus provided overall coordination (including governance) to Emory University Hospital.

14.          At all times relevant to this Complaint, EU was the employer or other principal of Dr. Khaidakova, Dr. Chang, and Dr. Kosiak. If another entity was the employer or other principal of one or more of those Defendants 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.

15.          EMORY HEALTHCARE, INC. (“EHI”) is a Georgia nonprofit corporation. Its Registered Agent is Amy Adelman. Its physical address is 201 Dowman Drive, 312 Administration Building, Atlanta, GA, 30322, in DeKalb County. Its principal office address is 201 Dowman Drive, 101 Administration Building, Atlanta, GA, 30322, in DeKalb County.

16.          EHI is subject to the personal jurisdiction of this Court.

17.          EHI is subject to the subject matter jurisdiction of this Court in this case.

18.          EHI is directly subject to venue in this Court because its principle office is in DeKalb County.

19.          EHI has been properly served with this Complaint.

20.          EHI has no defense to this lawsuit based on undue delay — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

21.          At all times relevant to this Complaint, EHI was the parent corporation of Emory University Hospital. EHI thus provided overall coordination (including governance) to Emory University Hospital.

22.          At all times relevant to this Complaint, EHI was the employer or other principal of NP Lay, RN Tyler Hall, RN Shaquira Hall, and RN Price. If another entity was the employer or other principal of one or more of those Defendants 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.          THE EMORY CLINIC, INC. (“ECI”) is a Georgia nonprofit corporation. Its Registered Agent is Amy Adelman. Its physical address is 201 Dowman Drive, 312 Administration Building, Atlanta, GA, 30322, in DeKalb County. Its principal office address is 1365 Clifton Rd NE, Atlanta, GA, 30322, in DeKalb County.

24.          ECI is subject to the personal jurisdiction of this Court.

25.          ECI is subject to the subject matter jurisdiction of this Court in this case.

26.          ECI is directly subject to venue in this Court because its principal office is in DeKalb County.

27.          ECI has been properly served with this Complaint.

28.          ECI has no defense to this lawsuit based on undue delay — whether based on the statute of limitations, the statute of repose, laches, or any other similar theory.

29.          At all times relevant to this Complaint, ECI was the employer or other principal of Dr. Alabi, Dr. Chang, and Dr. Sharifpour. If another entity was the 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.

30.          OLAMIDE ALABI, MD, is a Georgia resident. She resides at 2233 Peachtree Rd, NE, Unit 901, Atlanta, GA 30309, in Fulton County.

31.          Dr. Alabi is subject to the personal jurisdiction of this Court.

32.          Dr. Alabi is subject to the subject matter jurisdiction of this Court in this case.

33.          Pursuant to OCGA § 9-10-31, Dr. Alabi is subject to venue in this Court, because at least one of her co-defendants is directly subject to venue here.

34.          Dr. Alabi has been properly served with this Complaint.

35.          Dr. Alabi has no defense to this suit based on undue delay, whether based on the statute of limitations, the statute of repose, laches, or any other similar theory.

36.          At all times relevant to this Complaint, Dr. Alabi acted as an employee or other agent of ECI.  

37.          GALIMAT KHAIDAKOVA, MD, is an Alaska resident. She resides at 7817 Brentwood Dr, Anchorage, AK 99502, in Anchorage County.

38.          Dr. Khaidakova is subject to the personal jurisdiction of this Court.

39.          Dr. Khaidakova is subject to the subject matter jurisdiction of this Court in this case.

40.          Pursuant to OCGA § 9-10-31, Dr. Khaidakova is subject to venue in this Court because one or more of her co-defendants is directly subject to venue here.

41.          Dr. Khaidakova has been properly served with this Complaint.

42.          Dr. Khaidakova has no defense to this lawsuit based on undue delay — whether based on the statute of limitations, the statute of repose, laches, or any other similar theory.

43.          At all times relevant to this Complaint, Dr. Khaidakova acted as an employee or other agent of EU.

44.          RONALD CHANG, MD, is a Texas resident. He resides at 518 Kingfisher Dr, Sugar Land, TX 77478, in Fort Bend County.

45.          Dr. Chang is subject to the personal jurisdiction of this Court.

46.          Dr. Chang is subject to the subject matter jurisdiction of this Court in this case.

47.          Pursuant to OCGA § 9-10-31, Dr. Chang is subject to venue in this Court because one or more of his co-defendants is directly subject to venue here.

48.          Dr. Chang has been properly served with this Complaint.

49.          Dr. Chang has no defense to this suit based on undue delay, whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

50.          At all times relevant to this Complaint, Dr. Chang acted as an employee or other agent of EU or ECI.

51.          MILAD SHARIFPOUR, MD, is a California resident. He resides at 640 S Curson Ave, Apt 605, Los Angeles, CA 90036, in Los Angeles County.

52.          Dr. Sharifpour is subject to the personal jurisdiction of this Court.

53.          Dr. Sharifpour is subject to the subject matter jurisdiction of this Court in this case.

54.          Pursuant to OCGA § 9-10-31, Dr. Sharifpour is subject to venue in this Court because one or more of his co-defendants is directly subject to venue here.

55.          Dr. Sharifpour has been properly served with this Complaint.

56.          Dr. Sharifpour has no defense to this lawsuit based on undue delay — whether based on the statute of limitations, the statute of repose, laches, or any other similar theory.

57.          At all times relevant to this Complaint, Dr. Sharifpour acted as an employee or other agent of ECI.

58.          PAULA LAY, NP, is a Georgia resident. She resides at 309 Forest Pointe Dr, Forsyth, GA 31029, in Monroe County.

59.          NP Lay is subject to the personal jurisdiction of this Court.

60.          NP Lay is subject to the subject matter jurisdiction of this Court in this case.

61.          Pursuant to OCGA § 9-10-31, NP Lay is subject to venue in this Court because one or more of her co-defendants is directly subject to venue here.

62.          NP Lay has been properly served with this Complaint.

63.          NP Lay has no defense to this lawsuit based on undue delay, whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

64.          At all times relevant to this Complaint, NP Lay acted as an employee or other agent of EHI.

65.          ALEXANDER KOSIAK, MD, is an Ohio resident. He resides at 1947 E 85th St, Cleveland, OH 44106, in Cuyahoga County.

66.          Dr. Kosiak is subject to the personal jurisdiction of this Court.

67.          Dr. Kosiak is subject to the subject matter jurisdiction of this Court in this case.

68.          Pursuant to OCGA § 9-10-31, Dr. Kosiak is subject to venue in this Court because one or more of his co-defendants is directly subject to venue here.

69.          Dr. Kosiak has been properly served with this Complaint.

70.          Dr. Kosiak has no defense to this suit based on undue delay, whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

71.          At all times relevant to this Complaint, Dr. Kosiak acted as an employee or other agent of EU.

72.          Tyler Hall, RN, is a Georgia resident. He resides at 5130 Akbar Chase, Atlanta, GA 30339, in Cobb County.

73.          RN Tyler Hall is subject to the personal jurisdiction of this Court.

74.          RN Tyler Hall is subject to the subject matter jurisdiction of this Court in this case.

75.          Pursuant to OCGA § 9-10-31, RN Tyler Hall is subject to venue in this Court because one or more of his co-defendants is directly subject to venue here.

76.          RN Tyler Hall has been properly served with this Complaint.

77.          RN Tyler Hall has no defense to this suit based on undue delay, whether based on the statute of limitations, the statute of repose, laches, or other theory.

78.          At all times relevant to this Complaint, RN Tyler Hall acted as an employee or other agent of EHI.

79.          SHAQUIRA HALL, RN, is a Georgia resident. She resides at 3795 Butler Springs Dr, Loganville, GA 30052, in Gwinnett County.

80.          RN Shaquira Hall is subject to the personal jurisdiction of this Court.

81.          RN Shaquira Hall is subject to the subject matter jurisdiction of this Court in this case.

82.          Pursuant to OCGA § 9-10-31, RN Shaquira Hall is subject to venue in this Court because one or more of her co-defendants is directly subject to venue here.

83.          RN Shaquira Hall has been properly served with this Complaint.

84.          RN Shaquira Hall has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any other similar theory.

85.          At all times relevant to this Complaint, RN Shaquira Hall acted as an employee or other agent of EHI.

86.          KEERA PRICE, RN, is a Georgia resident. She resides at 2404 Hadlow Ln, Unit 24, Atlanta, GA 30339, in Cobb County.

87.          RN Price is subject to the personal jurisdiction of this Court.

88.          RN Price is subject to the subject matter jurisdiction of this Court in this case.

89.          Pursuant to OCGA § 9-10-31, RN Price is subject to venue in this Court because one or more of her co-defendants is directly subject to venue here.

90.          RN Price has been properly served with this Complaint.

91.          RN Price has no defense to this suit based on undue delay, whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

92.          At all times relevant to this Complaint, RN Price acted as an employee or other agent of EHI.

93.          AMN HEALTHCARE, INC. (“AMN”) is a foreign profit corporation. Its registered agent is Corporation Service Company. Its physical address is 2 Sun Court, Suite 400, Peachtree Corners, GA, 30092. Its principal office address is 12400 High Bluff Dr, Ste 100, San Diego, CA 92130.

94.          AMN is subject to the personal jurisdiction of this Court in this case.

95.          AMN is subject to the subject matter jurisdiction of this Court in this case.

96.          Pursuant to OCGA § 9-10-31, AMN is subject to venue in this Court because one or more of its co-defendants is directly subject to venue here.

97.          AMN has been properly served with this Complaint.

98.          AMN has no defense to this suit based on undue delay, whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

99.          At all times relevant to this Complaint, AMN was the employer or other principal of RN Veronica Harsany. If another entity was the employer or other principal of RN Harsany 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.

100.       VERONICA HARSANY, RN, is a South Carolina resident. She resides at 324 Caston Way Ln, Cheraw, SC 29520, in Chesterfield County.

101.       RN Harsany is subject to the personal jurisdiction of this Court.

102.       RN Harsany is subject to the subject matter jurisdiction of this Court in this case.

103.       Pursuant to OCGA § 9-10-31, RN Harsany is subject to venue in this Court because one or more of her co-defendants is directly subject to venue here.

104.       RN Harsany has been properly served with this Complaint.

105.       RN Harsany has no defense to this lawsuit based on undue delay in bringing suit — whether based on the statute of limitations, the statute of repose, laches, or any similar theory.

106.       At all times relevant to this Complaint, RN Harsany acted as an employee or other agent of AMN.

107.       JOHN/JANE DOES 1-10 are yet-unidentified natural and legal persons who may be wholly or partly liable for the damages alleged here. Once served with process, John/Jane Does 1-10 are subject to the jurisdiction and venue of this Court.

Negligent Administration: General Notice of Claim

108.       Plaintiff here incorporates by reference all paragraphs of this Complaint.

109.       EU, EHI, ECI, and AMN (the “Corporate Defendants”) owed ordinary duties of care to Yolanda Ratchford.

110.       The Corporate Defendants breached those duties.

111.       The Corporate Defendants are directly liable for the breach of those duties.

112.       The Corporate Defendants breached those duties through the actions of administrators not licensed for professions listed in OCGA 9-11-9.1(g).

113.        The Corporate Defendants breached those duties through the actions professional staff performing purely administrative tasks.

114.       Negligent administration by Corporate Defendants created unnecessary and unreasonable potential for medical error by the physicians and nurses involved in the care of Yolanda Ratchford. Negligently administered systems and organizational cultures promoted, rather than prevented, medical error.

115.       By violating their duties of ordinary care, the Corporate Defendants harmed Yolanda Ratchford.

116.       The persons directly responsible for acts of negligent administration were actual or ostensible agents or otherwise employees or servants of the Corporate Defendants. The Corporate Defendants are vicariously liable for the ordinary negligence of its agents.

Negligent Administration: Detailed Notice of Claim

Statements not in numbered paragraphs require no response from the Defendants.

The foregoing averments suffice to state a claim. In keeping with the overriding goal of the Civil Practice Act — “to secure the just, speedy, and inexpensive determination of every action”[2] — the more detailed averments below are presented to provide further notice, narrow disputes, and simplify discovery and trial.

Nevertheless, Plaintiff does not waive Georgia’s notice-pleading requirements, or assume any obligation to provide more than the general notice required by law.[3]

Negligence, not Professional Malpractice

117.       Georgia law recognizes that ordinary negligence in the form of negligent administration can contribute to a chain of events that includes medical malpractice and harms a patient.[4]

118.       Georgia law recognizes that both ordinary negligence and medical malpractice can exist and combine to cause harm — creating liability for both ordinary negligence and medical malpractice.

119.       Any negligence by a person not licensed for a profession listed in OCGA 9-11-9.1(g) is ordinary negligence, not professional malpractice.

120.       Georgia courts have not catalogued every purely administrative duty in a hospital.

121.       Plaintiff’s Negligent Administration claim is not a claim for professional malpractice as defined in OCGA 9-11-9.1. Instead, it is a claim for negligence — that is, “ordinary” or “simple” negligence.

122.       This claim is premised largely on the negligence of persons who are not licensed for professions listed in OCGA 9-11-9.1.

123.       To the extent this claim is premised on the negligence of persons who are licensed for professions listed in OCGA 9-11-9.1, this claim addresses only acts that could permissibly be performed by people who are not so licensed.

124.       To the extent trial and appellate courts ultimately determine that any particular act constituted professional malpractice as defined in OCGA 9-11-9.1, Plaintiff stipulates that the act does not support a claim for ordinary negligence.

Non-Licensed Administrators

125.       At all times relevant to this action, Emory University was responsible for managing or administering Emory University Hospital, located at 1364 Clifton Rd NE, Atlanta, GA 30322 (“the Hospital”).

126.       At all times relevant to this action, Emory Healthcare, Inc., was responsible for managing or administering the Hospital.

127.       The administrators of the Hospital included persons who were not licensed healthcare professionals and were not licensed for any profession listed in OCGA 9-11-9.1 (“Non-Licensed Administrators”).

128.       Non-Licensed Administrators had job responsibilities that impacted the safety of patients, including Yolanda Ratchford.

129.       Non-Licensed Administrators negligently failed in their duties and thereby contributed to causing injury to Yolanda Ratchford.

130.       The negligent administration by Non-Licensed Administrators included failures of monitoring, communication, supervision, training, staffing, and funding, and the failure to create and maintain a culture of safety, among other failings.

Licensed Administrators Acting in a Purely Administrative Capacity

131.       The administrators of the Hospital included persons who were licensed healthcare professionals but who at times performed purely administrative duties (“Licensed Administrators”).

132.       Licensed Administrators had some job responsibilities that were purely administrative and impacted the safety of patients, including Yolanda Ratchford.

133.       Licensed Administrators negligently failed in those purely administrative duties and thereby contributed to causing injury to Yolanda Ratchford.

134.       The negligent administration by Licensed Administrators included failures of monitoring, communication, supervision, training, staffing, and funding, and the failure to create and maintain a culture of safety, among other failings.

Healthcare Administration Generally

135.       The way healthcare facilities are managed is not obvious or intuitive.

136.       Even clinicians with years of experience in a healthcare facility may have limited knowledge of how that facility is administered.

137.       Because most adults will have significant experience with healthcare as patients or consumers, they may have “gut” or “common sense” intuitions about healthcare administration that are strong, but wrong.

Principles of Healthcare Administration

Scale of Medical Error, and System Failures as a Cause

138.       Preventable medical error is a leading cause of death in the United States.

139.       The complexity of hospital care creates potential for medical errors of various kinds — for example, inattention, failures of communication, lack of preparedness, mistaken assumptions that someone else is addressing a problem, and others.

140.       A central function of healthcare administration is to create systems and organizational cultures that facilitate exposing medical errors before they cause serious harm.

141.       Medical errors usually involve (a) error by the clinicians directly involved in a patient’s care, and (b) system failures that create unnecessary potential for error.

Management or Administration as a Distinct Discipline

142.       Hospital administrators need education, training, and skills different from those required to be a physician or nurse. Hospital administrators must have management training, but need not have gone to medical or nursing school.

143.       OCGA 9-11-9.1(g) does not include hospital administrators in the list of professionals to which OCGA 9-11-9.1 applies.

144.       Non-Licensed Administrators — because they are not medical professionals — do not apply medical judgment in their work.

145.       Where licensed medical professionals occupy administrative roles, some of their duties include administrative tasks that do not require being a licensed medical professional — for example, checking to make sure a certain policy has been communicated to hospital staff, or checking to make sure hospital staff has undergone certain training.

Non-Licensed Administrators & Patient Safety

146.       Clinicians treating patients usually are not in a position to fix problems with the systems and organizational cultures in a hospital.

147.       Hundreds or even thousands of individual providers may practice in a given hospital. The individual providers practice within the systems and organizational culture maintained by hospital administrators. The individual providers must rely on, and are constrained by, the work of hospital administrators.

148.       Patient safety is not solely the responsibility of the individual providers treating a patient.

149.       Hospital administrators acting in a purely administrative capacity have responsibilities for protecting patient safety.

150.       Negligence by Non-Licensed Administrators can and does foreseeably cause harm to patients. Within the healthcare industry, this principle is accepted and well understood by clinicians and non-clinicians alike.

Responsibilities of Hospital Administrators for Patient Safety

151.       Federal regulations impose requirements on hospital administrators concerning patient safety.

152.       The Joint Commission’s accreditation standards impose requirements on hospital administrators concerning patient safety.

153.       Pursuant to industry standards, Non-Licensed Administrators are responsible for the systems and organizational culture of the hospital.

154.       Non-Licensed Administrators must learn about and identify the common sources of medical error industry-wide, and must ensure that those general sources of error are addressed effectively in the administrators’ own hospital.

155.       Concerning policies or protocols for medical care, Non-Licensed Administrators have limited but important responsibilities.

156.       Concerning policies or protocols for medical care, Non-Licensed Administrators are responsible for:

a.    making sure need-assessments are performed to identify what policies or protocols should be created,

b.    making sure policies and protocols are communicated effectively to hospital staff (instead of just papering the file),

c.     making sure training is given so that hospital staff understand how to apply the policies and protocols in practice,

d.    making clear that the policies and protocols must be followed (that is, that they are not bureaucratic formalities which staff can disregard),

e.     monitoring compliance, and

f.      ensuring remedial actions are taken where compliance problems arise.

157.       Non-Licensed Administrators must engage all hospital staff in actively seeking out problems in the hospital’s system and culture — and fixing the problems before they cause further harm.

158.       Non-Licensed Administrators must ensure the hospital is actually implementing policies. Just papering the file is not enough.

159.       Non-Licensed Administrators have important responsibilities in a variety of specific areas. The following is a non-exhaustive list:

a.    Culture of Safety

b.    Quality Monitoring & Improvement

c.     Staffing & Training

d.    Communication, Transfers, & Hand-offs

e.     Patient Rights & Grievance Process

f.      Sentinel Events

Accountability of Hospital Administrators

160.       Purely administrative negligence can contribute substantially to medical error that hurts patients.

161.       It would be dangerous to exempt hospital administrators from accountability for their own negligence.

162.       Exempting hospital administrators from accountability for their own negligence would remove an important incentive for administrators to work diligently to create systems that protect patients. The exemption would thus facilitate medical error and extinguish important safeguards of patient safety.   

Negligent Administration in This Case

163.       The Corporate Defendants violated duties of ordinary care through administrative negligence, and in so doing, caused harm to Yolanda Ratchford.

164.       The care Yolanda received permits inferences of administrative negligence in the ways identified below. Discovery may reveal additional negligence.

a.             Communication & Coordination: Hospital administrators must ensure that protocols are in place to ensure proper communication and coordination among providers, including during hand-offs — to avoid gaps that lead to medical error.

b.             Policies and Procedures: Hospital administrators must ensure that policies for the investigation of complications, and the administration and management of high-risk medications are properly promulgated, enforced, and followed.

165.       The Corporate Defendants failed to take reasonable steps in those regards. Important parts of that work (though not all of it) are purely administrative. These Defendants thus committed administrative negligence that harmed Yolanda.

166.       Pursuant to OCGA Title 51, Chapter 4, Plaintiff is entitled to recover from the Corporate Defendants for all damages caused by their negligent administration.

Professional Malpractice: General Notice of Claim

Directly: Against Dr. Alabi, Dr. Khaidakova, Dr. Chang, Dr. Sharifpour, NP Lay, Dr. Kosiak, RN Tyler Hall, RN Shaquira Hall, RN Price, and RN Harsany.

Vicariously: Against each of the Corporate Defendants. 

167.       Plaintiff here incorporates by reference all paragraphs of this Complaint.

168.       On March 26-27, 2021, Dr. Alabi owed professional duties of care to Yolanda Ratchford — duties she breached, causing Yolanda harm.

169.       At that time, Dr. Alabi acted as an employee or other agent of The Emory Clinic, Inc. As Dr. Alabi’s employer or other principal at the time of her negligence, ECI is vicariously liable for her negligence, because Dr. Alabi was acting within the scope of her employment or agency at that time.

170.       On March 26-27, 2021, Dr. Khaidakova owed professional duties of care to Yolanda Ratchford — duties she breached, causing Yolanda harm.

171.       At that time, Dr. Khaidakova acted as an employee or other agent of Emory University. As Dr. Khaidakova’s employer or other principal at the time of her negligence, EU is vicariously liable for her negligence, because Dr. Khaidakova was acting within the scope of her employment or other agency at that time.

172.       On March 26-27, 2021, Dr. Chang owed professional duties of care to Yolanda Ratchford — duties he breached, causing Yolanda harm.

173.       At that time, Dr. Chang acted as an employee or other agent of Emory University or The Emory Clinic, Inc. As Dr. Chang’s employer or other principal at the time of his negligence, EU or ECI is vicariously liable for his negligence, because Dr. Chang acted was acting within the scope of his employment or agency at that time.

174.       On March 26-27, 2021, Dr. Sharifpour owed professional duties of care to Yolanda Ratchford — duties he breached, causing Yolanda harm.

175.       At that time, Dr. Sharifpour acted as an employee or other agent of The Emory Clinic, Inc. As Dr. Sharifpour’s employer or other principal at the time of his negligence, ECI is vicariously liable for his negligence, because Dr. Sharifpour was acting within the scope of his employment or other agency at that time.

176.       On March 26-27, 2021, NP Lay owed professional duties of care to Yolanda Ratchford — duties she breached, causing Yolanda harm.

177.       At that time, NP Lay acted as an employee or other agent of Emory Healthcare, Inc. As NP Lay’s employer or other principal at the time of her negligence, EHI is vicariously liable for her negligence, because NP Lay was acting within the scope of her employment or other agency at that time.

178.       On March 27, 2021, Dr. Kosiak owed professional duties of care to Yolanda Ratchford — duties he breached, causing Yolanda harm.

179.       At that time, Dr. Kosiak acted as an employee or other agent of Emory University. As Dr. Kosiak’s employer or other principal at the time of his negligence, EU is vicariously liable for his negligence, because Dr. Kosiak was acting within the scope of his employment or other agency at that time.

180.       On March 26-27, 2021, RN Tyler Hall owed professional duties of care to Yolanda Ratchford — duties he breached, causing Yolanda harm.

181.       At that time, RN Tyler Hall acted as an employee or other agent of Emory Healthcare, Inc. As RN Tyler Hall’semployer or other principal at the time of his negligence, EHI is vicariously liable for his negligence, because RN Tyler Hall was acting within the scope of his employment or other agency at that time.

182.       On March 26-27, 2021, RN Shaquira Hall owed professional duties of care to Yolanda Ratchford — duties she breached, causing Yolanda harm.

183.       At that time, RN Shaquira Hall acted as an employee or other agent of Emory Healthcare, Inc. As RN Shaquira Hall’s employer or other principal at the time of her negligence, EHI is vicariously liable for her negligence, because RN Shaquira Hall was acting within the scope of her employment or agency at that time.

184.       On March 27, 2021, RN Price owed professional duties of care to Yolanda Ratchford — duties she breached, causing Yolanda harm.

185.       At that time, RN Price acted as an employee or other agent of Emory Healthcare, Inc. As RN Price’s employer or other principal at the time of her negligence, EHI is vicariously liable for her negligence, because RN Price was acting within the scope of her employment or other agency at that time.

186.       On March 26-27, 2021, RN Harsany owed professional duties of care to Yolanda Ratchford — duties she breached, causing Yolanda harm.

187.       At that time, RN Harsany acted as an employee or other agent of AMN Healthcare, Inc. As RN Harsany’s employer or other principal at the time of her negligence, AMN is vicariously liable for her negligence, because RN Harsany was acting within the scope of her employment or other agency at that time.

Professional Malpractice: Detailed Notice of Claim

Defendants need not respond to statements or other matter (e.g., citations or screenshots) not set forth in numbered paragraphs.

The foregoing averments suffice to state a claim. In keeping with the overriding goal of the Civil Practice Act — “to secure the just, speedy, and inexpensive determination of every action” — the more detailed averments below are presented to give Defendants further notice, narrow disputes, and simplify discovery and trial.

Nevertheless, Plaintiff does not waive Georgia’s notice-pleading requirements, or assume any obligation to provide more than the general notice required by law.

Medical Principles

Hematology: Clotting

188.       The human body is constantly maintaining a balance between clotting and bleeding. A clot stops bleeding.

189.       Injury to a blood vessel causes platelets, a component of blood, to clump together and adhere to the site of the injury. A release of enzymes leads to the formation of fibrin, which holds together the platelets and other blood components to create a blood clot.

190.       If there is blood clot inside a blood vessel, this condition is called thrombosis. Thrombosis can reduce or block circulation.

Hematology: Lab Tests

191.       Test results for red blood cells, hemoglobin, hematocrit, and platelets can demonstrate hematological problems.

192.       A decrease in the number of red blood cells or in hemoglobin indicates anemia.

193.       Anemia is defined as a hemoglobin count of less than 12 g/dL.

194.       Anemia can be caused by active bleeding.

195.       Acute anemia occurs when there is an abrupt drop in red blood cells. This is most commonly caused by either bleeding or a destruction of red blood cells.

196.       A nurse should report to a physician a drop in hemoglobin below 10 g/dL or a trend downward from baseline.

197.       If a patient receives a transfusion of red blood cells, one unit of packed red blood cells has a hematocrit of 55-80% and a volume of 250 mL. In a 70kg male, one unit will raise his hemoglobin by 1 g/dL and his hematocrit by 3%.

Alteplase: Mechanism of Action

198.       Alteplase causes the lysis, or disintegration, of fibrin.

Alteplase: Monitoring

199.       Due to the risk of bleeding, providers must carefully monitor patients during the infusion of alteplase and even for several hours afterward.

·       Genetech, Inc. (2022). Activase: Highlights of Prescribing Information.

200.       During alteplase therapy, providers must also monitor the patient’s neurological status.

201.       During alteplase therapy, providers must also monitor hemoglobin, hematocrit, platelets, fibrinogen, and activated partial thromboplastin time.

Alteplase: Complications

202.       Bleeding is the most important known side-effect of alteplase therapy.

203.       Bleeding is the most common adverse reaction to alteplase.

204.       A spinal hematoma is a debilitating complication of alteplase therapy.

·       Gupta, K., Sharma, R., Agrawal, N., Puttegowda, B., Basappa, R., & Manjunath, C. N. (2013). Spinal epidural hematoma – A rare and debilitating complication of thrombolytic therapy. Journal of Cardiovascular Disease Research, 4 (4), 236-238. http://dx.doi.org/10.1016/j.jcdr.2014.01.005

Heparin: Mechanism of Action

205.       Heparin binds to proteins in the blood, blocking several factors of the clotting cascade. Through this process, heparin prevents the formation of blood clots.

Heparin: Monitoring

206.       Dosages of heparin must be adjusted based on lab results.

207.       Activated partial thromboplastin time (“PTT”) is one parameter used for the therapeutic monitoring and titration of heparin.

208.       Anti-factor Xa levels are another parameter for monitoring heparin. The therapeutic level is 0.3 to 0.7 international units per milliliter.

209.       Monitoring for adverse effects includes monitoring the values for hemoglobin, hematocrit, and platelets.

210.       During heparin administration, if hemoglobin or hematocrit drop, the possibility of hemorrhage should be investigated.

211.       A patient should not receive heparin if the patient has active, uncontrollable bleeding.

Heparin: Complications

212.       Heparin is a high-risk medication that requires many safety barriers to avoid errors and protect patients.

·       Warnock, L., & Huang, D. (2022). Heparin. In StatPearls. StatPearls Publishing. Retrieved November 6, 2022 from https://www.ncbi.nlm.nih.gov/books/NBK538247/?report=printable

213.       Bleeding is a major complication associated with heparin use. Bleeding is the chief complication that may result from heparin. Bleeding can occur at any site.

214.       One rare but critical complication from anticoagulation therapy is spinal epidural hematoma.

·       Stetkarova, I., Ehler, E., Brabec, K., Jelinkova, L., Chylova, M., Weichet, J., Ungermann, L., & Peisker, T. (2021). Spontaneous spinal epidural hematoma: management and main risk factors in era of anticoagulant/antiplatelet treatment. Polish Journal of Neurology and Neurosurgery. 55, (6), 574–581. DOI: 10.5603/PJNNS.a2021.0066

215.       The occurrence of spinal epidural hematoma is strongly associated with induced coagulopathy due to anticoagulants.

·       Alahmadi, M., Almolky, K., & Rezai, D. (2022). Spontaneous Spinal Epidural Hematoma Associated With Short-Term Dual Antiplatelet Therapy: A Case Report. Cureus. 14, (9), e29415. DOI: 10.7759/cureus.29415

216.       Spinal epidural hematomas tend to develop after therapeutic anticoagulation.

·       Lawton, M., Porter, R., Heiserman, J., Jacobowitz, R., Sonntag, V., & Dickman, C. (1995). Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. Journal of Neurosurgery. 83, 1-7.

Alteplase and Heparin in Combination

217.       Data on intracranial hemorrhage suggests that the combination of alteplase and heparin creates a greater risk of bleeding than either drug by itself.

218.       Anticoagulants increase the risk of bleeding when administered with alteplase.

219.       Anticoagulants increase the risk of bleeding if administered prior to, during, or after alteplase.

220.       When alteplase thrombolytic therapy and anticoagulant therapy are provided in combination, the patient must be carefully monitored for neurological symptoms.

The Spine: Anatomy of Spinal Meninges

221.       The spinal cord is wrapped in cerebral spinal fluid, enclosed by three spinal membranes. They are, from innermost to outermost, the pia mater, the arachnoid mater, and the dura mater. The spinal epidural space lies outside of the dura mater.

222.       The spinal epidural space is located between the dura and the surrounding margins of the vertebral canal.

223.       The spinal epidural space contains adipose tissue, and the internal vertebral venous plexus — the veins that drain the spinal cord.

The Spine: Vasculature

224.       The main arterial blood supply to the spinal cord is by way of the anterior spinal artery and the posterior spinal arteries.

225.       The spine drains venous blood by way of the anterior spinal vein and the posterior spinal vein, which drain into the internal venous plexus.

Spinal Epidural Hematoma: Presentation, Diagnosis, and Treatment

226.       Spinal epidural hematoma is the accumulation of blood in the spinal epidural space, which compresses the spinal cord and causes acute neurological deficits.

227.       A spinal epidural hematoma may be caused by back trauma, anticoagulant or thrombolytic therapy, and lumbar puncture.

·       Rubin, M. (2021). Spinal Subdural or Epidural Hematoma. Merck Manuals Professional Edition. Retrieved August 24, 2022 from https://www.merckmanuals.com/professional/neurologic-disorders/spinal-cord-disorders/spinal-subdural-or-epidural-hematoma

228.       Spinal epidural hematoma is defined as spontaneous if it occurs in the absence of vertebral fractures.

229.       Pain is the most common first symptom of a spinal epidural hematoma, accompanied by neurological deficits.

230.       A spinal epidural hematoma should be suspected in any anticoagulated patient who complaints of sudden, severe back pain with neurological symptoms.

·       Stetkarova, I., Ehler, E., Brabec, K., Jelinkova, L., Chylova, M., Weichet, J., Ungermann, L., & Peisker, T. (2021). Spontaneous spinal epidural hematoma: management and main risk factors in era of anticoagulant/antiplatelet treatment. Polish Journal of Neurology and Neurosurgery. 55, (6), 574–581. DOI: 10.5603/PJNNS.a2021.0066

231.       The symptoms of a spinal epidural hematoma can vary based upon the severity and the level of the spinal cord affected.

232.       For a suspected spinal epidural hematoma, MRI is the best diagnostic tool. A patient with a suspected spinal epidural hematoma should rapidly undergo an MRI.

233.       If a physician suspects a spinal epidural hematoma, thrombolytic or anticoagulant therapy should be stopped immediately.

234.       Treatment for spinal epidural hematoma is a decompressive surgery of laminectomy or hemilaminectomy.

Spinal Epidural Hematoma: Prognostic Factors

235.       Hematoma in the lower thoracic spine and use of anticoagulants are factors associated with poor outcomes.

·       Peng, D., Yan, M., Liu, T., Yang, K., Ma., Y., Hu, X., Ying., G., & Zhu, Y. (2022). Prognostic Factors and Treatments Efficacy in Spontaneous Spinal Epidural Hematoma: A Multicenter Retrospective Study. Neurology. 99, (8), e843-e850. doi:10.1212/WNL.0000000000200844

236.       Rapid diagnosis and treatment of a spinal epidural hematoma increases the chance of neurological recovery, and the chances of neurological recovery increase as the time interval from symptom onset to surgery decreases.

·       Lawton, M., Porter, R., Heiserman, J., Jacobowitz, R., Sonntag, V., & Dickman, C. (1995). Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. Journal of Neurosurgery. 83, 1-7.

237.       Conversely, delay before surgery decreases the chances of recovery.

238.       Patients taken to surgery less than 12 hours from symptom onset have higher rates of improvement than patients taken to surgery after 12 hours.

239.       Patients whose maximum neurological deficit lasted less than 6 hours have better neurological outcomes than patients whose maximum neurological deficit lasted longer than 6 hours.

240.       Decompression of the spinal cord may be accomplished surgically.

241.       Surgery is indicated for patients with a worsening neurologic examination and ongoing spinal cord compression.

242.       The outcome of a spinal epidural hematoma correlates inversely with (a) the time interval from symptom onset to surgery and (b) duration of maximum deficit, both of which reflect duration of spinal cord compression.

243.       Immediate surgical evacuation of the spinal epidural hematoma is recommended.

244.       Preoperative severe neurological deficits and paraplegia time greater than 12 hours are independent adverse prognostic factors.

·       Peng, D., Yan, M., Liu, T., Yang, K., Ma., Y., Hu, X., Ying., G., & Zhu, Y. (2022). Prognostic Factors and Treatments Efficacy in Spontaneous Spinal Epidural Hematoma: A Multicenter Retrospective Study. Neurology. 99, (8), e843-e850. doi:10.1212/WNL.0000000000200844

245.       Surgical decompression later than 24 hours after the onset of symptoms may cause permanent neurological damage.

·       Xu, Q., Wang, Y., Wang, D., Xu, B., Yu, Z., Yin, X., Lang, D., & Ningbo, Z. (2020). Spontaneous Spinal Epidural Hematoma after Percutaneous Mechanical Thrombectomy Combined with Catheter-Directed Thrombolysis for Deep Venous Thrombosis: A Case Report. Annals of Vascular Surgery. 66, (670), e1–670.e4. https://doi.org/10.1016/j.avsg.2020.01.078

Spinal Cord Injury

246.       A spontaneous spinal epidural hematoma can cause a spinal cord injury in the absence of trauma.

247.       Spinal cord injury results in varying degrees of paralysis and of loss of sensation below the level of the injury.

248.       Factors affecting the severity of deficits caused by the spinal cord injury include whether or not the injury is complete and the level of the spinal cord affected.

249.       Complete spinal cord injury results in total loss of sensory and motor function below the level of injury. Incomplete spinal cord injury results in mixed loss of motor and sensory function.

250.       The level of spinal cord injury refers to the letter-and-number name of the vertebra at the site of the spinal cord injury.

251.       Deficits caused by a spinal cord injury are described by the American Spinal Injury Association Impairment Scale (AIS), a classification system that enables an accurate characterization of incomplete and complete spinal cord injuries.

252.       The AIS grades a spinal cord injury from A to E, in decreasing severity.

·      A 1186

Medical Facts

Admission and History & Physical

253.       On Thursday, March 25, 2021, at 2123 hours (“hrs”), Yolanda Ratchford is admitted to Emory University Hospital. 

·      EU 1976

254.       At 2140 hrs, RN Allyson Coleman performs a functional screening. Yolanda is independent in every category of function.

·      EU 1311

255.       At 2146 hrs, Dr. Stephanie Tom, resident physician of general surgery, takes a history and performs a physical examination of Yolanda. 

·      EU 45-46

256.       Yolanda’s chief complaint is extensive deep-vein thrombosis (“DVT”) of the iliofemoral. Yolanda has a history of inferior vena cava (“IVC”) thrombosis.

·      EU 45

257.       Yolanda has full range of motion in all extremities. 

·      EU 46

258.       Yolanda’s sensation and motor strength are grossly intact in the bilateral lower extremities (her legs).

·      EU 46

259.       Dr. Tom’s treatment plan includes a high-dose heparin drip and bilateral sequential compression devices.

·      EU 46

260.       In connection with the plan, vascular surgeon Dr. Olamide Alabi requests a hypercoagulable workup before starting the drip, and a hematology consultation the following morning.

·      EU 47

Administration of High-Dose Heparin

261.       At 2208 hrs, consistent with the treatment plan, vascular surgery resident physician Galimat Khaidakova orders high standard heparin protocol for Yolanda.

262.       Per Emory’s High Dose Heparin Protocol and Flowsheet, Dr. Khaidakova orders the heparin drip to be titrated to an anti-Xa level of 0.5-0.7 units/mL.

·      EU 1050

263.       The Heparin Protocol and Flowsheet reflects Emory’s policies for administering heparin to patients by infusion in 2021. 

·      See EU 2024

264.       At 2232 hrs, Yolanda’s white blood count, red blood count, hemoglobin, and hematocrit are each normal—within the reference range.

·      EU 1941

Labs

265.       At 2232 hrs, Yolanda’s platelet count is within the reference range.

·      EU 1943

266.       At 2232 hrs, Yolanda’s values for PTT, INR, and PT are each within the reference range.

·      EU 1946

Heparin Administration Begins

267.       At 2242 hrs, Yolanda receives a bolus of high-dose heparin.

·      EU 1762

268.       At 2242 hrs, Yolanda is put on the heparin drip (infusion).

·      EU 1786

269.       At 2351 hrs, Yolanda’s heparin is on hold until her labs are drawn.

·      EU 292

270.       On March 25, 2021, Emory providers do not give Yolanda pain medication.

·      See EU 1762

Labs and Heparin Adjustments

271.       On Friday, March 26, 2021, at 0008 hrs, Yolanda’s coagulation values have all risen above the reference range:

a.    Her PT is 13.4 seconds.

b.    Her PTT is greater than 249 seconds.

c.     Her heparin anti-Xa is 1.66 units/mL—more than double the upper range of the therapeutic level for high dose heparin protocol.

·      EU 1946

·      See EU 2024

272.       At 0040 hrs, as Yolanda has “no visible distress” and shows “no bleeding or other signs of HIT,” RN Coleman restarts Yolanda on the heparin drip, at a rate of 18 units per kilogram per hour.

·      EU 291

273.       At 0334 hrs, Yolanda’s anti-Xa remains elevated at 1.38—nearly double the upper limit of the therapeutic range.

·      EU 1946

274.       At 0334 hrs, Yolanda’s platelet count has dropped from 195 to 176.

·      EU 1943

275.       At 0615 hrs, RN Adams stops the heparin drip for two hours.

·      EU 2025

Nursing Assessments

276.       At 0800 hrs, RN Ana Perry performs a neurological assessment. Yolanda has a steady gait and 5/5 normal motor strength in all extremities.

·      EU 1410

277.       At 0825 hrs, with the two-hour hiatus over, RN Adams restarts Yolanda on the heparin drip.

·      EU 1786

278.       RN Adams lowers the rate by 3 units—from 18 to 15 units per kilogram per hour.

·      EU 1786

·      EU 2025

279.       At 1029 hrs, Yolanda denies pain.

·      EU 1508

Vascular Surgery Evaluation & Progress Note

280.       At 1141 hrs, under Dr. Alabi’s supervision, PA-C Naomi Lux performs a pre-operative assessment. Yolanda is doing well, her lower extremity swelling is greatly improved, and she is ready for the OR.

·      EU 287

281.       At 1141 hrs, Dr. Alabi’s treatment plan consists of a cavagram, bilateral lower extremity venogram with possible thrombectomy, possible lysis, possible intervention, and other procedures as indicated, to be started later the same day.

·      EU 289

282.       At 1341 hrs, prior to the start of the thrombectomy, providers have not administered pain medication to Yolanda so far during the hospital admission.

·      See EU 1762

First Procedure: Thrombectomy

283.       At 1341 hrs, Dr. Alabi enters the OR as primary surgeon.

·      EU 102

284.       At 1420 hrs, the thrombectomy begins.

·      EU 152

285.       Over the three hours that follow, from approximately 1420 hrs to 1715 hrs, Dr. Alabi performs the thrombectomy, with:

a.    ultrasound-guided access of bilateral popliteal veins;

b.    left and right lower extremity venograms;

c.     left and right iliocaval venogram;

d.    selective injection of iliolumbar vein and hemiazygos vein;

e.     intravenous intravascular ultrasound evaluation of bilateral femoral popliteal segments, bilateral iliac vein segments, and inferior vena cava;

f.      percutaneous mechanical thrombectomy of bilateral femoral popliteal and iliocaval segments with the 12-French lightening device by penumbra; and

g.    balloon angioplasty of bilateral iliocaval vein segments.

·      EU 119

286.       During the venogram, when Dr. Alabi attempts to move the wire into the common iliac vein, she encounters a difficulty: the wire keeps coursing into Yolanda’s iliolumbar vein and hemiazygos system.

·      EU 120

287.       Dr. Alabi nevertheless goes forward with the thrombectomy.

288.       On March 26, 2021, intraoperative DSA extremities imaging shows extravasation of contrast in Series 11, 12, 13, and 14.

289.       Dr. Alabi does not document these findings.

290.       The presence of contrast agent outside the blood vessels indicates that one of Yolanda’s blood vessels has a puncture and is leaking.

291.       Dr. Alabi does not document the likely puncture, leak, or bleeding.

292.       Nor does Dr. Alabi take any step to diagnose or treat Yolanda’s bleeding.

Blood Transfusion

293.       At 1709 hrs, while Yolanda is still undergoing the thrombectomy, Emory providers give her a blood transfusion of one unit of red cells.

·      EU 1374

·      EU 153

End of Thrombectomy Procedure

294.       At about 1715 hrs, at the close of the thrombectomy procedure, Dr. Alabi and her team place thrombolysis catheters bilaterally in Yolanda’s popliteal veins.

·      EU 122

295.       At 1715 hrs, the thrombectomy procedure ends.

·      EU 152

296.       On March 26, 2021, despite encountering difficulties during the thrombectomy, Dr. Alabi does not take any steps to address complications of the procedure, including bleeding.

Post-Procedure Care, Alteplase & Heparin Drips

297.       At 1735 hrs, RN Veronica Harsany performs a neurological assessment. Yolanda has motor strength of “5-normal movement” in all four extremities.

·      EU 1410

298.       At 1735 hrs, Yolanda’s Modified Aldrete Score is 8. Yolanda moves only two extremities. This is inconsistent with the contemporaneous neurological assessment.

·      EU 1510

299.       At 1735 hrs, Yolanda also has pain in her back. RN Harsany applies a lidocaine patch.

·      EU 1508   

300.       This appears to be the first time Yolanda complains of back pain during this admission.

301.       On March 26, 2021, even though it is a new complaint, RN Harsany does not report Yolanda’s back pain to a physician.

302.       On March 26, 2021, Dr. Alabi, Dr. Khaidakova, and Dr. Chang do not consider, let alone address, Yolanda’s back pain.

303.       At 1735 hrs, Yolanda is started on alteplase and heparin drips in her legs.

·      EU 1785-1786

304.       At 1737 hrs, Yolanda receives IV Plasma-Lyte.

·      EU 1759

305.       At 1738 hrs, Yolanda receives sodium chloride solution, by IV.

·      EU 1759

306.       On March 26, 2021, prior to beginning the heparin and alteplase infusions, no provider assesses Yolanda for complications from the thrombectomy.

Orders from Vascular Surgery

307.       At 1742 hrs, Dr. Khaidakova notes the following: Yolanda has two ports in each popliteal vein, requires complete blood counts and fibrinogen checks every Q 6 hours, is to keep her legs straight, must have frequent neuro checks, and must have frequent neurovascular and pulse/signal checks of the bilateral lower extremities.

·      EU 286

308.       At 1746 hrs, Dr. Khaidakova orders neurovascular assessments of Yolanda’s extremities with each vital-sign check.

·      EU 980

309.       At 1746 hrs, Dr. Khaidakova orders vital signs checks PRN per ICU protocol, with neuro checks.

·      EU 984

·         

310.       At1746 hrs, Dr. Khaidakova also orders that a physician or provider be notified of excessive bleeding at access sites, change in level of consciousness, back pain, bloody urine, headache, and/or neurovascular changes.

·      EU 981

311.       At 1746 hrs, Dr. Khaidakova orders to hold additional anticoagulants while Yolanda is on tPA (alteplase).

·      EU 976

312.       At 1751 hrs, Dr. Ronald Chang, vascular surgery fellow, orders a sub-therapeutic heparin protocol, not to be titrated, of 500 units per hour through the systemic IV.

·      EU 969

313.       At 1752 hrs, Dr. Chang orders a sub-therapeutic heparin protocol, not to be titrated, of 250 units through the popliteal port.

·      EU 968

314.       On March 26, 2021, the therapeutic range for sub-therapeutic heparin protocol is an anti-Xa level of 0.1-0.29 units/mL.

·      EU 2024

315.       On March 26, 2021, Dr. Alabi, Dr. Khaidakova, and Dr. Chang do not assess Yolanda for complications from the thrombectomy.

316.       On March 26, 2021, Dr. Alabi, Dr. Khaidakova, and Dr. Chang do not address Yolanda’s bleeding complication.

Labs

317.       At 1804 hrs, Yolanda’s white blood count has jumped from 4.1 to 10.4, which is above the reference range. Accordingly, the value is now flagged as high.

·      EU 1941

318.       At 1804 hrs, Yolanda’s red blood cell count has dropped from 3.93 to 3.56, which is below the reference range. Accordingly, the value is now flagged as low.

·      EU 1941

319.        At 1804, Yolanda’s hemoglobin has dropped from 11.5 to 9.7, which is below the reference range. Accordingly, the value is now flagged as low.

·      EU 1941

320.       At 1804, Yolanda’s hematocrit has dropped from 35.5 to 30.9, which is below the reference range. Accordingly, the value is now flagged as low.

·      EU 1941

321.       At 1804 hrs, Yolanda’s platelet count has dropped from 176 to 158.

·      EU 1943

322.       On March 26, 2021, even though Yolanda’s 1804 lab results are evidence of active bleeding, no nurse notifies a physician or anyone else.

323.       On March 26, 2021, Dr. Alabi, Dr. Khaidakova, and Dr. Chang, do not address Yolanda’s 1804 hematology lab results.

324.       Instead, at 1830 hrs, Yolanda receives a continuous infusion of alteplase on her left leg.

·      EU 1785

325.       At 1900 hrs, Yolanda receives continuous infusions of alteplase and heparin on her left and right legs.

·      EU 1785

Pain Management

326.       At 1911 hrs, Yolanda is now “grimacing” with back pain.

·      EU 1508

327.       At 1911 hrs, RN Harsany administers Yolanda fentanyl for pain, by IV.

·      EU 1758, EU 1831

328.       RN Harsany does not notify any physician or other provider of Yolanda’s continuing back pain.

329.       Consequently, Dr. Alabi, Dr. Khaidakova, and Dr. Chang do not consider, much less address, the back pain.

330.       At 1916 hrs, Yolanda receives an injection of IV lactated ringers.

·      EU 1757

331.       At 2000 hrs, Yolanda receives continuous infusions of alteplase and heparin on her legs.

·      EU 1784-1785

332.       At 2027 hrs, Yolanda receives 100 micrograms of fentanyl, by IV.

·      EU 1757

Orders from Vascular Surgery

333.       At 2056 hrs, Dr. Khaidakova orders frequent neuro checks of Yolanda.

·      EU 956

334.       At 2056 hrs, Dr. Khaidakova also orders frequent neurovascular assessments of Yolanda’s extremities.

·      EU 956

335.       At 2100 hrs, Yolanda receives continuous infusions of alteplase and heparin on her legs.

·      EU 1784

336.       At 2103 hrs, Yolanda again receives 100 micrograms of fentanyl, by IV.

·      EU 1757

337.       At 2200 hrs, Yolanda again receives continuous infusions of alteplase and heparin on her legs.

·      EU 1783

338.       At 2210 hrs, RN Tyler Hall signs Dr. Khaidakova’s order for vital signs with neuro checks.

·      EU 984

Critical Care Consultation

339.       At 2230 hrs, intensivist physician Milad Sharifpour and NP Paula Lay are consulted.

·      EU 69-80

340.       According to NP Lay’s note, the reason for Yolanda’s admission to the ICU is postoperative hemodynamic management.

·      EU 69

341.       At about 2230 hrs, Yolanda has had an estimated blood loss of 700 mL. NP Lay does not note the red blood cell transfusion Yolanda received during the thrombectomy.

·      See EU 74

342.       At approximately 2230 hrs, NP Lay reviews Yolanda’s labs, including red blood cell count, hemoglobin, hematocrit, PT, PTT, and heparin level.

·      EU 77

343.       At approximately 2230 hrs, Yolanda has acute post-procedural pain. Accordingly, NP Lay plans for frequent neuro checks.

·      EU 78

344.       At about 2230 hrs, Yolanda also has “acute blood loss anemia.”

·      EU 79

345.       Yolanda thus has acute blood loss anemia despite the transfusion of red blood cells she received during the thrombectomy. 

346.       At about 2230 hrs, NP Lay orders (i) monitoring for active bleeding, (ii) stat labs, (iii) coagulation tests and complete blood counts every 6 hours, and (iv) compliance with the protocol for heparin titration.

·      EU 79

347.       On March 26, 2021, NP Lay does not notify a provider about Yolanda’s acute blood loss anemia. As a result, no provider, including Dr, Alabi, Dr. Khaidakova, Dr. Chang, Dr. Sharifpour, and NP Lay, addresses Yolanda’s anemia.

Nursing Care

348.       At 2233 hrs, Yolanda receives continuous infusions of alteplase and heparin on her leg.

·      EU 1782-1783

349.       At 2233 hrs, Yolanda is now moaning with pain at a level of 7/10.

·      EU 1507

350.       RN Tyler Hall does not notify any physician or other provider about Yolanda’s 7/10 pain. As a result, no provider, including Dr, Alabi, Dr. Khaidakova, Dr. Chang, Dr. Sharifpour, and NP Lay, takes any step to diagnose or treat the cause of Yolanda’s pain.

351.       At 2233 hrs, RN Tyler Hall performs a neurological assessment of Yolanda.

·      EU 1410-1411

352.       Yolanda’s motor strength in the right and left lower extremities has dropped from 5/5 to 2/5, which means “lateral movement not against gravity.”

·      EU 1410-1411

353.       RN Tyler Hall does not notify a physician or other provider about the lack of anti-gravity movement in Yolanda’s lower extremities. As a result, no provider, including Dr, Alabi, Dr. Khaidakova, Dr. Chang, Dr. Sharifpour, and NP Lay, takes any step to address those deficits.

354.       At 2233 hrs, RN Tyler Hall performs a musculoskeletal assessment of Yolanda.

·      EU 1468

355.       Yolanda has a weak level of motion in her left lower extremity and her right lower extremity.

·      EU 1468

356.       RN Tyler Hall does not notify a provider about the weak motion in Yolanda’s legs. As a result, no provider, including Dr, Alabi, Dr. Khaidakova, Dr. Chang, Dr. Sharifpour, and NP Lay, takes any step to address those deficits.

357.       At 2249 hrs, Yolanda receives hydromorphone, by IV.

·      EU 1757

358.       At 2249 hrs, Yolanda receives PO acetaminophen.

·      EU 1757

359.       At 2300 and 2305 hrs, Yolanda receives continuous infusions of alteplase and heparin on her legs.

·      EU 1781-1782

Orders from Vascular Surgery

360.       At 2309 hrs, Dr. Khaidakova orders that a “doctor/provider” be notified if Yolanda’s hematocrit drops “greater than 10% of baseline” or if her PTT is “greater than 60 seconds.”

·      EU 948

361.       At 2309 hrs, Dr. Khaidakova orders that “Vascular Surgery MD” be notified of “heparin level of 0.1 or greater.”

·      EU 950

362.       At 2309 hrs, Dr. Khaidakova also orders that a “doctor/provider” be notified of back pain and neurovascular changes.

·      EU 947

363.       Dr. Khaidakova does not address Yolanda’s back pain, lack of anti-gravity movement, or weak motion.

Labs

364.       At 2358 hrs, Yolanda’s PTT is elevated to 168.1 seconds—obviously greater than 60 seconds.

·      EU 1946

365.       Despite Dr. Khaidakova’s order entered 49 minutes earlier (at 2309 hrs), no one notifies any physician/provider that Yolanda’s PTT is greater than 60 seconds. As a result, no physician addresses Yolanda’s PTT of 168.1 seconds.

366.       At 2358, Yolanda’s heparin is 1.42 units/mL.

·      EU 1946

367.       That is nearly five times the upper range for the therapeutic level of sub-therapeutic heparin protocol.

·      See EU 2024

368.       That is also 14.2 times the threshold (0.1) requiring notification to a vascular surgery physician, pursuant to Dr. Khaidakova’s order.

·      See EU 950

369.       Yet neither RN Tyler Hall, nor anyone else, notifies any physician. As a result, no physician even considers, much less addresses, Yolanda’s heparin level.

370.       At 2358 hrs, Yolanda’s red blood cell count, hemoglobin, and hematocrit remain below the reference range, and are therefore flagged as low. In fact, Yolanda’s hematocrit has decreased further, this time from 30.9 to 30.2.

·      EU 1941

371.       At 2358 hrs, Yolanda’s platelet count has decreased further, this time from 158 to 138. It is now below the reference range.

·      EU 1943

372.       At 2358 hrs, Yolanda’s acute blood loss anemia is worsening.

373.       No one notifies a physician of these lab results. As a result, no physician even considers, much less addresses, the abnormal findings.

Overnight Assessments and Medications

374.       On Saturday, March 27, 2021, at 0000 hrs, Yolanda receives continuous infusions of alteplase and heparin on her legs.

·      EU 1780-1781

375.       At 0000 hrs, RN Tyler Hall performs a musculoskeletal assessment. Yolanda has a weak level of motion in her left lower extremity and her right lower extremity.

·      EU 1467

376.       RN Tyler Hall does not notify a physician of the weak motion in Yolanda’s lower extremities. As a result, no physician addresses those deficits.

377.       At 0053 hrs, Yolanda receives continuous infusions of alteplase and heparin on her legs.

·      EU 1780

378.       At 0100 hrs, Yolanda receives Plasma-Lyte on right her arm, and continuous infusions of alteplase and heparin on her legs.

·      EU 1779

379.       At 0146 hrs, Yolanda receives an infusion of Plasma-Lyte on her right arm.

·      EU 1779

380.       At 0158 hrs, Yolanda receives continuous infusions of alteplase and heparin on her legs.

·      EU 1778-1779

381.       At 0158 hrs, RN Tyler Hall performs a musculoskeletal assessment. Yolanda has a weak level of motion in her left lower extremity and her right lower extremity.

·      EU 1467   

382.       RN Tyler Hall again does not notify a physician of the weak motion in Yolanda’s lower extremities. As a result, no physician addresses those deficits.

383.       At 0200 hrs, Yolanda receives Plasma-Lyte on right her arm, and continuous infusions of alteplase and heparin on her legs.

·      EU 1777-1778

384.       At 0253 hrs, Yolanda receives continuous infusions of alteplase and heparin on her legs.

·      EU 1777

385.       At 0300 hrs, Yolanda receives Plasma-Lyte on right her arm, and continuous infusions of alteplase and heparin on her legs.

·      EU 1776-1777

386.       At 0345 hrs, Yolanda receives continuous infusions of alteplase and heparin on her legs.

·      EU 1776

387.       At 0356 hrs, Yolanda receives continuous infusions of alteplase and heparin on her legs.

·      EU 1775

388.       At 0356 hrs, RN Tyler Hall performs a musculoskeletal assessment. Yolanda has a weak level of motion in her left lower extremity and her right lower extremity.

·      EU 1467

389.          RN Tyler Hall again does not notify a physician of the weak motion in Yolanda’s lower extremities. As a result, no physician addresses those deficits.

390.       At 0400 hrs, Yolanda receives Plasma-Lyte on right her arm, and continuous infusions of alteplase and heparin on her legs.

·      EU 1774-1775

391.       At 0402 hrs, Yolanda receives PO acetaminophen-oxycodone.

·      EU 1755

392.       At 0500 hrs, Yolanda receives Plasma-Lyte on right her arm, and continuous infusions of alteplase and heparin on her legs.

·      EU 1774

393.       At 0509 hrs, Yolanda receives continuous infusions of alteplase and heparin on her legs.

·      EU 1773

Labs

394.       At 0545 hrs, Yolanda’s PT is 13.1 seconds, and her PTT is 87.9 seconds. Both values are flagged as high.

·      EU 1946

395.       At 87.9 seconds, Yolanda’s PTT continues to be greater than 60 seconds. 

396.       Despite Dr. Khaidakova’s order at 2309 hrs the night before, no one notifies any physician or other provider that Yolanda’s PTT is greater than 60 seconds.

·      See EU 950

397.       As a result, on March 27, 2021, no physician even considers, much less addresses, Yolanda’s elevated PTT of 87.9 seconds.

398.       At 0545 hrs, Yolanda’s heparin level is 0.87 units/mL.

·      EU 1946

399.       That is three times the upper range for the therapeutic level of sub-therapeutic heparin protocol.

·      See EU 2024

400.        That is also 8.7 times the threshold (0.1) requiring notification to a vascular surgery physician, under Dr. Khaidakova’s order at 2309 hrs.

·      See EU 950

401.       No one notifies any physician of Yolanda’s heparin level.  As a result, no physician even considers, much less addresses, Yolanda’s heparin level.

402.       At 0545 hrs, Yolanda’s red blood cell count, hemoglobin, and hematocrit remain below the reference range. Each is flagged as low.

·      EU 1941

403.       In addition, Yolanda’s red blood cell count has decreased from 3.57 to 3.31, her hemoglobin from 9.8 to 9.0, and her hematocrit from 30.2 to 28.1.

·      EU 1941

404.       At 0545 hrs, Yolanda’s platelet count remains below the reference range and is therefore again flagged as low.

·      EU 1943

405.       In addition, Yolanda’s platelet count has dropped further—from 138 to 124.

·      EU 1943

406.       At 0545 hrs, Yolanda’s acute blood loss anemia is worsening.

407.       No one notifies a physician of these lab results. As a result, no physician even considers, much less addresses, the abnormal findings.

Nursing Care

408.       At 0600 hrs, Yolanda remains on alteplase, heparin, and Plasma-Lyte infusions.

·      EU 1773

409.       At 0610 hrs, Yolanda remains on alteplase and heparin drips.

·      EU 1772

410.       At 0610 hrs, RN Tyler Hall performs a musculoskeletal assessment. Yolanda continues to have a weak level of motion in both legs.

·      EU 1466

411.       RN Tyler Hall does not notify a physician of the weak level of motion in Yolanda’s legs. As a result, no physician addresses those deficits.

412.       At 0655 hrs and 0728, Yolanda remains on alteplase and heparin drips.

·      EU 1771-1772

Hematology Consultation

413.       At 0741 hrs, Dr. Christine Kempton, of hematology and oncology, is consulted, for evaluation of protein S deficiency and for anticoagulation recommendations.

·      EU 66

414.       At 0741 hrs, Yolanda is in significant pain in her left leg.

·      EU 67

415.       Yolanda does not have a clinically significant protein S deficiency or other relevant thrombophilia. Accordingly, Dr. Kempton recommends cancelling the ordered thrombophilia testing.

·      EU 68

416.       At 0800 hrs, Yolanda is again moaning in pain.

·      EU 1506

417.       Nevertheless, RN Keera Price forgoes a neurological assessment of Yolanda.

·      See EU 1409 

Second Vascular Surgery Procedure

418.       At 0817 hrs, Yolanda is admitted to the OR for a vascular procedure.

·      EU 95

419.       Prior to the procedure, Dr. Alabi does not document any exam or evaluation of Yolanda. Dr. Alabi does not document whether Yolanda can move her legs.

420.       Prior to the procedure, Dr. Alabi does not address any of Yolanda’s clinical changes, including her hematology lab results and neurological deficits.

421.       At 0907 hrs, Dr. Alabi, as primary surgeon, begins the procedure.

·      EU 95

422.       The procedure includes lysis check, venogram, and bilateral iliofemoral venoplasty. 

·      EU 95

423.       At 1006 hrs, Dr. Alabi completes the vascular procedure.

·      EU 95

424.       At 1042 hrs, RN Leela Miller receives Yolanda from the OR.

·      EU 1155

Nursing Assessment of Neurological Deficits

425.       At 1113 hrs, RN Shaquira Hall performs a musculoskeletal assessment. Yolanda now has absent motion and tingling sensation in both lower extremities.

·      EU 1466

426.       At 1113 hrs, RN Shaquira Hall notes that a resident is aware of Yolanda’s absent motion in the bilateral lower extremities (left and right legs).

·      EU 1155

Notification of Neurological Deficits to Critical Care

427.       At approximately 1130 hrs, a nurse informs Dr. Alexander Kosiak, critical care resident physician under Dr. Milad Sharifpour, that Yolanda is unable to move her legs.

·      EU 283

Nursing Assessment

428.       At 1200 hrs, RN Shaquira Hall performs a neurological assessment. Yolanda’s legs have 0/5 motor strength, demonstrate no movement, and are flaccid.

·      EU 1409

429.       Nevertheless, RN Shaquira Hall does not inform a physician of these findings, let alone request a physician to examine Yolanda.

Labs

430.       At 1213 hrs, Yolanda’s PT is 13.6 seconds, and her PTT has risen to 110.2 seconds. Both values are again flagged as high.

·      EU 1946

431.       At 110.2 seconds, Yolanda’s PTT continues to be greater than 60 seconds. 

432.       Despite Dr. Khaidakova’s order at 2309 hrs the night before, no one notifies any physician or other provider that Yolanda’s PTT is greater than 60 seconds.

433.       As a result, no physician addresses Yolanda’s elevated PTT.

434.       At 1213 hrs, Yolanda’s heparin level is 1.00 units/mL.

·      EU 1946

435.       That is more than three times the upper range for the therapeutic level of sub-therapeutic heparin protocol.

·      See EU 2024

436.       That is also 10 times the threshold (0.1) requiring notification to a vascular surgery physician, pursuant to Dr. Khaidakova’s order.

·      See EU 950

437.       Yet no one notifies a physician of Yolanda’s heparin level. As a result, no physician even considers, much less addresses, the heparin level.

438.       At 1213 hrs, Yolanda’s red blood cell count, hemoglobin, and hematocrit remain below the reference range. Each is again flagged as low.

·      EU 1941

439.       In addition, each value has decreased further: her red blood cell count from 3.31 to 3.24, her hemoglobin from 9.0 to 8.9, and her hematocrit from 28.1 to 27.7.

·      EU 1941

440.       At 1213 hrs, Yolanda’s platelet count (138) remains below the reference range and is therefore again flagged as low.

·      EU 1943

441.       At 1213 hrs, Yolanda’s acute blood loss anemia is worsening.

442.       Yet no one notifies a physician of these hematology lab results. As a result, no physician even considers, much less addresses, the abnormal findings.   

Nursing Assessment

443.       At 1300 hrs, RN Shaquira Hall performs a musculoskeletal assessment. Yolanda continues to have absent motion and tingling sensation in both legs.

·      EU 1465   

444.       Yet RN Shaquira Hall does not even inform a physician of these findings, let alone request a physician to examine Yolanda.

445.       At 1300 hrs, Yolanda remains on a heparin drip, on her left leg.

·      EU 1769

Critical Care Assessment

446.       At 1345 hrs, Dr. Kosiak reassesses Yolanda. She is unable to move her legs bilaterally and has sensory deficits at the L2-L3 dermatomal level.

·      EU 283

447.       At 1353 hrs, Yolanda remains on a heparin drip, on her left leg.

·      EU 1769

448.       At 1400 and 1401 hrs, Yolanda remains on a heparin drip, on her left leg.

·      EU 1769

449.       At 1401 hrs, RN Shaquira Hall performs a musculoskeletal assessment. Yolanda continues to have absent motion and tingling sensation in both legs.

·      EU 1465

450.       At 1406 hrs, Yolanda remains on a heparin drip, on her left leg.

·      EU 1769

Critical Care Physician at Bedside

451.       At 1410 hrs, Dr. Milad Sharifpour, of anesthesiology and critical care, consults on Yolanda’s case.

·      EU 285

452.       Yolanda is not moving her bilateral lower extremities but has intact sensation.

·      EU 285

453.       Vascular surgery is then notified.

·      EU 285

Vascular Surgery at Bedside

454.       At 1420 hrs, Dr. Chang consults on Yolanda’s case. 

·      EU 275

455.       Yolanda is unable to move her bilateral lower extremities.

·      EU 275

456.       Yolanda complains of paresthesia.

·      EU 275

457.       Yolanda cannot flex at the hips.

·      EU 275

458.       Yolanda’s motor exam is 1/5 for left knee extension, 0/5 for right knee extension, 0/5 for bilateral knee flexion, and 0/5 for bilateral foot and toe plantar and dorsiflexion.

·      EU 275

459.       Yolanda has abnormal sensation below the mid thighs bilaterally.

·      EU 275

460.       Yolanda has weak but not flaccid rectal tone.

·      EU 275

461.       At 1427 hrs, a vascular fellow notifies Dr. Alabi that Yolanda cannot move her legs.

·      EU 276

462.       Noting that she saw Yolanda move her legs prior to the morning’s procedure, Dr. Alabi notes difficulty in identifying the time of onset. 

·      EU 276

463.       Dr. Alabi decides to stop the heparin drip, noting an “initial concern” that bleeding may be causing deficits.

·      EU 276

464.       At 1428 hrs, the heparin drip is stopped.

·      EU 1769

Imaging Orders

465.       At 1445 hrs, because of the motor loss on Yolanda’s legs and because of her sensory deficits, Dr. Kosiak orders an MRI of the thoracic spine with and without contrast.

·      EU 882

466.       The order asks to “rule out epidural hematoma vs. spinal cord ischemia, etc.”

·      EU 882

467.       At 1445 hrs, Dr. Kosiak also orders an MRI of the lumbar spine with and without contrast.

·      EU 881

468.       This order also asks to “rule out epidural hematoma vs. spinal cord ischemia, etc.”

·      EU 882

469.       At 1500 hrs, Dr. Chang orders a stat CT scan of the abdomen and pelvis without IV contrast.

·      EU 880

470.       At 1509 hrs, Dr. Shi orders a stat CTA of the neck with contrast.

·      EU 879

471.       At 1509 hrs, Dr. Shi orders a stat CTA of the head with and without contrast.

·      EU 877

472.       At 1533 hrs, Yolanda undergoes the CT scan of the abdomen and pelvis.

·      EU 1096-1097

473.       The CT scan is severely limited without contrast.

·      EU 1096-1097

474.       The CT scan reveals a calcified thrombus within Yolanda’s IVC.

·      EU 1096-1097

475.       At 1536 hrs, Yolanda undergoes the CTAs of the head and neck.

·      EU 1093

476.       The studies reveal no acute intracranial abnormality and no large vessel occlusion or flow-limiting stenosis within the head and neck.

·      EU 1095

477.       At 1540 hrs, RN Shaquira Hall performs a musculoskeletal assessment. Yolanda continues to have absent motion and tingling sensation in both legs.

·      EU 1464

Neurology Consultation

478.       At 1541 hrs, neurology resident physician Dr. Ashley Nutt and neurologist Dr. Hang (Helen) Shi, consult on Yolanda’s case.

·      EU 62

479.       Dr. Nutt notes that Yolanda has bilateral lower extremity weakness. Yolanda’s bilateral lower extremities are flaccid.

·      EU 62

480.       Yolanda’s presentation is concerning for an ASA infarction.

·      EU 62

481.       Dr. Nutt considers spinal hematoma as less likely because of the popliteal access for Yolanda’s vascular procedures.

·      EU 62

482.       Nevertheless, noting the presence of spinal epidural air on Yolanda’s CT imaging, Dr. Nutt recommends a stat MRI of the thoracic and lumbar spine. 

·      EU 62

483.       Dr. Nutt recommends that neurosurgery be urgently consulted if Yolanda’s MRIs show spinal cord pathology.

·      EU 62

484.       At 1640 hrs, RN Shaquira Hall performs a musculoskeletal assessment. Yolanda continues to have absent motion and tingling sensation in both legs.

·      EU 1464

MRI Results

485.       At 1926 hrs, Yolanda’s MRIs, ordered by Dr. Kosiak, are interpreted.

·      EU 1090-1092

486.       The MRIs reveals critical abnormalities, including.

a.    an extensive epidural hematoma within the dorsal epidural space from the cervicothoracic junction into the lumbar spine, causing multiple levels of severe spinal canal stenosis; and

b.    a ventral epidural hematoma within the lumbar spine.

·      EU 1090-1092

487.       The combination of these two hematomas results in critical thecal sac stenosis and cauda equina compression.

·      EU 1090-1092

488.       The CTA of the head and neck taken earlier the same day reveals that the dorsal epidural hematoma has extended into the dorsal cervical epidural space.

·      EU 1090-1092

489.       At 1939 hrs, Dr. Frederick Kebbel reads back and verifies the MRIs’ critical findings with Dr. Chang.

·      EU 1092

490.       At 1952 hrs, PA-C Lenoci notes that Yolanda’s imaging shows a large and extensive epidural hematoma resulting in significant spinal cord compression and multiple levels of spinal canal stenosis.

·      EU 272

491.       By 1952, Vascular Surgery has consulted “Spine,” who is currently at another hospital tending to “another emergency.”

·      EU 272

Spine Surgery Resident at Bedside

492.       At 2045 hrs, a spinal surgery resident physician is at Yolanda’s bedside.

·      EU 273

493.       At 2105 hrs, surgical teams plan to take Yolanda to the OR emergently for spinal decompression.

·      EU 273

Spine Surgeon at Bedside

494.       At 2113 hrs, Dr. Dheera Ananthakrishnan, of orthopedic spinal surgery, notes an extensive dorsal hematoma in Yolanda’s cervicothoracic spine and a multilevel hematoma, both dorsal and ventral, in her lumbar spine.

·      EU 271

495.       Dr. Ananthakrishnan determines that Yolanda will likely need a perioperative blood transfusion.

·      EU 271

Laminectomy

496.       From March 27, 2021, at 2225 hrs to March 28, 2021, at 0258 hrs, Dr.  Ananthakrishnan acts as primary surgeon for Yolanda’s laminectomy surgery.

·      EU 84

497.       At approximately 2321 hrs, the laminectomy begins.

·      EU 144

498.       On March 28, 2021, at 0310 hrs, Dr. Ananthakrishnan writes the operative report for Yolanda’s laminectomy.

·      EU 116-117

499.       Yolanda was frankly coagulopathic during the entirety of the operation.

·      EU 116-117

Hematology Progress Note

500.       On March 29, 2021, at 0751 hrs, Dr. Kempton evaluates Yolanda.

·      EU 257

501.       Dr. Kempton concludes that Yolanda’s risk factors for bleeding were supratherapeutic unfractionated heparin in conjunction with alteplase.

·      EU 257

Discharge from Emory University Hospital

502.       On April 9, 2021, at 0854 hrs, Yolanda is discharged from Emory University Hospital.

·      EU 14

503.       Yolanda’s discharge diagnosis is “epidural hematoma with severe bilateral lower extremity paresis.”

·      EU 14

Admission to Shepherd Center

504.       At 1511 hrs, Dr. Brock Bowman admits Yolanda to inpatient treatment in the spinal cord injury unit at Shepherd Center.

·      SC 861

505.       Yolanda is admitted to Shepherd Center for assessment of physiological impairments and inpatient rehabilitation.

·      SC 876

506.       Shepherd Center providers plan for an acute rehab level of care for Yolanda.

·      SC 961-962

Impairment Testing

507.       On April 10, 2021, Yolanda has an Asia Impairment Scale (AIS) score of C.

·      SC 1299

508.       Yolanda’s neurological level of spinal cord injury is T5.

·      SC 1299

Wheelchair Prescriptions

509.       On April 29, 2021, Physical Therapist Sarah Leonard prescribes Yolanda a wheelchair.

·      SC 1275

510.       Yolanda has a T5 incomplete spinal cord injury and will need a wheelchair her whole “lifetime.”

·      SC 1275

511.       On May 5, 2021, Physical Therapist Lindsay Brinker prescribes Yolanda a power assist device for her wheelchair, to assist with propulsion.

·      SC 1279

Discharge from Shepherd Center

512.       On May 26, 2021, Yolanda is discharged from the Shepherd Center inpatient acute rehabilitation program.

·      SC 876

513.       Yolanda’s primary discharge diagnosis is incomplete paraplegia.

·      SC 877

514.       At discharge, Yolanda’s active problems include paraplegia, neurogenic bowel, neurogenic bladder, lumbar canal stenosis, and neuropathic pain.

·      SC 877

515.       Yolanda will require a manual wheelchair for safety, mobility, and to perform activities of daily living.

·      SC 879

Admission to Shepherd Center Day Program

516.       On May 27, 2021, Yolanda is admitted to the Shepherd Center Spinal Cord Injury Day Program.

·      SC 2378

Discharge from Shepherd Center Day Program

517.       On June 18, 2021, Yolanda is discharged from the Program, with these high-priority problems: incomplete paraplegia, lumbar canal stenosis, neurogenic bladder, neurogenic bowel, neuropathic pain, and paraplegia.

·       SC 6-7

Admission to EAMC

518.       On September 7, 2021, Yolanda is admitted to East Alabama Medical Center (“EAMC”) hospital for abdominal pain and bilateral lower extremity weakness.

·      EAMCb 236

519.       On September 8, 2021, Yolanda undergoes an MRI at EAMC.

·      EAMCb 236

520.       The MRI reveals that Yolanda has spinal cord pathology throughout her spine, including dramatic distortion of cauda equina nerve roots which is thought to be severe arachnoiditis and scarring from spinal surgery.

·      EAMCb 236

521.       On September 8, 2021, Neurologist Nojan Valadi consults on Yolanda’s case. Yolanda has chronic lower extremity weakness, which may be permanent. Yolanda’s prognosis for ambulation may remain poor.

·      EAMCb 247

NCEA Neurology Consultation

522.       On December 7, 2021, Neurologist Amanda Reimer consults on Yolanda’s case at Neurology Center of East Alabama (“NCEA”). Yolanda has “paraplegia following spinal cord injury.” She is wheelchair-bound with severe injury to her lumbar spine.

·      NCEA 3

523.       In reviewing the treatment Yolanda received at Emory in March 2021, Dr. Reimer notes that Yolanda awoke from the thrombectomy unable to move her legs and that Yolanda has been wheelchair-bound ever since.

·      NCEA 4

524.       Dr. Reimer personally reviews Yolanda’s MRI imaging.

·      NCEA 7

525.       The post-surgical changes in Yolanda’s lumbar spine “look absolutely awful.”

·      NCEA 7

526.       Dr. Reimer has “never seen this degree of swelling cauda equina.”

·      NCEA 7

527.       Dr. Reimer cannot conceive an explanation for this “a lumbar spine disaster.”

·      NCEA 4

Specific Acts of Professional Malpractice

528.       Plaintiff here incorporates by reference all paragraphs of this Complaint.

Dr. Alabi

Violation One: Failure to Abort Difficult Procedure

529.       The standard of care requires a vascular surgeon to recognize problems that render a thrombectomy too dangerous to continue, and to abort the procedure when such problems arise.

530.       On March 26, 2021, Dr. Alabi encountered problems with Yolanda’s thrombectomy, in the form of the thrombectomy wire not entering the correct veins. Dr. Alabi documented these difficulties in her operative report.

531.       Dr. Alabi was required to abort the thrombectomy procedure when she  encountered these difficulties, because continuing the thrombectomy exposed Yolanda to unnecessary risk, during a procedure for which Yolanda did not have an emergent indication.

532.       Because Yolanda did not have an emergent indication for the completion of the thrombectomy procedure, Dr. Alabi could have easily postponed Yolanda’s thrombectomy and continued the procedure on a later date.

533.       Puncture of blood vessels is a complication which is inherently risked during a thrombectomy. Difficulties during a thrombectomy increases this risk.

534.       By continuing the procedure after encountering difficulties that put Yolanda at risk, Dr. Alabi violated the standard of care.

Violation Two: Failure to Diagnose and Treat a Bleeding Complication

535.       The standard of care requires a vascular surgeon to diagnose and treat a patient’s bleeding complication from a thrombectomy procedure.

536.       On March 26, 2021, the intraoperative DSA imaging for the thrombectomy showed extravasation of contrast agent on Series 11, 12, 13, and 14. The presence of contrast agent outside of the blood vessels indicated that a blood vessel had a puncture and was leaking.

537.       On March 26, 2021, Yolanda incurred a bleeding complication during the thrombectomy procedure.

538.       On March 26, 2021, and March 27, 2021, Dr. Alabi failed to diagnose and treat Yolanda’s bleeding complication. Dr. Alabi thus violated the standard of care.

Violation Three: Improper Administration of Alteplase and Heparin

539.       The standard of care requires a vascular surgeon to forgo the administration of alteplase and heparin after a thrombectomy in which difficulties indicate alteplase and heparin would cause an unreasonable danger to the patient.

540.       On March 26, 2021, Dr. Alabi performed Yolanda’s thrombectomy and experienced difficulties, in the form of the thrombectomy wire not entering the correct veins. Dr. Alabi documented these difficulties in her operative report.

541.       On March 26, 2021, after this difficult procedure, it was unreasonable for a physician to order alteplase and heparin for Yolanda. Yolanda had a high likelihood of having a bleeding complication from the thrombectomy, and the administration of alteplase and heparin would worsen any existing bleeding complication.

542.       The administration of alteplase and heparin should not have been ordered until Yolanda was cleared from any complications from the thrombectomy.

543.       On March 26, 2021, Dr. Khaidakova and Dr. Chang failed to hold the administration of heparin and alteplase to Yolanda after her thrombectomy.

544.       On March 26, 2021, Dr. Alabi failed to properly supervise and direct Dr. Khaidakova and Dr. Chang. Dr. Alabi thus violated the standard of care.

Violation Four: Failure to Assess for Complications

545.       The standard of care requires a vascular surgeon to monitor and assess a patient and to investigate potential complications, after a difficult procedure.

546.       On March 26, 2021, Dr. Alabi performed Yolanda’s thrombectomy and experienced difficulties, in the form of the thrombectomy wire not entering the correct veins. Dr. Alabi documented these difficulties in her operative report.

547.       On March 26, 2021, immediately after the thrombectomy procedure, Yolanda began to complain of back pain, began to require regular doses of pain medication, and was moving only two of four extremities normally. On March 26, 2021, and March 27, 2021, RN Tyler Hall documented, across multiple assessments, weak motion in Yolanda’s lower extremities.

548.       On March 26, 2021, and March 27, 2021, Dr. Alabi failed to assess and monitor Yolanda for complications after the thrombectomy. Dr. Alabi thus violated the standard of care.

Dr. Khaidakova

Violation One: Failure to Assess for Complications

549.       The standard of care requires a vascular surgeon to monitor and assess a patient and to investigate potential complications after a difficult procedure.

550.       On March 26, 2021, Dr. Alabi performed Yolanda’s thrombectomy and experienced difficulties, in the form of the thrombectomy wire not entering the correct veins. Dr. Alabi documented these difficulties in her operative report.

551.       On March 26, 2021, immediately after the thrombectomy procedure, Yolanda began to complain of back pain, began to require regular doses of pain medication, and was moving only two of four extremities normally. On March 26, 2021, and March 27, 2021, RN Tyler Hall documented, across multiple assessments, weak motion in Yolanda’s lower extremities.

552.       On March 26, 2021, and March 27, 2021, Dr. Khaidakova failed to assess and monitor Yolanda for complications post-thrombectomy. Dr. Khaidakova violated the standard of care.

Violation Two: Improper Administration of Alteplase and Heparin

553.       The standard of care requires a vascular surgeon to forgo the administration of alteplase and heparin after a thrombectomy in which difficulties indicated alteplase and heparin would cause an unreasonable danger to the patient.

554.       On March 26, 2021, Dr. Alabi performed Yolanda’s thrombectomy and experienced difficulties, in the form of the thrombectomy wire not entering the correct veins. Dr. Alabi documented these difficulties in her operative report.

555.       On March 26, 2021, after this difficult procedure, it was unreasonable for a physician to order alteplase and heparin for Yolanda. Yolanda had a high likelihood of having a bleeding complication from the thrombectomy, and the administration of alteplase and heparin would worsen any existing bleeding complication.

556.       The administration of alteplase and heparin should not have been ordered until Yolanda was cleared from any complications from the thrombectomy.

557.       On March 26, 2021, Dr. Khaidakova failed to hold the administration of heparin and alteplase to Yolanda after Yolanda’s thrombectomy procedure. Dr. Khaidakova thus violated the standard of care.

Dr. Chang

Violation One: Failure to Assess for Complications

558.       The standard of care requires a vascular surgeon to monitor and assess a patient and to investigate potential complications, after a difficult procedure.

559.       On March 26, 2021, Dr. Alabi performed Yolanda’s thrombectomy and experienced difficulties, in the form of the thrombectomy wire not entering the correct veins. Dr. Alabi documented these difficulties in her operative report.

560.       On March 26, 2021, immediately after the thrombectomy procedure, Yolanda began to complain of back pain, began to require regular doses of pain medication, and was moving only two of four extremities normally. On March 26, 2021, and March 27, 2021, RN Tyler Hall documented, across multiple assessments, weak motion in Yolanda’s lower extremities.

561.       On March 26, 2021, and March 27, 2021, Dr. Chang failed to assess and monitor Yolanda for complications post-thrombectomy. Dr. Chang thus violated the standard of care.

Violation Two: Improper Administration of Alteplase and Heparin

562.       The standard of care requires a vascular surgeon to forgo the administration of alteplase and heparin after a thrombectomy in which difficulties indicated alteplase and heparin would cause an unreasonable danger to the patient.

563.       On March 26, 2021, Dr. Alabi performed Yolanda’s thrombectomy and experienced difficulties, in the form of the thrombectomy wire not entering the correct veins. Dr. Alabi documented these difficulties in her operative report.

564.       On March 26, 2021, after this difficult procedure, it was unreasonable for a physician to order alteplase and heparin for Yolanda. Yolanda had a high likelihood of having a bleeding complication from the thrombectomy, and the administration of alteplase and heparin would worsen any existing bleeding complication.

565.       The administration of alteplase and heparin should not have been ordered until Yolanda was cleared from any complications from the thrombectomy.

566.       On March 26, 2021, Dr. Chang failed to hold the administration of heparin and alteplase to Yolanda after her thrombectomy. Dr. Chang thus violated the standard of care.

Dr. Sharifpour

Violation One

567.       On March 26, 2021, NP Lay failed to review Yolanda’s anesthesia records and failed to consider the impact of a transfusion of red blood cells on Yolanda’s lab results. NP Lay thus violated the standard of care.

568.       On March 26, 2021, Dr. Sharifpour failed to properly supervise and direct NP Lay. Dr. Sharifpour thus violated the standard of care.

Violation Two

569.       On March 27, 2021, Dr. Kosiak failed to quickly investigate Yolanda’s severe neurological deficits. Dr. Kosiak thus violated the standard of care.

570.       On March 27, 2021, Dr. Sharifpour failed to properly supervise and direct Dr. Kosiak. Dr. Sharifpour thus violated the standard of care.

NP Lay

Violation One

571.       The standard of care requires a critical-care nurse practitioner to review a patient’s operative records, including anesthesia records.

572.       On March 26, 2021, NP Lay noted that Yolanda had acute post-procedure pain and acute blood loss anemia. NP Lay apparently failed to review the anesthesia records for Yolanda’s thrombectomy that day, which documented a transfusion of red blood cells. NP Lay then failed to consider how the transfusion impacted Yolanda’s hematology lab values. NP Lay thus violated the standard of care.

Dr. Kosiak

Violation One

573.       The standard of care requires a physician to immediately investigate a patient’s severe neurological deficits.

574.       On March 27, 2021, Dr. Kosiak failed to promptly investigate Yolanda’s severe neurological deficits. Dr. Kosiak thus violated the standard of care.

RN Tyler Hall

Violation One

575.       While a patient is receiving infusions of alteplase and heparin, the standard of care requires a nurse to monitor and report clinically significant changes in the patient’s hemoglobin, hematocrit, and platelet values.

576.       From 1804 hrs on March 26, 2021, through 2023 hrs on March 27, 2021, Yolanda’s hemoglobin, hematocrit, and platelets values decreased repeatedly below the reference range, as reflected in her hematology lab results.

577.       On March 26, 2021, and March 27, 2021, RN Tyler Hall failed to monitor and report the clinically significant decreases in Yolanda’s hemoglobin, hematocrit, and platelet values. RN Tyler Hall thus violated the standard of care.

Violation Two

578.       The standard of care requires a nurse to monitor and report a patient’s clinically significant PTT and anti-Xa values.

579.       From March 26, 2021, at 0008 hrs, through March 27, 2021, at 1213 hrs, elevations in Yolanda’s PTT and anti-Xa results indicated that the dose of heparin she was receiving was at a supratherapeutic level.

580.       On March 26, 2021, and March 27, 2021, RN Tyler Hall failed to monitor and report Yolanda’s clinically significant PTT and anti-Xa levels. RN Tyler Hall thus violated the standard of care.

Violation Three

581.       The standard of care requires a nurse to follow a physician’s orders.

582.       On March 26, 2021, at 1746 hrs, Dr. Khaidakova ordered the following: perform post-procedural vital signs with frequent neurovascular checks, notify a provider if PTT is greater than 60 seconds, notify a provider of back pain or neurovascular changes, and perform neurovascular assessments with each vital sign check.

583.       On March 26, 2021, and March 27, 2021, RN Tyler Hall repeatedly failed to follow Dr. Khaidakova’s orders. RN Tyler Hall thus violated the standard of care.

RN Shaquira Hall

Violation One

584.       While a patient is receiving infusions of alteplase and heparin, the standard of care requires a nurse to monitor and report clinically significant changes in the patient’s hemoglobin, hematocrit, and platelet values.

585.       From 1804 hrs on March 26, 2021, through 2023 hrs on March 27, 2021, Yolanda’s hemoglobin, hematocrit, and platelets values decreased repeatedly below reference range, as reflected in her hematology lab results.

586.       On March 26, 2021, and March 27, 2021, RN Shaquira Hall failed to monitor and report the clinically significant decreases in Yolanda’s hemoglobin, hematocrit, and platelet values. RN Shaquira Hall thus violated the standard of care.

Violation Two

587.       The standard of care requires a nurse to monitor and report a patient’s clinically significant PTT and anti-Xa values.

588.       From March 26, 2021, at 0008 hrs, through March 27, 2021, at 1213 hrs, elevations in Yolanda’s PTT and anti-Xa results indicated that the dose of heparin she was receiving was at a supratherapeutic level.

589.       On March 26, 2021, and March 27, 2021, RN Shaquira Hall failed to monitor and report Yolanda’s clinically significant PTT and anti-Xa levels. RN Shaquira Hall thus violated the standard of care.

Violation Three

590.       The standard of care requires a nurse to follow a physician’s orders.

591.       On March 26, 2021, at 1746 hrs, Dr. Khaidakova ordered the following: perform post-procedural vital signs with frequent neurovascular checks, notify a provider if PTT is greater than 60 seconds, notify a provider of back pain or neurovascular changes, and perform neurovascular assessments with each vital sign check.

592.       On March 26, 2021, and March 27, 2021, RN Shaquira Hall failed to follow Dr. Khaidakova’s orders. RN Shaquira Hall thus violated the standard of care.

Violation Four

593.       The standard of care requires a nurse to provide timely, accurate, and concise reports on a patient’s clinical status.

594.       On March 27, 2021, at 1113 hrs, RN Shaquira Hall noted that there was tingling and absent motion in Yolanda’s lower extremities, which was an acute change from the previous assessment which noted sensation intact.

595.       At 1130 hrs, although she notified Dr. Kosiak that Yolanda was not moving her lower extremities, RN Shaquira Hall failed to notify Dr. Kosiak that Yolanda’s lower extremities had tingling sensation.

596.       Instead, RN Shaquira Hall provided additional information that muddied her incomplete report and that appears to be inaccurate: she informed Dr. Kosiak that Yolanda was difficult to assess because of the effects of the general anesthesia.

597.        Subsequently, after performing at least three additional assessments, RN Shaquira Hall failed to update Dr. Kosiak on Yolanda’s clinical status. 

598.       On March 27, 2021, RN Shaquira Hall failed to report that: (a) Yolanda’s lower extremities were flaccid with no movement, (b) Yolanda had tingling in the lower extremities, and yet (c) Yolanda was able to follow simple commands.

599.       Though RN Shaquira Hall repeatedly documented that Yolanda’s acute neurovascular changes were continuing, RN Shaquira Hall failed to report their continuation.

600.       On March 27, 2021, RN Shaquira Hall thus violated the standard of care.

Violation Five

601.       When a patient experiences acute clinical changes, the standard of care requires a nurse to advocate for the patient by reporting the changes and requesting a physician evaluation at bedside.

602.       On March 27, 2021, at 1113 hrs, RN Shaquira Hall noted that a resident physician was aware of the absence of motion in the bilateral lower extremities. On March 27, 2021, at 1200 hrs, RN Shaquira Hall assessed Yolanda, and noted that Yolanda had continuing absent movement and flaccidity in her lower extremities.

603.       On March 27, 2021, RN Shaquira Hall failed to report Yolanda’s acute neurovascular changes and failed to request that a physician evaluate Yolanda at bedside. RN Shaquira Hall thus violated the standard of care.

RN Price

Violation One

604.       While a patient is receiving infusions of alteplase and heparin, the standard of care requires a nurse to monitor and report clinically significant changes in the patient’s hemoglobin, hematocrit, and platelet values.

605.       From 1804 hrs on March 26, 2021, through 2023 hrs on March 27, 2021, Yolanda’s hemoglobin, hematocrit, and platelets values decreased repeatedly below the reference range, as reflected in her hematology lab results.

606.       On March 27, 2021, RN Price failed to monitor and report the clinically significant decreases in Yolanda’s hemoglobin, hematocrit, and platelet values. RN Price thus violated the standard of care.

Violation Two

607.       The standard of care requires a nurse to monitor and report a patient’s clinically significant PTT and anti-Xa values.

608.       From March 26, 2021, at 0008 hrs, through March 27, 2021, at 1213 hrs, elevations in Yolanda’s PTT and anti-Xa results indicated that the dose of heparin she was receiving was at a supratherapeutic level.

609.       On March 27, 2021, RN Price failed to monitor and report Yolanda’s clinically significant PTT and anti-Xa levels. RN Price thus violated the standard of care.

Violation Three

610.       The standard of care requires a nurse to follow a physician’s orders.

611.       On March 26, 2021, at 1746 hrs, Dr. Khaidakova ordered the following: perform post-procedural vital signs with frequent neurovascular checks, notify a provider if PTT is greater than 60 seconds, notify a provider of back pain or neurovascular changes, and perform neurovascular assessments with each vital sign check.

612.       On March 27, 2021, RN Price failed to follow Dr. Khaidakova’s orders. RN Price thus violated the standard of care.

RN Harsany

Violation One

613.       While a patient is receiving infusions of alteplase and heparin, the standard of care requires a nurse to monitor and report clinically significant changes in the patient’s hemoglobin, hematocrit, and platelet values.

614.       From 1804 hrs on March 26, 2021, through 2023 hrs on March 27, 2021, Yolanda’s hemoglobin, hematocrit, and platelets values decreased repeatedly below the reference range, as reflected in her hematology lab results.

615.       On March 26, 2021, RN Harsany failed to monitor and report the clinically significant decreases in Yolanda’s hemoglobin, hematocrit, and platelet values. RN Harsany thus violated the standard of care.

Violation Two

616.       The standard of care requires a nurse to follow a physician’s orders.

617.       On March 26, 2021, at 1746 hrs, Dr. Khaidakova ordered the following: perform post-procedural vital signs with frequent neurovascular checks, notify a provider if PTT is greater than 60 seconds, notify a provider of back pain or neurovascular changes, and perform neurovascular assessments with each vital sign check.

618.       On March 26, 2021, RN Harsany failed to follow Dr. Khaidakova’s orders. RN Harsany thus violated the standard of care.

Causation

619.       Plaintiff here incorporates by reference all paragraphs of this Complaint.

620.       On March 26, 2021, Vascular Surgeon Olamide Alabi performed a thrombectomy on Yolanda at Emory. The procedure ended at about 1735 hrs.

621.       On March 27, 2021, over 30 hours later, Orthopedic Spine Surgeon Dheera Ananthakrishnan performed a laminectomy on Yolanda, to evacuate hematomas that had gone undiagnosed and untreated, likely since the thrombectomy.  

622.       By that time, as a result of the acts and omissions that delayed the diagnosis and treatment of the hematomas, it was too late.

623.       By that time, Yolanda had already suffered irreversible nerve damage resulting in the neurological deficits she will live with for the rest of her life.

624.       Had providers recognized and treated the hematomas earlier, Yolanda would have recovered with fewer and less severe neurological deficits, if any.

625.       In fact, had providers at Emory promptly diagnosed and treated Yolanda’s hematomas, Yolanda would have recovered with no neurological deficits.

626.       Insofar as it delayed the diagnosis and/or treatment of the hematomas, each violation of the standard of care outlined above caused Yolanda preventable neurological deficits she will live with for the rest of her life.

__________________

627.       As a direct and proximate result of the 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 Plaintiff suffered, including physical, emotional, and economic injuries.

628.       WHEREFORE, Plaintiff demands a trial by jury and judgment against the Defendants as follows:

a.    compensatory damages in an amount exceeding $10,000.00 to be determined by a fair and impartial jury;

b.    all costs of this action;

c.     expenses of litigation pursuant to OCGA 13-6-11;

d.    punitive damages; and

e.     such other and further relief as the Court deems just and proper.

March 20, 2023

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

[1] OCGA §§ 14-2-510 and 14-3-510 provide identical venue provisions for regular business corporations and for nonprofit corporations:

“Each domestic corporation and each foreign corporation authorized to transact 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 § 14-7-3.

These venue provisions also apply to Limited Liability Companies, see OCGA § 14-11-1108, 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.”

[2] See OCGA 9-11-1.

[3] See Atlanta Women’s Specialists v. Trabue, 310 Ga. 331 (2020) (“Georgia is a notice pleading jurisdiction. Generally, our Civil Practice Act (CPA) advances liberality of pleading. … [A] complaint need only provide fair notice of what the plaintiff's claim is and the grounds upon which it rests . … [The] objective of the CPA is to avoid technicalities and to require only a short and plain statement of the claim that will give the defendant fair notice of what the claim is and a general indication of the type of litigation involved; the discovery process bears the burden of filling in details.”) (cleaned up).

[4] See, e.g.: Dent v. Memorial Hospital, 270 Ga. 316 (1998) (reversing judgment in favor of hospital, because jury instructions did not make clear that both ordinary negligence and professional malpractice would authorize a verdict against the hospital); Lowndes County Health v. Copeland, 352 Ga. App. 233 (2019) (affirming verdict for both ordinary negligence and professional negligence against skilled nursing facility).