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                                      CAUSE NO. B-182575

 PAUL SEBILE, SR., INDIVIDUALLY                  §      IN THE DISTRICT COURT
 AND AS HEIR AND                                 §
 REPRESENTATIVE OF THE                           §
 ESTATE OF LAURA SEBILE,                         §
 DECEASED; PAUL SEBILE, JR.;                     §
 LAWRENCE C. SEBILE; ERIC                        §
 SEBlLE; DON C. SEBILE; CLARA                    §
 J. SEMIEN; FRANKIE L. COBB                      §
 AND SHARON K. DEAN, AS                          §
 CHILDREN OF DECEASED                            §
                                                 §
V.                                               §     JEFFERSON COUNTY,TEXAS
                                                 §
ARFEEN QAMAR, M.D., FALLON                       §
GORDON, M.D., DR. JUAN                           §
MANUEL GONZALEZ                                  §
And BAPTIST HOSPITALS OF                         §
SOUTHEAST TEXAS D/B/A                            §
MEMORIAL HERMANN BAPTIST                         §
BEAUMONT HOSPITAL                                §     60TH JUDICIAL DISTRICT


                                            ORDER


         BE IT REMEMBERED that on the 8th day of May 2009, came on to be heard Defendant

Juan Manuel Gonzalez, M.D. 's Objections to the Report and Qualifications of Shabir Bhimjl, M.D.,

Pli.D, Objections to the Report and Qualifications of Hector J. Herrera, M.D, and Objections to the

Amended Report and Qualifications of Shabir Bhimjl, M.D, PhD, and the Court, having

considered the Objections and Motion, and Plaintiffs' Responses, and argument of the parties,

grants Plaintiffs' request for a thirty (30) day extension pursuant to § 74351(c) of the TEX Cry.

PRAC & REM. CODE ANN. Plaintiffs have until June 8, 2009 to file and serve reports and curricula

vitae.
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451630.1 PLD 000)555 6922 DOC
TAB 2
                                CAUSE NO. B0182-575

 PAUL SEBILE, SR., INDIVIDUALLY §IN THE DISTRICT COURT OF
AND AS HEIR AND                §
REPRESENTATIVE OF THE          §
ESTATE OF LAURA SEHILE,        §
DECEASED; PAUL SEBU,E JR.,     §
 LAWRENCE C. SEBILE, EIUC      §
SEBILE, DON C. SEBILE, CLARA §
J. SEMIEN, FRANKIE 1. COBB     §
AND SHARON K. DEAN, AS         §
CHILDREN QF DECEASED           §
                               §
VS.                            §JEFFERSON COUNTY, TEXAS
                               §
ARFEEN QAMAR, M.D., ,FALLON §
GORDON, M.D., DR. JUAN         §
MANUEL GONZALEZ                §
and BAPTIST HOSPITALS OF       §
SOUTHEAST TEXAS D/B/A          §
MEMQRTAL HERMANN BAPTIST §
BEAUMONT H.OSPITAL             §    60'h JUDICIAL DISTRICT

     ORDER DENYING DEFENDANTS, .JUAN MANUEL GONZALEZ, M.D.'S
 OBJECTIONS TO THE SECOND AMENDED REPOR'l' AND QUALIFICATIONS OF,
   SHAMIR BHIMn. M.D.. Ph.D. A.ND MOTION TO DISMISS WITH PREJUDICE

      CAME ON July 10,2009 to be heard Defendant, JUAN MANUEL GONZALEZ,

MO,'S    OBJECTIONS        TO    THE    SECOND      AMENDED       REPORT      AND

QUALIFICATIONS OF SHAMIR BHIMJI, M,D., Ph.D, AND MOTION TO DISMISS

WITH PREJUDICE in the above-styled and numbered cause, and the Court, having

considered the Motions, and after hearing oral argument, is of the opinion that the

Motions should be Denied, and it is, therefore:
     ORDERED, ADJUDGED and DECREED that Defendant JUAN MANUEL

GONZALEZ, M,O:S OBJIECTIONS TO THE SECOND AMENDED REPORT AND

QUALIFICATIONS OF SHAMIR BHIMJI, M,D" PhD, AND MOTION TO DISMISS

WITH PREJUDICE is hereby DENIED.

     SIGNED AND ENTERED this the   IO~y of July. 2009.




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TAB 3
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                                       Hector J. Herrera MD
                                         2233 Chilton M
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                                      Houston. T~ 77019



                                                                                                           I
                                           713·409-983S
                                      hbmlQ6Q7@aoLcDm

 January 20. 2009

 Jane Logcr
 Attorney at Law
1'ro110st;md Dmphrey Law Finn
 490 Pane Street
Btlfl1lm on1:, Texl\S 7779 J
Plwne 409-8354)00
Fill( 409-813 -8622


Re; Laura Sebilc:

         I lU'O a boan:! certified llI1esthesiologist 1>)' the AmericllIl BQflrd of Anesthesiology
who is li=d to ptaeMe in the $\at(l of TeX8S. lluive been in Pfl\Cticc: at the Methodist
H:ci~pital in HO\l9tOI1, Taxas s~e 1991. My experience includes pl'oviding lllIesthesia
se."vices for canliot!1ora"io, j;e~a1 surgery, n~mrgery, o\1hopedk, ob.netrioallUld
gy.necologieftl cases.
           [.hAve ~yiewed the following medical records of Laura Seb;lle; Mt'llnorlal :Baptist
 Beawnontdated 9115/06, Memorial Baptist B~Ulnont dated 9/22/06 to 9126106,
 Mecnorial Baptillt BeaulnOl1t Hospital datedlO/05106, Mem<r.rial Baptist Beaumont
 H09piud datcld lOfj4/08, MllTIloria1 Baptist SfllIUUIont Hospital dated IO/17/Q6, Memorial
 B$p1i.st BeBUmotJt HospiraJ dated lOI22JOO, Memocilll Baptist Beaumont Hospitll.l dated
 10/25/06 to l1/O811115.
          The sUlJ)d!l1"d of ~ in the SlaW ofTexlIlI requires an evallllltioll of a patiell1 by lUl
 llI1e8thesiolo~jst prior to ~. This evll1u~ion nhould include a histOry, phy&l.cal, and
review of the patients' chart. Blood teat, x-rays, IUId!UJ elOClrocarc:llogran'llnllY be
ordered. Consultations wlth other !!JlCcialtics may be .soug!lt out A1cl1as Internal
Medicine. l11e Intent ofa pre-sUrgery evaluation is to detel'llllne~.patients' medical
condition And if nlllle!lSalY, improVe upon it URing the aid of otJlet medlcal splOCialties.
          ill the calle of Laura Sebile dated 10125/06 to 11/0&/06, the \Ule~elliolo8iRt, Dr.
Juan Manuel Go=.aJez improp~ly eval\ffited Mr.J. Sebjl", prior to surgery on 10125106.
Dr. Oortzalcz's' pre-lIDBllt1wgUj work-\lP did Il(>t meet tM $tandard of cllle for the SUIte of
Tex811. Given Mr history "fheart dis"Wie, cQrdi<1puhnonlllr bypP3S lIUl'gI:Iy, 11M.
COD~e;,tiYe heart failure, Mr.I. Sehile nc:eded a Cllrdiology COD Bul1ation. Dr. Gontalez
should hlI~ cllIIcelled the case In order to further e-valu:tte Mrs. Sebik The ease was n.C>t
Ii medlCllll ernerS¢licy. Att evll1ua11on wolJld baye rC'l'ealed her pJ'C-Sur~y cardiac 1:1at\l!>,
which proved to be Il\lboptirnaJ giv"" thc: ca.rdi~ decompensation that was datootl!ld post-
opet'atlvtly. lIad Dt. OOllZlllcz evll1uated Mrs Sebile CQnectly, he would hHVe
disoovetW her suboptiInll1 OOIldition. Because of the improper pte-5l.Itge!Y eve1\l1l.tiQll.
                                                                                                      i=

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MTi. 8ebile WIIS DOt in the best xnedkal condition to withstand tfu< sfn;!ls of sW'B'6CY.
Furtharm.;>re, ru.d per me\'llilal stl\(:Us been optlrn~, ,<jhc would have better withstood the
lJIjlld~ she 1mbsequently incUrred d4ring her operatiQn 01' 1Of') S106. The.ge inj\lrles
ultimately resulted in her dea1h. It is more likely thlOn not) 11Iat hall Dr. GMZll1ez delayed
sUlaery for further eva1uation, Mrs. SebiJ.e would not have <lied.
        My op1nllnlS &r¢ bllSed on my review offhe records listed sbove. Should any new
iniOtmllUOl\ arlse, 1 reset'V(' the tLght to ehlltlSe DIy opil1ions. Thank )'ou.




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TAB 4
                                CAUSE NO. B0182-575

PAUL SEBILE, SR., INDIVIDUALLY §                IN THE DISTRICT COURT OF
AND AS HEIR AND               §
REPRESENTATIVE OF THE         §
ESTATE OF LAURA SEBILE,       §
DECEASED; PAUL SEBILE JR.,    §
 LAWRENCE C. SEBILE, ERIC     §
SEBILE, DON C. SEBILE, CLARA §
J. SEMIEN, FRANKIE L. COBB    §
AND SHARON K. DEAN, AS        §
CHILDREN OF DECEASED          §
                              §
VS.                           §                 JEFFERSON COUNTY, TEXAS
                              §
ARFEEN QAMAR, M.D., FALLON §
GORDON, M.D., DR. JUAN        §
MANUEL GONZALEZ               §
and BAPTIST HOSPITALS OF      §
SOUTHEAST TEXAS D/B/A         §
MEMORIAL HERMANN BAPTIST §
BEAUMONT HOSPITAL             §                  60 th JUDICIAL DISTRICT
                                                                                                         ,/
                                                                                               ~:-~RJ)
      NOTICE OF FILING OF PLAINTIFFS SECONND AMENDED EXPERT REPORT
                      OF SHABIR BHIMJI, M.D., Ph.D.

      COMES NOW, PAUL SEBILE, SR, INDIVIDUALLY AND AS HEIR AND

REPRESENTATIVE OF THE ESTATE OF LAURA SEBILE, DECEASED; PAUL SEBILE

JR , LAWRENCE C SEBILE, ERIC SEBILE, DON C SEBILE, CLARA J. SEMIEN,

FRANKIE L. COBB AND SHARON K. DEAN, AS CHILDREN OF DECEASED Plaintiffs

herein, and files with the official record the second amended rep.Ret of P\51lntiff'~~xpert,
                                                                             ~~\)               ~,~~~~
Shabir Bhim]l, M.D., Ph.D                                       ~~ ~~                      ~    '~F:        .    t
                                                                ~,>

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                                            Respectfully submitted,
                                            PROVOST * UMPHREY
                                            LAW FIRM, LLP
                                            490 Park Street
                                            P O. Box 4905
                                            Beaumont, Texas 77704
                                            (409) 835-6000
                                                                                                  I
                                            Fax No. (409) 813-8622




                           CERTIFICATE OF SERVICE

        I hereby certify that a true and correct copy of the above and foregoing Notice of
                                                                             s
Filing Report has been forwarded to all known counsel of record on this the 1 \ day of May,
2009.




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                                                                                              ,
Ms Jane Leger
April 30, 2009

Dear Ms, Leger,

I am a Board certified Cardiothoracic and Vascular surgeon who has been in active
practice for more than 10 years, I am licensed to practice in the States of Texas, Virginia,
PeoosyJvania and Califorma, I also hold a PhD in Pharmacology, The majority of my
prllctice deals with cardiothoracic surgery and the management of patients in the critical
care units. I am very knowledgeable in the field of cardiothoracic surgery, am well
published and have been in active clinical research for more than 20 years, From my
extensive experience in the field of thoracic slItgery, I feel I am suitably qualifIed to
review the chart of the patient, LalIta Sebile, My CV lS included with this report.

This is a medical report on patient Laura Sebile. I have reviewed the chart provided to me
by Ms. Wendy, My review of the chart is based on what has been provided to me and
subject to change if additional material will be forth coming, After reViewing the chart, I
have rendered my professional opinion regarding the surgery and postoperative care of
Ms, Laura Sebile at Memorial Hermann Baptist Beaumont Hospital, Beaumont, In brief,
the cause of death of Laura Sebile was due to the direct actions of the surgeon, Dr Fallon,
gross negligence of the anesthesiologist, Dr Gonzalez and the numerous medical
mistakes made by the nurses.

Summary of Case

Ms Laura Sebile was 8 70 year old black female who had not been feeling well for a long
time, On 9116/06, she presented to the ER at Memorial Hermann Hospital with
complaints of a cough, getting out of breath and left sided chest pain. She arrived without
any assistance and was ambulating without difficulty. The patient had been having
similar complaints for a very long time and had just been seen in the ER 2 weeks ago (pg
12).

She had a pretty complex medical history of having undergone open heart surgery in. J989.
She was diabetic, had ischemIC heart disease, was hypertensive, had elevated cholesterol
levels and Was morbidly obese(wt 260 lbs, height Sft 3 inches, BM! > 45). She was also
a past smoker and had a family history of heart problems, On Sept 16, in the ER she was
found to have normal vital signs and RR of 20, and pulse OXimetry on 99% on room air.
She did not appear to be in any distress except that she had chest pain when she took a
deep breath. Her respiration was regular and symmetrical (page 9). The patient was
assessed in the ER, did not have any significant investigations and sent home, The ER
physician told her that she should take her medications as prescribed and had a chronic
condition (page 13). All ber investigations were nonnal and the ER physicians were not
impressed with her Chest x ray
On 9/22/06, she again presented to the ER at Hermann memorial hospital. She arrived
without any assistance She claimed that her family doctor Dr, Stout had told her she had
a pneumonia and she was to be seen in the ER. Her vitals revealed a high BP (171/96)
and pulse Oximetry of 99% on room air (page 30). Her breathing was unlabored and
regular. She was breathing at 20 times a min. She did report a nan productive cough. She
hM vague pains graded 9/10, She was started on levaquin, zithromax and keflex (page
31). She was given respiratory nebulizer therapy and admitted (p. 32). The routine blood
work and Chest x ray were again repeated. She did not appear to be in any distress for
the rest of her hospital admission (pg 34). The history and physical exam done on thrs
admission (9/22/06) by the physician says the patient had a history of ischemic heart
disease, had symptom of cough, weakness and was SOB (pg 36) Pt was found to have a
BMI of 47.29 kg/m2 which is considered morbidly obese. Her WBC was 8, HB of 13.2
and HCT of39.2 (pg 40). She was observed in the hospital for 3 days and discharged on
9/26/06. Her discharge diagnosis was pneumonia or pneumonitis (page 139) Prior to
discharge, patient did have a che.st x ray which was read as normal. She also had a CT
chest which revealed a consohdative process in the left lower lung witI1 an associ.ated kft
pleural effusion (pg 143). The pI1ysician said patient had improved and was discharged
on levaquin (pg 145).

She was then referred to a pulmonologist, who proceeded to order a US guided drainage
of her left pleural effUSIOn.

B~ause  the chest X ray and CT scan had revealed a pleural effusion and a left lower lobe
consolidation, a left thoracentesis cytology was done on 10/5/06.

On 10/5/06 patient underwent ultrasound guided drainage of the left pleural effusion The
fluid was. clear and about 750 cc was aspirate (pg 167). The fluid turned out to be
negative for malignancy (pg 159).

Chest x ray of 10/5/06 showed that the pUlmonary vascular cengestion was improving but
there was still an infiltrate in the left lower lobe (pg 158) (compared to 9/25/06) x ray was
improved. This was the first indication that the patient likely also had congestive heart
fai lure but this was agllin never addre~8ed. The patient was never referred to a
cardiologist. Despite every report indkating that she had perlpheral edema, an enlarged
hemt and was SOB, tile patient Was never placed on diuretics either. What is even more
sbockillg is that thIS patient had a known history of heart disease and had already had
open heart surgery in tbe past- alld yet she was never once referred to a cardiologjst to
evaluilte her heart.

On 10/14/06 patient again pJ:esented to the ER at Hermann memorial hospital willi
complaints of chest pain. Her breathing was the same (pg 181). She was thoroughly
worked up again. She had a pulse Oximetry of 100% on room air. Patient was discharged
horne with a diagnosis of pleurisy and told to follow up with the pulmonologist (pg 183).
The Chest x rayon 10114/06, showed increasing density in the lower left lung. The heart
appears to be mildly enlarged. Conclusion was a left lung atelectasis and left pleural
effusion. Enlarged heart may be suggestive of worsening heart failure

The CT Scan on 10115/06-revealed multiple nodules in the Aorta pulmonary window all
are 8 nun. only one nodule was 12 mm. Also observed was that the Left adrenal gland
was enlarged. The left lower lobe of the lung was collapsed. (Page 184).

On 1011 7/06 patient underwent a bronchoscopy by the pulmonologist. The findings were
Severe edema in LL bronchus, 60% occlusion of the LL bronchus. Thick secretions but
no mass visualized (page 226). The cytology from the bronchoscopy was again negative
for malignancy. (pg 228, 229). Report indicated that the problem was related to chronic
inflammation but no malignancy (page 229).

On 10/22/06 presented to ER again with same complaints of SOB and pain. RA oxygen
was 100% and BP was 185/103. She was found to be comfortable and in no distress and
discharged on supportive advice and a pain pill (pg 259).

10122/06. Chest x-ray report suggested vascular redistribution and interstitial edema,
suggesting CHF. And left lung atelectasis still persisted (pg 260)

The pUlmonoJogist then referred the patient to the surgeon (DR Fallon) Within 3 days,
the patient was immediately booked for surgery by Dr Fallon. She was admitted by DR
Holly James, ordering physician was Gordon Fallon The date of surgery was set for
10/25/06. So far every study had showed no signs of malignancy and no work up was
done to eliminate CHF as the cause of the pleural effUSIOn.

Despite the fact that the patient had IHD and had prior open heart surgery, no cardiology
consult was called to clear her. She did not even have a stress test or a blood gas. Despite
the fact that her blood pressure had been elevated, cardiology was not called. Nor was
endocrine called to monitor her diabetes. The patient did have an ECHO (a normal
ECHO does not rule out coronary artery disease). The surgeon indicated he would do a
thoracoscopy to biopsy the lymph nodes. Despite the fact this was an extremely high risk
patient, he decided to place her under general anesthesia without a single medical
consultation. And most important, he appeared to have neglected the fact that any patient
who has 1100 open hean SUJgery develops severe acDlCsions itl the left chest. ALL
PATIENTs WHO HAVE OPEN HEART SURGERY DBVELOP SEVERE
ADHESIONS THIS IS THE ACHILLES HEEL OF AIL SURGEONS WHO


                                                                                               I
OPERATE ON PATIENTS WITH PRIOR OPEN HEART PROCEDURES.



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There was no blood gas done prior to surgery nor was there any blood sent for type and
cross. The surgeon did write in the chart that he would perform a thoracotomy iithe
                                                                                               ,
thoracoscopy was not successful" and yet did not even order a single pint of blood. Even
If there is a remote possibility of a thoracotomy, the smgcoll is obligated to make sure
that some blood is available in case there is a complication. ThIS was a patient who
already had prior open heart surgery and should have had some blood on stand by
                                                                                             ,
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On the day of the surgery, the history and physical revealed the following coagulation       t
parameters.                                                                                  t
PT w~s 22.5, JNR 2.6, done after patient was in surgery (13.26 pm) 10/] 5/06 (page not
readable). To ensure there Was no mistake, tlle Remlts were verified. Also of significance
was the following: WBC 1,J, HB 8.4/243 at 1325 pm (pg not readable). It is simply
                                                                                             ,
incredible that the surgeon and the anesthesiologist disregarded these numbers and still
took the patient to the Operating Room. A thoracic procedure in the face of such numbers
is simply negligent to say the least Elective or emergent surgery in the face of an
elevated INR can be associated with massive bleeding which is difficult to stop- which is
exactly what happened in this case.

Patient was then scheduled for surgery on her lungs on 10/25/06. The nursing assessment
noted before surgery. No pain, alert, aWake, p\llse Oximetry 96% on room air
 (p. 0085-0091). Patient had nO complaints about her lung condition minutes before het
surgery.

History Bnd physical   Oll   d8y of admission for surgery (I 0J25/06) page 287

Prior to the surgery, the patient showed signs of a pneumonia or CHF. Respiratory,
pleuritic chest pain, peripheral edema, productive cough, and blood tinged- all this was
simply ignored. Chest pain at rest and exertion, dyspnea, fatigue

Her BP is 182/84 and yet she was taken to the operating room. This is negligent on part
of anesthesia.




Operating Note Dictation by the Surgeon- Discrepancies

Indications for surgery are not explained and whatthe postoperative diagnosis is not
mentioned either. Procedure was a thoracoscopy in 2 places and a left thoracotomy with
surure of bleeding areas. Dr Myrick the card\ac surgeon is also mentioned as an assistant.
                                  \
Claims blood loss was 600-800 as per Dr Gonzalez- 1bis is an obvious lie (see anesthesia
notes and cell saver- 955 cc).

Claims patient had chronic hypertension and chronic congestive heart failure with
shortness of breath and a cough. Not a single physician at lJem,alln bothered to ftnd out
jf tJ1C patient had eRF. The surgeon believed it was cancer                                  1=
                                                                                             .-
Claims that on Oct 22, patient went to Baptist hospital ER and was treated for heart         !
failw:e (FALSE· she was never admitted on Oct 22, but spent time in the ER She has
Oxygenation 99% on room air, RR l8 and BP of 182/1 03. She was discharged on Oct 22
with just supportive advice. She did not receive a single heart medication, no cardiology
cousult was called. There was no mention of even the word CHF in the chart- page 254).

The CT scan done on Oct 15 mentioned numerous mediastinal lymph nodes and an
enlarged adrenal gland. The patient had only one large lymph node (1,2 mm), not several
as the surgeon implies- another deliberate falsification,

Since that time the patient had already undergone a bronchoscopy which was negative
and an ultrasound guided thoracentesis-all of which were negative for malignancy). DR
Fallon says there were several lymph nodes which were enlarged- wrong there was only
one lymph node which was 1.2 mm, all the rest were less than 8 nun.

The surgeon mentions that the patient was being treated for CHF just a few days ago. It is
even more shocking to know that a few days later; he is taking such a patient for surgery
under general anesthesia. The mortality of surgery in patients who have CHF and general
anesthesia is close to 90%. If the patient hadCBF like the surgeon mentions, there was
zero effort to have had the patient cleared for surgery by cardiology. It is unheard of that
a surgeon will take a patient with CHF to the OR and perfonn a procedure under general
anesthesia

Procedure description by Surgeon

Patient had a double lumen endotracheal tube, The first incision was made in the
posterior aXillary line in the 6 th ICS and palpation was done of the inside of the chest with
the finger. Dissection resulted in bleeding, This was aborted and the next inciSIOn was
made in the mid axillary line and a cryo clamp was used for dissection. Trocar was
placed and pulsatile bleeding was encO\U1tered. Uncontrolled bleeding happened and a
thoracotomy was now performed, Says opening in the heart or pulmonary artery. False-
Dr Myrick Who was requested to come and assist said that the heart had been punctured
with the Trocar. Dr Myrick took control of the bleeding with a bovine pericardial patch.
The lung had been deflated, so it could not have been the lung. The left atrium may also
have been damaged. After a tumultuous 3 hrs in the OR, patient was salvaged and taken
to the ICU. The surgery to determine the lung problem was never completed and the only
tissues sent to pathology were rib fragment. Dr Fallon mentions that theputient was
ex.tubated the next day and began feeding, What he fails to mention is that the patient was
extubated but never could eat again, never walk again and subsequently developed
multiorgan failure and died 13 days later

Even UlOugh the surgery was done on 10/25. The operating note was diotated on 10/29
Herman hospital rules and regulations mandates that all operating notes be dictated
within 24 hours (page 914)

Cell saVer during OR by technioian official report blood loss was 925 ml and 497 ml was
returned to the patient (page 55).
Operating note by DR Myrick (page] 7).

Says preop diagnosis was injw)' to the heart and perfomlcd a ventr1cuJorapphy. The op
note was dictated on 10/28. Says he was called emergently by DR Gordon due to
in~dyertent injury to heart lluring thoracoscopy. The injury was either to the left atrium of
left ventticle. Bleeding was controlled with sutures.

Hand written note by Dr Fallon (pg 415)

Says heart and lung attached to chest wall preventing entry. Yet he persisted doing the
surgery.
Says patient was only given 2 units of blood - (anothcr lie). Patient was given close to
2000 cc of fluid by anesthesia and 6 units of blood products.

No bleeding at close of surgery, patient received 3 more units over the next 48 hrs. The
patient did bleed a lot more in the chest because the entire left hemithorax was opacified.

Blood prodtlcts lra:lls11..lSed on 10/25/06

Heavy blecding
3 unit pRBCs, (pg 752,751, 749)
3 units FFP (pg748, 747, 753)
2 units LPC (750)

All products are 0 positive, indicating that the transfusion was urgent and patient was not
typed and matched prior to surgery.

More hlood product transfusions

10/26 FFP (p. 754)
10/27 pRBC (p. 755)
10/27 pRBCs (p. 756)

In surgery, 10/25/06, surgeon sent rib tissue and bone for pathological analysis. No lung,
pleural tissue identified in specimen. No evidence of TB or any other malignancy
Identified. (Page 906)


On 10126, Unlike what the surgecn claims, the patient continued to receive more blood in
the ICU. Chart says patient received 4 units RBC and 3 FFP (page 417)

Page 418, Note by PCCM says INR elevated and FPP administered. This was the one
and only note in the chart which indicated that the cause of bleeding was an elevated PT
(which was neglected ptior to surgery) and the il~ury caused by the surgeon.
Anemia secondary to bleeding
Post op courSe was very rocky
                                                                                                    ~   .. ,




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After the surgery, the patient (jid get extubated but she continued to require oxygen.
Her chest x-rays done after surgery revealed complete opacification of the left chest-
suggesting more bleeding had occurred. Patient remained tachycardic and was unable to
eat She continued to spike temperatures and had a very high WEC (34). She continued to
wheeze and remained at bed rest. She basically just remained at bed rest and struggled to           r
breathe. At times it appeared that she had suffered a stroke and her heart function also
started to decline. Her urine output continued to decline and she gradually became SOB.
Despite all the notes by Helman physicians mentioning that the patient had a malignancy,
tbis is completely fEllse 811d misleadillg. E,V('ry investigation, bio!Jsy Il.J1.d cytology hili!
revealed that the putient bad no mallgnll.n~'Y'

The patient never ate again after her surgery and finally was made DNR by the family.
She developed renal and respiratory failure. She expired on Nov 8. 2006

Consent (pg 289) - Discrepancy

The surgeon wanted to do a thoracoscopy on the left chest Yet like any minimally
in vasive procedure, there is always a chance that the procedure may be converted to an
open thoracotomy. This was never ex.plained to the patient and there is no indication of it
on the consent This patient had multiple co morbrdities, was morbidly obese and had a
heart problem and she was at an enormous risk for surgery- WAS THE RlSK OF
SURGERY EXPLAINED TO THE PATIENT? It appears that the patient simply has no
idea because in the nursing preop notes, the patient indicates the surgeon will simply look
around with a camera. This consent is vague and does not fully explain the patient what is
at stake. Had she known what the nsks were,she may have never agreed to the procedure.

Summary of Above

Based on the review of Laura Sebile's medical records from Memorial Hermann Baptist
Hospital, it is my professional opinion that the surgeon, and the Anesthesiologist (Dr
Gonzalez) at facility have failed to adhere to the barest minimum of standards of medical
practice in their management of the patient

Without doubt, the surgeon (Dr Fallon Gordon) adhered to very low standards of care 8l1d
failed to mange the patient satisfactorily. It is my professional opinion that the patient
should never have been operated. Even if she required this surgery, the patient should
have been mote thoroughly prepared. Which was not the case. The most fundamental of                       i
blood tests were ignored 8l1d a high risk patient was taken to the OR without adequate                    -
preparation. The physicians in charge ofMs Sebile performed well below the accepted                      1 t-
                                                                                                               ,-




standard of care.                                                                                          j
                                                                                                           ,
IT IS MY OPINION THAT "IN ALL REASONABLE MEDICAL
PROBABILITY" THE BELOW STANDARD OF CARE ACTIONS AND/OR
OMISSIONS OF BOTH THE SURGEON, DR. Fallon Gordon and Dr Gonzalez
                                                                                                ,
                                                                                                i
                                                                                                ,
                                                                                                1
CAUSED THE INJURIES SUFFERED BY Laura Sebile AS WELL AS HER DEATH                               c


Arcus where the Stundard of Care for Mrs. Laun Scbile Wll.'l compromised by the
Surgeon

DEV1ATIONS FROM STANDARD OF CARE as per Texas Adm~njstrlltive code of
Standurds of Physician Practice
                                                                                                I
a. The patient WM first seen in the ER for similar complaints which had been on going
   for a long time. She was ambulating, was breathing comfortably at room air and had
   saturations of 96-99% on every visit to the ER. Even the ER physician observed that
   the {'Mit.nl h,d similar cornplaiht.3 unci ,cut hel LUlIlc.
b_ The patient should never ever have this surgery. She was morbidly obese (BMI >45)
   and had many co morbidities. According to the Texas Administrative Standards of
   Physician Practice, the patient should have been prepared well before any surgery.
   This is a patient who simply was not prepared for surgery. According to the Texas
   Administrative Code of Practice, any reasonable physician would have worked up
   the patient with a few simple tests. The patient had numerous complaints about every
   system in her body and yet the surgeon simply out to perform a procedure which was
   not required. According to the Texas Administrative Code of Practice, it is important
   for a physician to ensure that all reasonable disorders are elimmated from the
   differential diagnosis before rushing a patient to surgery. The patient had normal
   oxygenation at room air, her respiratory rate was always 20, she was ambulating and
   yet she was taken for surgery. According to the Texas Administrative code of
   Physician hactice would it not have been necessary to obtain an (jJteriaJ blood g~~ in
   a patient who was having breathing difficulty? Shockingly there was no arterial
   blood gas done to detennine her breathing status- this most basic of all blood work
   was neglected and the patient rushed to surgery.
c. According to the Texas Administrative Stand.uds of Physician Practice, one should
   always rule out the most obvious disorder first. Secondly, According to the Texas
   Administrative Standards of Physician Practice would not a reasonable physician
   perform simple lung function studies in a patient who was having breathing problems?
   Once a malignancy was not discovered on by a negative bronchoscopy, this patient
   was booked for open surgery in a few days she was booked for surgery. There was
   not a single pulmonary function test done to determine If she was a candidate for
   surgery. Thirdly, According to the Texas Administrative Standards of PhysiciaQ
   Practice would it not be important to assess whether the patient would be able to
   tolerate general <lQesthesia but also whe1l1er the patient would be able to tolerate any
    type ofJung surgery" Incredibly, the patient did not have any type of cardiac work up
   despite the fact that she had already had open heart surgery nearly 20 years ago. It is
                                                                                                    II':-

    extremely rare for bypass grafts to stay patent after 10 years, let alone 20                    .--
                                                                                                    j
                                                                                                    ,
d. The patient had open heart surgery nearly 20 years ago and yet the patient had no
    work up by a cardiologist to determine if she would tolerate the procedure.
   According to the Texas Administrative Standards bfPhys.lcian Practice would not a
   reasonable physician who sees a patient with prior head disea.~e not refer the patient
    to a cardiologist? The patient has fluid coJlection in her chest, she was short of breath
     and she had already had a bypass 20 years ago, which reasonable physician would
     not work this patient for heart disease? This was never done with this patient
e.   It is very well knowu that adhesions of the heart form near 1he left lung base. The
     surgeon noted bleeding when he dissected near the 6th res. Then he proceeded to dig
     in the 3'd intercostal space and inserted the Trocar into the heart. This injury could
     simply have been avoided if the surgeon had simply aborted the procedure or placed
     the Trocar under vision. According to the Texas Administrative Standards of
     Physician Ptnctice WOl\ld not a reasonable physicianimmedilitely stop after a major
     complication has already occurred in the operating room? Not so, Dr Fallon
     proceeded to open up the groin to place the patient on a heart lung machine If the
     injury was minor as Dr Fallon put is, then why did he proceed to open the groin?
     According to the Texas Administrative Standards of Physician Practice would not a
     reasonable surgeon do what is safe for tile patient, then if only the left atrium was
     injured why was there a need to go on by pass? Why not simply oversewand apply
     digital pressure? Atrial pressure is less than 10 rumBG. Any physician even with
     basic general surgery skills can easily take care of bleeding in the atrium This is
     because Dr Fallon injured the ventricle (not the atrium as he claimed) and had to caJl
     a professional heart surgeon to assist him. The injury to the ventricle was verified by
     the cardiac surgeon in the operating note.
f.   According to the Texas Administrative Standards of Physician Practice would not a
     reasonable physician who sces a complicated patient with prior 'heart di.seasc not fnst
     do the simpler procedure first') This patient had numerous other lymph nodes in the
     AP window and tile surgeon had a much safer and easier option of getting to lymph
     node- the chamberlain procedure. This was never entertained
g.   According to the Texas AdministratlVe Standards of Physician Practicc would not it
     reasonable physician. who sees a patient with shortness of breath, chest pain, fluid in
     the left chest and prior open heart surgery 20 years ago think of the heart first'), What
     would be the first diagnosis entertained? Any reasonable physician would think of
     heart disease and not malignancy. Remember, every study for malignancy
     investigation was negative.
h.   According to the Texas Administrative Standards of Physician Practice would not a
     reasonable physlcian who sees a patient WitJl prior heatt disease not refcr the patient
     to it cardiologist? If all the testing for malignancy was negative, then any reasonable
     physician would have thought of a failing heart, not of malignancy I
i.   According to the Texas Administl'ative Standards of Physician Pl3Ltice if all the
     testing done has been negative for a malignancy, then wound not a reasonable
      physician wait to find Ollt the cause oftlle patient's problems? Is there any
     reasonable practicing physician who would rush a patient with numerous co-
     morbidities to surgery without a proper diagnosis?
j.   According to the Texas Administrative Standards of Physician Practice would not a
     reasonable physician delayed sllrgery to find out the cause of this patient's illness
     There was no evidence of malignancy. The CT scan of the chest says all lymph
                                                                                                 t
                                                                                                 I
                                                                                                 ,
     nodes were small except for one- so what was the rush for surgery, especially in a
     patient who was on multiple medications for several disorders including hear heart
k.   According to the Texas Administrative Standards of Physician Praotice patieDt safety
     should be foremost among all surgeons. This is an obese patient with many medical
    disorders and had prior open heart surgery, then is it not absolutely necessary to have
    a prior consult with anesthesia to determine her fitness to tolerate general anesthesia?
    Sadly this patient was not referred to a carctiologist or an anestheslologist prior to
    surgery. According to the Texas Administrative Standards of Physici all Practice
    safeTy of patients come first and in this case the safety of the patient was ignored.
I. According to the Texas Administrative Standards ofphysician Practice is it not
    reasonable to ask the anesthesiologist to evaluate the patient for surgery, especially
    one who is at very high risk for surgery? the anesthesiologist in this c4Se is just as
    culpable of gross neghgence for putting this patient under general anesthesia without
    appropriate cardiac workup
m. According to the Texas Administrative Standards of Physician Practice prior to any
    surgery, is it not reasonable for both physicians and nmses to check blood work for a
    patient going to s~gery? This is not some obscure fancy or exotic blood work up but
    a standard laboratory test used by millions everyday in the USA. It is vital that all
    surgeons and anesthesiologists check blood work prior to surgery. This patient had
    the first set of INR obtained at 13.25 pm reveals tbilt the patient had twice the
    norma) INk. According to the Texas Administrative Standards of Physician
    Practice what would a reasonable physician do ifhe saw the INR was twice the
    normal? An INR of even 1.3- J .5 times normal can lead to torrential bleeding and
    reports of deaths are not unheard off This patient had an INR of 2.6. According to
    the Texas Adminiso'ative Standards of 'Physician Practice would not Ii reasonable
    physicillil have ca.ncelled the Slll'gery or repeated the blood work to ensme that it was
    not an error? It is not only incredible but shocking that no one checked the INR
    before taking the patient for surgery. Surgery is always cancelled when the INR
    is more than 1.5, l\lld this patient had an INR of 2.6. it is impossible to find IIny
    elective case in the history of modem day surgery where a patient with such
    high lNR has undergone thoracotomy- most of these patients are dead!
 n. Accordwg to the Texas Administrative StandMds of Physician Practice would not a
    reasonable physician who is doi.ng a major procedure on the lung have some blood
     available just in caSe something happeM? This patient did not have blood set aside
     for transfusion just in case she ran into problems. What is shocking is that the
     anesthesiologist completely disregarded the availability of blood and put the patient
    under anesthesia. The patient had to receive 0 positive blood as a desperate measure
     to save her life. Accord.ing to the Texas Administrative Standards of Physician
    Practice is it not reasonable 10 delay surgery until blood is available prior to major
     surgery? This patient did not even have a singie drop of blood cross matched in the
     event of an accident AN ACClDENT DlD HAPPEN CAUSED BY THE
     SURGEON.
 o. According to the Texas Administrative Stillldards of Physician Practice wouid not a
     reasonable physician who sees a patient with documented heaJt failure just a few
     days ago, delay major elective surgery until the patient has been worked up by the
     cardiologist? Surgery in the presence of CHF carries one of the highest mortality-
     apparently Dr Fallon was more interested in looking for a hypothetical malignancy!
     It is impossible to find any surgeon in America who would operate on a patient with
     a diagnosis of CHF after 3 days- impossible. unless it is Dr Fallon.
p. Accordi.ng to the Texas Administrative Standards of Physician Practice would not a
   reasonable physician who sees a patient with documented heart fail ure refer the
   patient to a cardiologist and not the surgeon? Is it not reasonable to find out the cause
   of the CHF? Until that point the patient had being all worked for a malignancy which
   never existed and the surgery was elective. SO WHY WAS THISPADENT
   TAKEN TO SURGERY? It is difficult to understand What was important to Dr
   Fallon- urgent surgery in a patient with heart failure or elective surgery in a stable
   patient cleared by the cardiologist?
q. According to th" Texas Administrluive Standards of Physician Practice would Dot a
   reasonable surgeon seek a cardiologist opinion if a patient has just had a diagnosis of
   congestive heart failure? This was never done with this patient.
r. According to the Tcxas Administrative Standards of Physician Practicc would not a
   reasonable anesthesiologist cancel the smgety and have the patient seen by a
   cardiologist prior to elective surgery? This was never done with this patient.
s. Despite all thc writings in the chart about a malignancy, all the factual evidence
   indicates there wa~ no maliglIllucy. The patient was never worked up for her heart
   which could easily have been the cause of left pleural effuSIOn. She had her bypass
   20 years ago and almost everyone requires repeat open heart after 10-15 years. Not a
   single cardiologist was asked to see the patient before her surgery.
t. According to the Texas Administrative Standards of Physician Practice woul.d not a
   reasorrable surgeon who sees a paticnt with no evidence of malignancy and vet has a
   previous bypass not aU a cardiologiSl for an opinion? This was never done with this
   patient.
u. According to the Texas Administrative Standards of Physician Practice would not a
   reasonable surgeon explain a high risk patient tJJe appropriate procedure and the risks?
   The surgeon never c·harted down in the chart that h" was going to do anything more
   than a thoracoscopy, yet he ended up opening the patient's chest? Considering the
   extreme high risk of this patient for general anesthesia, would the patient have
   consented to the procedure if all the facts were available? The patient had a vague
   consent of a thoracoscopy but the fact that she may have needed a thoracotomy was
   never explained or indicated in the chart.
v. According to the Texas Administrative Standards of PhysIcian :Practice, would not a
   reasonable physician who secs a patient with prior heart disease not refer the patiellt
   1O a cardiologist? This Was a patient who had a bypass done 20 years ago, and was

   known to have all the symptoms and signs of IHD and CHF. Yet she was never"
   worked up for her heart. It is incredible that no one even bothered to find out what
   procedure had been done to her heart preViously
w. According to the Texas Admmistrative Standards of Physician Practice would not a
   reasonable surgeon stop with surgery once a complication has occurred? This patient
   did not even have blood available for transnlsion. She simply was not prepared for
   surgery.
x. According to the Texas Administrative Standards of Physician Practice should a
   physician be honest about reportmg facts which occun:ed In lhe Opel'ating room? Dr
   Pallon writes in his notes that t1Je injury was very snperficial and to the lcft attiUnl.
   How does the surgeon explain the findings that the injury was deep into the hem and
   the Trocar had pierced the left atrium (Cardiac surgeon's note). This indicates that Dr
   Fallon had sImply inserted the Trocar deep into the chest- this again is verified by
   what the anesthesiologist wrote in the anesthesia chart. Please Dr Fallon, the heart is
   not located next to the left chest wall. During a thoracotomy, infact the heart falls
   further away into the right chest. This means you full penetrated the chest cavity w1th
   your Trocar and injured the left ventricle!
y. According to tbe Texas Admin.istrative Standards of Physician Practi(e would not 8
   reasonable physician who sees a patient with prior heart disease not refer thepllllent
   to a cardiologist? Despite having all the signs and symptoms of heart failure, no
   change was made in her medication status to assess if she would improve. Both DR
   Gonzalez and Dr Fallon disregarded patient safety.
z. The surgeon, Dr Fallon writes in his Operating Note that the patient had Congestive
   heart failure just a few days ago and yet he never even bothered to work the patient
   up. General anesthesia in the presence of CHF carries a mortality in excess of 50-
   90%.



Role oftbe Anesthesiologist, Dr Gonzalez

DEVJATJONS FROM STANDARD OF CARE as per Tcxas Administrative code of
Stands rds of Physician Practice

It is shocking to see thatthe anesthesiologist took such an ill patient to the
Operllting room without checking the most basic blood work. The INR (a profile of
the ability of the blood to clot) was abnormal. First of all, it is unheard of tbat II
patient with such. complex medical disorder would be rushed to the OR witbout a
set of proper blood work. Moreover, this blood work must be checked. Laura
Sebile's coagulation profile was so high that no reasonable doctor would eVer take
her to the Operating rooUl. Even in dire emergency cases, such cases are turned
down because the patient Cll.I\ bleed to death. The responsibility for checking the
blood work is on both the surgeon and the anesthesiologist. It is shocking tbat this
patient was eVen allowed to come to the Operating room, with such abnormal blood
coagulation parameters. StJRGEl<Y WITH SUCH AN ABNORMAL
COAGULATION PROFILE HAS EXTREMELY HIGH MORTALlTY- THERE
IS NO REASONABLE SURGEON IN THE WHOLE UNIVERSE WHO WILL
PERFORM ELECTIVE SURGERYIN THE FACE OF SUCH AN INR. Tne
majority of patients who undergo surgery under such scenarios do not fllre well.
The other poiot was that tbis was Dot enD an emergency case. This case was done
at 8 am on a weekday. The blood work was Simply not checked. Another physician
did a history and physical and noted the abnormal numbers but it appears did not
notify anyone. In any case, it is the absolute responsibility of Dr Gonzalez to check
these numbers before aUowing the surgeon to operate.
                                                                                             t
                                                                                             ,
                                                                                             I
D.lLVIATIONS FROM STANDARD OF CARE as per Texas Administrlltivc code of
Staudllrds of Physician PI'actiee it is vital that all patients who are at high risk for
surgery get proper work up and are cleared for surgery. Anesthesiologists grade
patients based on tneir medical illness. The higher the grade, the more the risk of
surgery. Laura Sebilc has bypass surgery 20 years ago, she was being worked up
for a hypothetical cancer, she was obese, had multiple medical problems and yet
DR Gonzalez agreed to put this patient to sleep. There is a vast amount of literature
that says patients need to be worked up if they have any type of serious medical
disorder and the anesthesiologist must demand tbis work up. Dr Gonzalez failed in
this most basic duty to ask for a proper work up before putting the patient to sleep.

The patient bad already bad prior had surgery and was now going for another
thoracic procedure. There is no proced ure in thoracic surgery that is considered
safe, especially when the plltient has already bad one prior thoracic procedure. So
one would think that the sUJ'geon and anesthesiologist would make sure that the
patient would have blood ready just in case there was a problem. Apparently, Dr
Gonzalez, like Dr Fallon, seems to have bccn grossly negligent. It is shoclting that
an anesthesiologist would put a paticnt to sleep and not have any blood on stand by
incase it was needed. Laura Sebile had no blood ready when she had a complication
in the OR.

According to Texas Administrative codc of Standards of Physician Practice, Dr
Gonzalez has performed way beyond the accepted standnrd of care. Any reasonable
anesthesiologist would have check blood work prior to putting the patient to sleep,
any reasonable ancsthesiologist would have dcmlUJdcd that the surgeon properly
work up the plltientprior to any elective surgery and llny reasonable
anesthesiologist would hilve made sure that the patient bas blood available in casc
there was Ii complication. Dr Gonzalez perlormance is shocking and is falls well
beyond acceptcd standards of care for patients not only in Texas but aho anywherc
in the world.


Medical errors by nurses

The post operative care of Laura Sebile was compounded witha few medical errors,
Some of the drug errOrs played a role in causing her death,

CAUSATION, DAMAGES AND lNJURlES to               Mr~.   Laura Seblle

   a. The whole case of Mrs Laura Sebile resolves on what happened to her, She had
      presented countless time to the ER with complaints of chest pain, SOB and
      general malaise, Yet each time, she was discharged from the ER A CXR showed

                                                                                           t~
      left lobe atelectasis plus a left pleural effusion, The fluid was drained and was
      negative for malignancy, Yet her doctors simply could not reSIst doing more
      procedures on her. The patient already had bypass surgery 20 years ago and
      this was completely ignored, The fact that the fluid could have been from heart      r
                                                                                           ,
      failure was never entertained, Infact every X ray showed signs of cardiomegaly
      and interstitial edema, A cardiology consult was never called and the patient was
      sent from the puJmonologist to the surgeon, The surgeon never bothered to work
      the patient up. Despite knowing that the patient had a previous bypass, he 19nored
      the dangers of adhesions. Plus this was a morbidly obese patient with
      uncontrolled hypertension, diabetes, was a past smoke~ and had high choleste~ol
      levels. She was simply not worked up and Was prematu~ely taken for surgery
      under general anesthesia. According to the Texas Adnlil1istrative Standards of
      Physician Practice would not a reasonable physician check blood work in it
      patient going to the operating room? This was never done with this patient. The
      most tragic thing that is that the very fundamental basic blood tests which defines
      anti coagulation status was never checked by the surgeon or the anesthesiologist.
      The surgeon then pe~forated the heart with the Trocar and could not control the
      bleeding. The patient lost a lot of blood and a cardiac surgeon was asked to come
      in and help. Even though the patient Was extubated, she continued to bleed and
      he~ entire left chest was pacified. She continued to spike temperatures from the
      empyema (completely ignored by the entire team) and she developed multi organ
       failure and expired. Even though this was simple surgery, the patient was at
      extremely high risk and the surgeon did not even have blood ordered for her.
       According to the Texas Admmistrative Standards of Physician Practice would not
       a reasonable surgeon who is taking a high risk patient for surgery have adequate
       blood rearly in c~se there is a complication? Thoracic surgeons generally always
       have blood ready for any type of elective sur get),. This was never done with this
       patient. According to the Texas Administrative Standards of Physician Practice
       would not a reasonable physician who sees a patient with prior heart disease not
       refer the palient to a cardiologist? This was never done with this patient There is
       not a single preoperative blood gas on the chart No cardiologist ever saw this
       patient prior to surgery to determine if CHF was the cause of the pleural effusion
       The surgery was strictly elective and every admission to the ER revealed that the
       patient was anlbulating and had a saturation of 96~99% on room air. Why the rush
       was sutgery was not explained. In the end, not a single study revealed the
       presence of a malignancy. According to the Texas Administrative Standards of
       Physician Practice is not patient safety a priority prior to any e1e(:tive surgery?
       Appa.rently not so. The patient should never have been operated in the first place.
       Both Dr Gordon and Dr. Gonzalez mismanaged the patient and were in a rush to
       perform unnecessary procedures. Dr Gonzalez placed a very sick patient under
       general anesthesia without any medical clearance. Being an anesthesiologist, he
       never even bothered to get a simple arterial blood gas on the patient prior to
       surgery.


Deviation of Care by the Surgeon and Dr Gonzalez

The basic standards of care guidelines requited of all physicians are clearly established    i
by the American Medical Association and State licensing Bomds. Further the Texas             r-
                                                                                             .
Administrative Standards of Physician Practice sets strict guidehnes for patient care        i,
which lficlude the following:

All physicians have a certain responsibility towards their patients. Besides simply
operating on the patient, the surgeon must
          personally examine the patient
          coillinn the chagnosis
          determine the course of treatment
          ensure that appropriate orders/services are carried out
          check the blood work prior to mshing a patient to surgery
          rule out the most obvious diagnosis first
          have blood ready for surgery
          be available jf an emergency arises
          be responsible for the patient's continuity of care while in hospital
          during the daily follow up write a note in the chart and any obvious problems
          or progress of the patient
          make a comment on the patient's condition
          Ensure timely and continuous care of patients, 24 hours per day, seven days
          per week, by clear identification of covenng physicians and by appropriate
          and timely answering service and electronic communications availability.
          Make himself available Immediate response to all calls deemed emergent by
          the requesting caregiver
          Response as soon as possible to all other (non~emergent) calls
          Be honest and ethical about patient reporting and fmdings

Upon Review of the case of Mrs. Sebile, it becomes obvious that both Dr Fallon Gordon
and Dr Gonzalez deviated significantly as physicians when it came to the care of their
own patient According to the Tr;oxas Administrative Standards of Physician Practi.ce both
Dr Fallon, the anesthesiologist (Dr Gonzalez) have significantly deviated [Tom
reasonable standard of care for Mrs. Sebile.

The patient was never worked up properly, there was no blood ready, nO appropriate
consults were called, the very basic blood tests were never checked prior to surgery and
the surgeon perforated the heart. It is very hard to believe that in a patient who has
already had a bypass surgery done nearly 20 years ago is never worked up for her heart,
despite every sign and symptom indicating that her heart may have been at the root of
the problem. This traumatic perforation of the heart combined with the fact that the
patient was morbidly obese and had multiple co morbidities directly resulted in her death
Accol'ding to the Texas Admmistrative SlImdal'ds of Physician Practice patient safety is
the foremost duty of all physicians and Dr Fallon has deviated significantly from
accepted standards of care. Not only did he rush a patient with CHF to surgery for a
hypotheticfll malignancy, but he had no blood available, he tried to minimize the injury
and omitted to look at the most basic of all blood work prior to surgery.

This was a strictly elective case and even though the patient had a known diagnosis of
                                                                                            I~
IHD for over 20 years, this was never entertained as a cause. The surgeon was simply in     I
a rush to do an unnecessary high risk procedure in a very high risk patient The work up
prior to surgery was non existent. The surgeon has deliberately made attempts to
minimize the fault by making numerous false statements. There is absolutely no excuse
for fiat checking blood work prior to surgery in an elective case, especially in surgery
which has the potential to cause severe complicatIons. Infact the physician who
perfo,med the history and physical on the day of adm.ission is also guilty of not
mentioning the abnormal parameters. The laboratory department never brought it to
anyone's attention that the INR was elevated.

According to the Texas Administrative Standards of Physician Practice the
anesthesiologist is just as responsible for the patient as the surgeon once the patient
anives to the operating room. What is more shocking is how could the anesthesiologist
place such a high risk patient under an.esthesia and this patient also had a very low
hemoglobin and a very high INRi How the anesthesiologist could Iulve placed this
patient under general anesthesia without work up of her heart is astonishing to say the
least. In the end, it is the responsibility of the surgeon to ensure that the patient IS worked
up and that all the blood work is normal. In any case, this patient was extremely high risk
and her consent was very vague. The fact that she would have required a thoracotomy is
not explained to her and one wonders whatrisks of the procedure were explained to this
patient. In the end, the patient died prematurely from the many mistakes made by the
surgeon and Dr Arfeen. She never had any malignancy Had the patient been left alone,
she could have survived a lot longer.

According to the Texas Administrative Standards ofPhysician Practice, the physician LS
responsible for acimitting the patient, for documenting the history and physical and for
obtaining the coment and explaining to the patient what the smgery is all about. It is the
surgeon who operates on the patient (not the nurse), iI is the surgeon who writes the
postoperative O1'ders and follows the patient. In each and every one of the above, Dr
Fallow grossly deviated from the accepted standards of care, This is unacceptable patient
care in the STATE OF TEXAS and all over the world. Dr Fallon took a patient who
never had a cancer, never was worked up for her heart disease, did not even bother to
check the most basic blood work, went prematurely to The OR. pierced the heart with a
spesr like i.nstrument and has attempted to minimize his role.


IT IS MY OPINION THAT" According to the Texas Administrative Standards of
Physicia.n Prac.tice IN ALL REASONABLE MEDICAL PROBABILITY" THE
BELOW STANDARD OF CARE ACTIONS AND/OR OMISSIONS OF THE
SURGEON, DR. Fallon Gordon, the anesth<;siologist, Dr Gonzalez, CAUSED THE
INJURIES SUFFERED BY Laura Sebile as WELL AS Her DEATH.

Conclusion

This is a tragic case of an elective thoracic case which went awry. From the beginning,
                                                                                                  J~
it appears that the surgeon simply did not care about the patient and was only interested
in operating. Dr Fallon Gordon made several tragic mistakes including failing to work up
the patient prior to surgery, rushing to surgery, failing to check the essential
                                                                                                  r
                                                                                                  ,
Laboratory coagulation parameters and then puncTuring the heart with his Trocar. This
patient was morbidly obese with many uncontrolled morbidities, but these were simply
Ignored by the staff at Memorial. The patient was prematurely rushed to surgery where
she suffered a tragic and serious complication from which she never recovered and
ultimately died. Dr Fallon was the surgeon, it was he who was consulted about the patient,
it was he Was responsible for the patient, it was he who took the patient prematurely to
the operating room, it was he who pierced the heart with a spear-like instrument and it
was he who was responsible for the postoperative care of the patient.. Dr FALLON
ADMITTED THIS PATIENT, TOOK HER TO TIlE OPERATING ROOM AND
CAUSED A FATAL SURGICAL COMPLICATION,

Dr Gonzalez, the anesthesiologist also contributed to the death of this patient by uot
checking the most essential blood work, flliling to work up a patient prior to elective
surgery and not even mJlking sure that there was blood ready for transfusion, in
cllse of an emergency, Why did the nurses in the Operating room not identify the
abnormal JNR on the check list is beyond comprehension'? How could the
llucsthesiologist allow the surgeon to operate on a patient with no available blood? It
seems no one was bothered with the care of Laura Sehile.

The death of Mrs. Laura Sebile in my opinion is dir~tly attributable to the medical
negligence by the staff, esp, the J)r Fallon Gordon (surgeon) and 1)r Gonzalez, and
nurses llt Memorial Hermann Baptist hospital. How an anesthesiologist could place
such a high risk patient under general anesthesia is also shocking.

These opmions are based in the review of the records I received, my experience and
expertise as a cardiac surgeon.

Shabir Bhimji MD PhD




Cardiothoracic Surgeon

Ap,il 30,2009
TABS




       t
       ,
                                                                                     ,
                            Hector J. Herrera M.P.
                                                                                     ,
                                                                                     i
                                                                                     i
                              2233 Chilton Rd.
                            HOllSton, TeJUlS 77019
                                 7l3-2S6-0003
                        E~m.ai1; hbetr10607@ao1.com



January :43,2009

Curriculum Vitae


Birthplace         Houston. Texas, 3/28/1960.
High school        st. ThomflB H.S., Houston, Texas, 1975 -1979.
College            Univ. ofTex8S at Austin, 1979 - 1983, BA Biochemistry.

Medical School     Urn". of Texas at Ga!v¢$ton, 1983 -1981, Medical
                   Docror,

Internship         Baylor College of Medicine, Ben Tau.b Hospital, Internal
                   Medicine, 1987 - 1988.

Residency          Dniv. ofTmrns at HQ'USt.on. Hennann Hospi.W,
                   AnesthesiolQgy, 1988 - 1991.

:Fellowship        Duiv. of Texas a.t Houston, f.lermann Hospital, Pain
                   Management, 1991.

Board Certification
                   American Board of Anesthesiology, 1993.

Hospital Affiliat/"ns
                    1. Methodist Hospital, Houston, Texas· Active
                    2. Texas Orthopedic Hospital, Houston, Tex.us - Active
                    3. Willowbrook Mmbodillt Hoapital, Houston, Texas -
                    Active



                                                                                 I
                    4. Sugar]a.nd Methodist Hospital, Houston, Texas -
                   Active

                                                                                 ,
                                                                             1
Professional Society Memberships
                   1. Harris County Medical Society, 1987 to pre9ent,
                   2, Texas Medical AMociation, 1987 to p:resem.
                   3, Texas Society ofAneslhesiologists, 1987 to pre~ent..
                   4, Amerioon Medical Association, 1987 w present.
                   5. Am.eriCllD Society of Anesthesiology, 1987 to present.

Licensure:         Texas State Board of Medical EXiUIliners
                   'fi3890

Employment         Groater Houston Anesthesiology, Methoclist Hnspital
                   Division, Full Partner 1995.

Position           Deputy Chief of Anesthesiology, Willowbrook Methodist
                   Hospital, Houston, Texas, 2008 to present



Scope ofPraetice: Hospital bailed private practice. GeneraJ and Regional
Anesthesia fur General Surgery, Cardiothoracic Surg~ry, N~urosurgery,
Gynecological SlII'g6lY, Ortlwpedi~ Swgety, Otorhino}/UYngology and
Ophthalmic S\U'gery.




                                                                               t
                                                                               ,
                                                                           2
TAB 6
                                 CURRICULUM VITAE

                                 Sbabir Bhimji MD l'hD


Address:              25 village sq
                      Midland, tx
                      79761

Ph one:               (905) 856 1885

EMail:                bhimli@lycos.L:om

PRESENT STATUS:               locum, Consultant Vascular & Thoracic Surgeon, UAE

TEACHING POSITIONS

Surgeon: KfMC, Riyadh, Saudi Arabia July 2005- Jan 2007

Visiting Locum Surgeon, HUKM, Malaysia, and Tanzania Heart Center, Dar es SaJamn,
June 2004 ·-Jan 2005

MD, Hean Place Hospital, Midland Texas-Jan 2003- Feb 2004

TRAINING

Fellow & InstruCTor, Institute of Caldio-Vasculilr·Thoracie Diseases, Rajavithi Hospital,
Thailand, Sept 2000-December 2002

Medical College of Georgia, Augusta Ga. Residency and        fellow~hip     in cardiothoracic
surgery training. July 98-july 2000

fellowshIp ill Thoracic slirgery, Meclical College or Georgia, 6/97--6/98

Fellow in Vascular surgery, Scripps Clinic, La JolJa, CA, July 1995-June 1997

AMEillCAN BOARD CERTIFICATION

General Surgery American Board Certified, June j 996
Vascular Surgery, Fellow 1996
Cardiac moracic surgery American Board certified 2001

MEDICAL SCHOOL & INTERNSJUP

Mounl Sinai, Toronto 7/90-6/91
                                                                                                t
                                                                                                i
                                                                                                !

Doctor of Medicine, University of [aronta, Toronto Canada, July 1986-June


                                                                                            1
       1990                                                                            J
                                                                                       ,
                                                                                       i
Gl{AOUATE SCHOOL

Postdoctoral r;ellow, Departnlent of Pharmacology, University of British
       Coillmhia, Vancol\ver 1985

GRADUATE SCHOOL & SUMMER WORK EXPERIENCE                                               J
                                                                                       c


Research Fellow, Dept of Endocrinology, Joslin Diabetic Center, Harvard
       Medical Center, Boston, Supervisor: Dr R KahnlEisenbarth, summer 1988

Research Fellow, Stroke Unit, Surmybrook Medical Center, Toronto,
       Supervisor: Dr] Norris, summer \987

Research F~\low, Dept of Orthopedic" Orthopedics & Arthritic Hospital,
       Toronto, Supervisor: Dr H Cameron, summer \986

Research Fellow, Addiction Research Foundation, Toronto Supervisor: Dr P
       Sellers summer \986

PhD Thesis. Myocardial Ischemic and Reperfusion Injury in Diabetic Animals;
      Role of Free Radicals, Dept of Pharmacology, University of Brittsh Columbia,
      Vancouver. Supervisors Dr CiodinJMcNeill, 1982-1985

MSc Thesis. Toxicokine\lcs a f Organophosphate and Carbamate Insecticides,
     Dept of PhfUTIlacy, Dalhousie UruveTsity, Hali fax, Supervisor: Dr F Lllw 1980-
      1981

Rese.arch Assistant, Dept of Immunology, lssak Walton Killam Hospital,
        Halifax, Supervisor: Dr A Issekutz 1978-1980

Research Trainee, Dept of Toxicology, Hoffinan La Roche, England, 1974
       -1975

PhD, Department of Pharmaceutical Science, University of British Columhia,
       Val1couver, 1982-J98~               "

BSc, DepilI1ment of Pharmacology, University of Bath, Bath, England, 1974
       -1978

CLINICAL TlUAL EXj'ERlENCE

   u. BenefIts of Aprotinin in pediatric open hean surgery
   b, Safely of Aprotinin in pediatric open heart surgery
   c. Safety and benefIts of TMR




                                                                                  2
                                                                                                     ,
   d Use of plasma lyre as a prime f[)r open heart surgery                                           ~
                                                                                                     ,
   e.    BeneJiLs oftr;illsxclllic aCid in ('pen hCElrl sLlfgel'y                                    l
                                                                                                     t
Presclltatiom dOllc in UAR 2008

Bhimji S. Cuncnt Slatus of Tre<ning Mesothelioma- has anything changed over the past
decade, Jan 7,2008
                                                                                                     I
Bhimji S. Combined Vascular and Onhopedic Injuries Feb 4, LUUIS

Bbjm.p S. Vascular compJicati'J\)s of the Intra Aortic Balloon Pump. March 4,2008

8himji S: Excessive sweating- role oJ'sympathectomy, March 16,2008

8him]i S. Quality control in slIrgO'ry in the UAE, fO'b 2008

Bhimji S How can we improve prniO'nt care in the outpatient clinic, March 2008

Bhtmjl S. Guidelines for rellal access surgery prior to dialysis, Apn12008

Bl1imj i S. AspiratlOn pneumonias In the ICU, april 2008

Books:

BhimJi   s. Yi:I.>:>L-l-\lA.r Surbery [or U/\.b P~Q£ident~_ Firgt p.riirinn 1n Preparation

Bhimji S Manual for ihoracic surgery residents, First Eclilion ill Preparation

Bhllnji S. Mllltiple Choice question; to prepare for Lhe USMLE

Bhim.ii S. Preparatory text for the Cardiothoracic Boards- Wrinen

Bhinlji S. Preparation for the Cardiolhoracic Oral Exams


CURRENT BASIC RESEARCH

   a     Can hypoplastiC heim be reversed in utero
   b.    Do Slem cells reverse repcrfusion inj ury                                               f

CURRRNT CLINICAL RJ<;SEARCH                                                                      t
                                                                                                 I
1. Ern.::rging medical treatments for aortic stenosiR statms, AnglOtensin converting
                                                                                                 ,
~n7.yme inhibitors, or both')




                                                                                             3
2. A<:<;uracy or \6~Row multidctector computed tomograph)'IEBT for the flSses,ment of
coronary artery stenosis.

3 Surgical correction of mitral regurgitation in the elderly.

4. l'rotective effects of erythrop~)jetit1 ill cardiac ischemia

5. lncidence and mana.gemem of occLllr hemothorax.

6. Self~expanding silicone sten! in pallJation of benign airway conditions.

7. Relrostemal goiter: do they all need median sternotomy

CLlNICAL RKSEARCH :2000-2007

Bhimji $; Sh0l1term inferior vena cava fdters~ Are {hey effective?

Bhim,ii S. Is Dual Chamber Pacing for effective for congenital heart defects? 1985~86.

Btaim,ii S: tI,e best treatment for Ph\eg.m~sia Cerulea Dolens and Phlegmasia Alba Dolen~.

Bbimji S: Trcatme.nt of Spontaneous Subclavian Vein Thrombosis with
Thromboembolism and Surge.ry.

Bhimji S: What    i~   the beSt exposure to the axillary artery?

Bhimji S: How long       ~hould   coumadin be adminislered to patients with BlT.

Bhimji S: What is the be~l \Ieatrnent for SVC syndrome from prolonged central venous
      catheters?

Bhimji S Are groin AY fistulas safe?

Bhimji S: what are rbe outcom<;s for firsl rib resection in patients with neurogenic
      thoracic outlet syndrome?

P'RESENTAnONS

Thoracic Trauma and Onhopedic Fr;lctmes, Aseer hospital, April 2007


                                                                                             ~
Slcnted Ul'aft~ for Thoracic Aortic Dissections, Asocr }Iospital, January 2007

'Thoracic Omlet Syndrome,       Kl~MC, July   2006
                                                                                             t
                                                                                             i
Combined CABO and Abdominal AneW)'sms KFMC, January 2006                                     !




                                                                                         4
Use of Radial Artery for T grafts- Waste of lime or life suving? KFMC, November 2005

Mediastinoscopy: J:; it a reqlliremenl ill all patients with lung cmcer'i KFMC, October
      2005

En1crgent Surgery in Infective El1docilrditis: Issues und Approaches. HUKM,    Malay~ia,
       Octobllr 2004

Aortic Aneurysm. Crilical Care Nursing Seminar, HUKM, Malaysia, September 2004

Thoracic Trauma. Surgery Grand Rounds, Heart Hospital, Midlmd Texas, September
       2003

TMR: Is it beneficial, Grand Rounds, Heart Hospital, Midland, Texas August 2003.

Robotic Applications in Cardiac Snrgery, Surgery Grand Rounds, Heart Hospilal,
       Midland Texas AugLlst 2003

Infective Endocarditis: Issues and SUJ gical Approach, Granel Rounds, Heart Hospital,
        Midland Texas July 2003

The Role DfCompmer Assisted Smgay in Cardiac Care, Grand Rounds, l-leart Hospital,
      TeICus, June 2003

Facilitated Coronary Anastomosis Us<ing the Nitinol U-Clip, Faculty, Grand Rounds,
        Midland Ho~pital, Odessa, Texas May 2003

Surgical gilles: Application in aortic surgery, Grand Rounds, Odessa Hospital, Odessa,
       Texas, May 2003


AnSTRACTS & PUBLICAnONS


Bhimji S, Kilnn T, Awdah A is preoperative ultrasound mandutory before

       cre~tion   of raclial AV fistulas. Saudi Nephrology Society, Jan 2007

Bhimji S, Khan '1', Riaz, M. Is femoral vein cannulation for dialysis safe'>
      Saudi Neph.rology Society, lm 2007

Bhimji S, Khan T, Ria;.: M. Shan: telm dialysis access via the neck Ycins-
      KFMC experience. Sandi Nephrology Society, Jan 2007

Bhimji S, Khrul T, Awdah A. Airway obstruction secondary to perclltaneous
                                                                                               t
                                                                                               I
                                                                                               ,
       placement of tempor,lfy dialysis catheters. Sauul Nephrology Society, Jan 2007



                                                                                           5
Bhirnji S, Khan T, Awdab A Complications of AV fistulas for dialysis done in
       peripheral Saudi hospitals, Saudi Nephrology Society, Jan 2007

                                                                      th
Bhirnji S, Khan T. Surgical management of supravalvuJar stenosis, 6
        B iewita] lr,tem£ll Conference of Palcistan Society of Cardiovascular Surgeons,
       Dec 15, Karachi, Palcistan
                                                                                                  !
Bhimji S, Khan T is rne.diastinitis increased with the use of bilateral internal
      mammary anery. 6'h Bienniallnternal Conference ofPakisran Society of
      Cardiovascular Surgeons, Dec 15. Kamehi, Pakistan

Bhirnji S, KhanT, complications of the Intrathoracic IAl3? 6 tlt Biennial
       Internal Conference of Pakistan Society of Cardiovascular Surgeons, Dec 15,
       Knrachi, Pakistan

Bhimji S. Acute Cardiac Care 2006- www,escardio,org

Bhimji S. Acute Cardiac Care, 2006-12-16

Bliimji S, Open hem surgery in dialysis patients, Italian Congress of Cardiac
       Surgery, Roma Italy 12/2/06

Bhimji S. 8'h MBCC, Milnn., Italy

Bhimji S, Awdah A, Spontaneous Pneumomediastinum- who needs
      Treatment? KFMC Rescarch Day, Jun 26, 2006

Bhimji S, Awdah A. Efiicacy of cenLrallines for mcdia,tinal and pleural
      drainftge of air and fluid_ KFMC Research Day, Jun 26, 2006

Bhimji   s:   ~ul'gical
                     approach ro sinus ofvalsalva aneljTysms, Saudi Beart
         Society, Dhammam, Jan 200(,-03·18

Bbimji S: Phrenic nerve injUry during open heart surgery, Canadian Surgical
      Society, Aug 2006-03- J 8

Bbimji S: Double valve endocarditi~ in chronic renal failure, Medical
      Assembly Meeting, Lebanon, MEMA, May 11-14,2006

Bhimji S: Airway and esophageal comprc5sion by vascular lings in children
      Medical Assembly Mt;eting, Lebanon, MEMA M~y l}·14, 2006

Bhimji S: Presentation of young diaberic patients with acute limb ischemia,                   f
      Oxford Childhood Diabetes Meeting, Nov 2006                                             I

                                                                                          6
Bbim.!i S: Open heart procedures in pa\ien13 wi lh acute renal failure. [talian
       Society of Ci'lrdiac Surgery, Rome, Italy, Dec 2006

Bhimji S Surgical Management ofHed ulcers in Diabetic patients King Fahd
      Medical City Research Day, Riyadh, Saudi Arabia, July 4,2006

Bhimji S. King Fahd Medical City Research Day, Pleurodesis for lualignant                     !
      pleural effusions RiyadJl, Saudi Arabia, July 4, 2006                                   E




Bhim.ii S. Khan T. Pyomyositis in Diabetic patients. Submitted to Saudi
       Medical Jonrnal. 2006

B\limji S, Fawzi AI·Jassir Ueel ulcers in Saudi pati<mts. Qatar Diabetic
       Society, Dalla Apr 2006-03-18

BhiJl1ji S, Mllbammed Abukl,aler. Acute Presentation of the Diabetic foot in
        Saudi Arabia. Qatar Diabetic Society, Doha Apr 2006-03-18

Bhimji S, Jamal Saleh AJ Wakeel, Muhammed AbuJdtater. Neuropathy in
      Saudi Patients presenting with the Diabetic foot Qatar Diabetic Society, Doha
      Apr 2006-03-18

Bbimji S, Jamal Saleh AI-Wakeel, M"hammed Humadi. Cornorbid conditions
       in Saudi patiems with the Diabetic fool.. Qatar Diabetic Society, Doha Apr 2006-
      03"18

Bbimji S. Zumbro L Management of delayed presentation of esophageal
      perforation. Asian Thoracic J, 2006-03-18

Bhimji S. Lung Abscess. E medicine 2006

Bb.imji 5 TMR E medicine 2006-03-18

Bhimji S Tetr,!logy of Fallot, E Medicine 2006-03-18

BhiJpji S. Postillfarct ventricular seplal rupture. B Medicine 2006-03-18

Bhimji S Ligation of patent ductus in neonates less th'lf1 1 kg Saudi Med J
      2006-03-18

Bbim.ii. S,.r Ooi, A Dastanpour. Morbidity of renal failure OIl open heart
       procedures. Indonesian nephrology meeting, 3'd WeN Post congress on acute
       renal failure. Jakarta, July 2005
                                                                                          t
                                                                                          I
                                                                                          ,
A   [)astanpour, S Bhimji. fndocarditls in chronic renal f'lilUte. Indonesian
         Nephrology meeting, Jakalta, July 2005



                                                                                      7
Bbilllji S, Lama S, Ooi JSM. Left Main Coronary Al1ery Disease til
        Patients under the Age 01' 50. Asian Cardio\horacic Surgery Meetmg, Dec 2004,
        Chang Mai, Thailand.

Ooi .ISM, Bbimji S. Coronary f"tel'y BY]lilSS (hafting in Malaysian Women.
       ASian Cardiothoracic Stugery Meeting, Dec 2004, Chang Mai, Thailand.

Bhimji S, Chaigasame O. Bilateral Pdicled Versus Skeletonized Internal
      Mammary Artery Graft.s in Diabetics. Asian Cardiolhor3cic Surgery Meeting, Dec
      2004, Chang Mai, Thailand.

Ooi JSM, Klunm S, Bhimji S Off-pump Revascularization in Patients with
      Non-Dialysis Dependent Renal Insufficiency AsiElll Cardiothoracic Surgery
      Meeting, Dec 2004, Chang Mai, Thailand.

Bh.imji S Ooi JSM, Vena M, Adeeb S. Patent Ductus Aneriosus Closlll'e
       in Very ·low-birth -weight lnfCUlts-Universiti K.ehangsaan University Experiel1ce.
       AsiM Cardio\horacic Surgery Meeting, Dec 2004, ChanB Mai, Thailand.

Vena, V, S Bhimji, JSM 001. Malignant Teratoma of the Right Diaphragm and
      Hemi\horax Submitted to Malaysian Medical Journal. Oct 2005.

VenaY8gfi Vena; Joanna SM Ooi, Shabir Bhimji. A rare case of middle mediastinal
      thymoma mimicking left lown lobe lung tumor. Case report. Submitted to
      Malaysian Medical Journal, Oct 2005

Bhimji S St Jude Aortic valve mismatch· 2 year re,ults. A:;ian
      Canliothoracic Surgery Meeting, Chang Mai, Thailand, Dec 2004.

S Bhimji, J Ooi, K Venayaga Closure of the Patent
       Ductus Ar1erio~;us io. Very Low Birth Weight Io.fams- the Kebangsaan University
       Hospital Experience. SUbmined to Malaysian Medical Journal, Sept 2005.

S Bhimji, JSM Ooi, Vena S. Primary Mediastina! Masses:
       The K,"bangsaan Ul1iversiti Experience. Submillcd to Malaysian Medical Joumal.
       Sept 2005

s. Bhimji, Nurshecn Bhimji, Ferdin;md Massall. Surgical treatment of
       ascending aorta disorderS. T"nzania Medical Society Meeting, Dec 2004

S Bhimji, Nursheen Bhimji, F"TdilliUld Ma~~uu. C0I1CU1TCn\ mirral nnd ao!'lic
      valve endocardilis. T'(JlzaniA Medical Society Meeling, Dec 2004.                         t
                                                                                                r
S Bhimji, Nurshecn Bbimji, Ferdinand Massau. Significance ofunrepaired                          ,


                                                                                            8
        u-icuspid regurgitation after mitral valve surgery. Tanzania Medical SocielY
                                                                                               i
                                                                                               !
        Mcetmg, [)ec 2004.

S Bhimji, Nursheen Bhimji, Ferdinand Ma.ssau. Mechanical aortic valve
      replacement in children Tanzania Medical Society Meeting, Dec 2004.

S Bhim,ji, N1lr>heen Bhimji, Ferdinand Massau. Complications of mechanical
      heart valvcs~role of pannu..q Tanzania Medical Society Meeting, Dec 2004.
                                                                                               I
SBbimji, N Bhimji, f Masoau. Rheumatic valvular hean disc:ase in children: u
     2 year experience in a developing COUl1'U')'. Tunzania Medical Society Meeting,
     Dec 2004.

:Bhimji S, Srivastava S. 100 Consecutive Internal Mammary take Down with
       Robotic Assistance. Scandinavian Association of Thoracic Surgery, June 2003

Bbilnji S, Srivastava S North America' First Complete Coronary Artery
       Bypw;, Surgnj U~i"g the DaVino; Robotic Sy<tem. <;"r.iMy nf Thorncic Sureery.
       November 2003

                    s: The 'I'HnR ArAB Approach for Patients with REDO
DI>;,..,ji s, g<".'=t~"o
        Coronary Artery Bypass Surgery Canadian Association of Thoracic Surgery,
        November 2003

Bhimji S, Sriva~tava S, MuJtivessel ()ffPump Coronary Anery Bypass
      Grafting Via a Lateral Thoracotomy (THORA.CAB). Canadian Cmdiothoracic
      Society, November 2003

Bllimji S, Srivaslava S The THORA CAB Approach for Patients with Lefl
       Main Disease. ] 3 LIl World Congress, San Francisco, November 2003

Bllimji S, Dar K Phrenic Nerve Injury after Open Heart Surgery. American
       College of Chest Physicians, October 2003

Bhimji S, SriV/iSl8Va S COrOL)iliY Altery Bypass Grafting Via a Lateral
      Thoracotomy. 14'" ASlan Pacific Cardiology Congress, December 2003

B/Jimji S, Phremc Nerve Injury duri[\g Open Heart Surgery, American College
       of Chest Physicians, October 2003

Bhimji S, blmbro L TransmyocurdiaJ Revascularization combined with
       Coronary Al1ery Bypass in High Risk Patients. Treatm~nt of Ischemic Heart
      Disease in the Third MiHennium. Thessaloniki, Greece, September 2000
                                                                                           f
Bhimji S, Zumbro L. Preoperative JABP in Patients with Severe Left Main                    i
                                                                                           ,



                                                                                       9
                                                                                              ,
       DIsease. TrealmenL of ischemic HC4rt Dise"""          In   the Third Millennium.
       Thessalonilci, Greece, September 2000

Bbimji S, Zumbro L. Surgical nUUlagement ofR~ophageal Perforation: Role
      of Esophageal ConservCllion in Ddayed Perforation EACTS, Frankfort,
      Gennany, November :2.000

Bhimji S, Zmnbro L. Complications of MlDCAB Surgery. ISMICS, Atlanta,
       IW1e 2000

Bhimji S, Zumbro L. Transmyocardial Revasc111ariwtion Combined with
      Minimally Invasive Coronary Anery Bypass Stlq:;ery MICS. Key West, Florida,
      May 2000

Bhimji S, Zumbro L. Atrial Septa} Defect Closure Combined with Minimally
      invagjve Coronary Artery Bypa;;s Surgery through a Left Thoracotomy. MICS,
      Key West, Florida, May 2000

Bhimji S, Z\.lrnbro L MIDCAB Surgery in Coronary Reoperations. MICS, Key
      West, Florida, May :2.000

Shimji S, ZLunbro L. MIDCAB Surgery: A Two Years Follow Up. St Thoma;;,
      US Virgin Isllillds. Am Call Chest Physicians, December 1999

Bhimji S, BannCl.!l M, Moore V. Early Surgical Management of Tetralogy of
      Fal\tJt, Arulual Update, ACCP, S) Thomas, December \999

Bhimji S, MokMapong P. Sinus of valsalva aneurysms. CREF, San Diego,
      Feb 2002

Bhimji S, Mokarapong P, Wiwai W. The Ross procedure for children with
      VSD and aonk regurgltatiol1. National foundation, Bangkok, Jan 2002

BlIimji S, Mokarapong, Wiwat W. (oronary artery aneurysms in south East
        Asia. National Foundation, Bangkok, Jan 2002

Bhimji S, Mokarapong 1", Surgical treatment of suprhvalvular stenosis,
      Thailand Cardiac surgery Meeting, Bangkok, Dec 2001

Bhimji S, Mokwapong P. The extracarcliac Fontan advantages. Thailand
      Cardiac Surgery meeting" BElngkok, Dec 200 1

Bhimji S, Mokampong P. Mechanical valves in children under the age of 16.
      Thailand Cardiac Surgery Meeting, Bangkok, 200]                                     t
                                                                                          i
                                                                                          t
Bhilllji S, WarinsirikuJ W, Mokara}long P. Initial experience with alienal swiiCh



                                                                                     )0
                                                                                                    ,
       with lransposition of great flTlel'ies. Thai Royal Foundation, Partaya, Sept 2001

J3hilll,ji S, Mokal'apong P, The ROSS procedure for aortic regtlrgitation
          associated with sl.lbpulmonary VSD, Thai Royal Foundation, Pattaya, Sept 2001

Bbimji S Mokarapong P. Pro"lhctic valve obstruction, 'Thai Royal Foundation,
      PaltaYD, Sept 200 I, Che.st Physicians, OClOber 2003

Bhimji S, Zumbro L Transmyocardi81 Revascularization combmed with
      Coronary Artery Bypass in Higb Risk Patients, Treatment of Ischemic Heart
      Disease in the Th.ird MllJennium. ThessaJoniki, Greece,September 2000

Bhimji S, Zumbro L. Preoperative IABP in Patients with Severe Left Main
       Disease. Treatment of Ischemic Heart Disease in the Third MillelUlitcm.
      Thessaloniki, Greece, September 2000

Bhimji S, Zumbro L. Surgical management of Esophageal Perforation: Role
      of Esophageal Conservalion in Delayed Perforation. EACTS,                   Frankfort,
      Germany, November 2000

J3himji S, Zumbro L. CompliGations of MlDCAB Surgery, ISMICS, Atlanta,
       June 2000

llhilllji S, Zumbro L. Transmyocardial RevasculariLation Combined with
         Minimally Inv8sive Coronary Artery Bypass Smgery. MICS Key West, Florida,
         May 2000

Bhimji S, Zumbro L. Auial Septal Defect Closure Combined with Minimally
      Invasive Coronary Artery Bypass Surgery through a Left Thoracotomy. MICS,
      Key West, Florida, May 2000

Bhimji S, Zumbro L. MIDC/\B Surgery ill Coronary Reoperalions. MICS, Key
      West, Flonda, May 2000

Bbimji S, Yeh D. Management of Malignant Pcricardi'11 Hfusions. CoMempt
      "Surg, 1999

Bbim,ji S, Bull J. Left Venrricular Aneurysms: Current Perspective. Comempt
       Sill'gery, 1999

Yeh D, Bhimji S, Post Intubation Tracheo-esophageal Fistulas.
       Surgical Rounds, 1999

Bhimji S, Biltman M Teualogy of Fallot. AORN, 1999
                                                                                                t
                                                                                                i
                                                                                                !

Bltimji S Acute Rheumatic Fever, December, Hospital Physician, 1999



                                                                                           II
Bhimji S. Po"r In raret Ventricular Seplal Rupture, Contempt Surg, 1999

BbiInji S, Moore V. Sarly surgie'+\ management oftetralogy of Fallot. Chest,
       Oct] 999
Bhimji S, Zumbro L. Ofr Pump Coronary Artery Bypass Surgery Using the
       Median Sternotomy lncision. South Med J, 1999
                                                                                      !
                                                                                      c

Bhlmji S Atrial Septal Defect,; in Adults. Submitted Clinician Reviews, 1999

Bllimji S The Evolution of th" Blalock 'raussig Shunt. AORN, 1999

Bhimji S. Sllperior Vena Cava Syndrome. I-lospital Physician, February 1999

Bhim.ii S. fqlcaY;l$u's Arteritis Rcsidem and StaffPhysician, in Press 1999

Bhimji S. Lung Abscess Resident and StaffPhysiciMl, February 1998

Bhimji S. Patem Ductus Arteriosus. Contempt Surg, ]999

Bhimji S, Yeh D Superior Sulcus Tumor, lls Management Contempt Surg,
      1999

Bhimji S. Amaurosis fugax Clinician Reviews, 1999

Bhimji S, McDevitt 1'1, Zumbro L. rransmyocardiaJ Laser RevascuJarizution.
      Contempt Surg, 1999

Zumbro L, Kitchens WR, Kamath V, Bhi01ji S. Early results ofTMR wilh a
      Holmium laser. Chest, Cayman islands, Nov 1998

Wishner JD, Bhimji S, Apostolides GY, Abrams AV, Melick CF. Toradol and
      urinary retention in hemorrhoid surgery. Amer Soc of colon and rectal smgcon,
      Montreal may 1995

Wishener JD, Bhimji $, AposlOlide,' GY. Benefits of lOradoI during
      henl0rrhoidal surgery Ches'1peake Bay Surgical Society, Nov 1994

Bhimj; S, Zumbro L. Orthotopic I--!eart Transplantation for Tricuspid AtTeSla
      with Intact Glenn Shllnt He;lrt Surgery Forum, in Press 1999

Zilmbro OL, Kitchens WR, Kamalh M, Bhimji S. Minimally Invasive COTonary
       Bypass Grafting; fvoilition ,,[Treatment Guidelines. Submitted Can J
       Cardiol,1999

Bhimji S, Yell D, Zumbro L. Extra Anatomic Subclavian Artery to Left Anterior
                                                                                      I
                                                                                 12
       Descending Coronary A.rtery Bypass. SwgicaJ Rounds December 1998

Bhim.ji S., Yel< D, Zumbro L. Left InlemaJ Mammary Artery \.0 Pulmonary
       Artery Fistula Texas Heart Inst J, J999

Bhim,ji S, Yeh D. Presen.l Day Tr~atrncm ofAspergill om as, Contemp Surg, in
       Press ]999

Bbimji S, Pale! H. Chest Wall Deformities VHJA,1999

BlJimji S, Yeh D Management of Mal ignam Pericardia] Effusions
       Contemp Surg, 1999

Bhimji S, Bull J. Left Ventricu lar AnellT)'sms. Current Perspective.
      Contemr Surgery, 1999

Yeh D, Bhim,ji S. Post Intubation Tracheo~esophagealFistulas. Surgical Rocmds, 1999

Bhimji S, Bannan M. Tetralogy of Pall at. AORN, J999

Bhimji S. Acute Rhewnatic Fever, H.()spilaJ Physician, 1999

Btlimji S. Post Infarn Ventncular Septal Rupture, Comemp Surg,
       1999

Bhimji S, Zumbro L Off Pump Coronary Artery Bypass Surgery Usmg the
       Median Stemotomy Incision. South Med J, J999

Bbimji S. Atrial   S~pW   Defect5 in Adults. Clinician Reviews, 1999

Bhimji S. The Evolution of the Blalock Taussig Shunt. J\ORN, 1999

Ilbimji S. Superior Vena Cava Syndrome Hospital Physician, Febn.lary 1999

Bhimji S. Takayasu's Arterills. Resident and Staff Physician, in Press 1999

Bllimji S Lung Abscess. Residem and Staff Physician, Febuary 1998

Bhimji S. Patent   DUC1US   Arteriosus Contemp Smg, 1999

Bhimji S, Yell D. Superior Sulcus 1ll111or, Its Management
       Contemp Surg, 1999

Bhimji S. Amaurosis Fugax. Clinician Reviews, 1999

Bhimji S, McDevin N, Zumbro L. TriU1smyocardial L8Se.r Rcvascularization
                                                                                           I
                                                                                           ,



                                                                                      13
       Contemp Surg, 1999

Bhimji S. Muscle Cramps. Hospital Physician, September 1993

Bhimji S. DaTcryoadenitis. Hospital Physician 29 (10),1993
Bbimji S. Treatment of HypcrhictJ'osis. Resident & Staff Physician, November
      1992
                                                                                         !
                                                                                         r
Bbimji S. Surgical Aspects of Dog Bi!lC,';. Family Practice March J6,1992

Bhimji 8. Helen M<icMas,er: Pioneer of Children's llospilal. Family Practice
      September 7, 1992

Bbimji S. Postpartum Depression. Family Practice March 4, 1992

B/limji S. Hyperbaric Medicine. Family Practice April 27, \992

Bhilnji S. Fragile x Syndrome. Resident & Staff Physician.      AUgUST   J992

llbjmji S. Hoarseness. Family Practic,-, February 2, 1991

Bhimji S, Dacryocystitis. Can J Dif\gllosis. g (4) April 91

Bhirnji S. Pamphilias. Family Praeti<.:e November 16,199]

Bhirnji S Blood Lening and Leaches Family Medicine. December 199]

BbilUji S Aids and Aftermath. Family Medicine. December 199J

Bhimji S. Chorionic Villus Sampling, Family Medicine, December 1991

Bbimji S, Zhu C, Norris J TIAs. Ca,l J Diagnosis. December 1991

Dbimji S. Ethics in the Age of Bure'cucracy. Humane Medicine 7 (2) 1991

Bbimji S. Supra Nuclear Palsy. Can J Geriatrics 7 (1) 1991
                                                            \

Bbimji S. Dr Mmgaret Norris Patterson. A Medical Missionary. Family
      PraClice. December I, ]990

Shim.ii S, Gawel M. Trigeminal NeLU'algia. Family Physician, September 1990

Bllimji S. Patien! Controlled Analgesia. Modern MEdicine, October 1990

Bhimji S: Type] Diabetes: An Autoimmune P.:rspective. Annals (Canadian)
       23 (7) 1990
                                                                                     I
                                                                                     ,


                                                                                14
                                                                                             ~
                                                                                             !
Bhimji S. Maude Menten.     AllI1fLls   (Canadian) 23 (3), \990                              i

Bbimji S. Hurwirz JJ. Immunosuppressive Trcat.ment fOT Grave's Orbitopathy.
      FQll'lily Medicine September 1990
Bhimji S, Hurwitz JJ. Differential Diagnosis of Graves' OrbitopatJw. Can J
      Diagno~is. October 1990


Bhimji S, Hurwitz, J1. DiagllQsis ofLlcrimal Disorders. Can J Diagnosis. ILlI)'
       1990

Bhimji S Carbamezepine     38   an Antidc:pressant Canadian Doctor 56 (6)'
      Septem ber 1990

Bbimji S. Gawel M. Cluster Headach.:. Can J Diagnosis. 7 (6): J1UIe 1990

Bhimji S. Kawasaki's Diseuse. Can J Diagnosis. 7 (12): 1990

Bhimji S. Reflex Sympatbetic Dystrophy. Can J Diagnosis 7 (9): 1990

Bhimji S, Hurwitz.J.J. Basal Cell Careioomas and Eyelicb. Canadian Doctor
      1990

Bhimji S. AUloerotic fatalities.   Anna\~   (Canadian) Sept 1990

Bhimjj S Geriatrics and £thi<;s. Humane Medicine, 1990

Bhimji S. Edna Mary Gues\. CMAl 141(10): 1989

Bhim.ii S. Linle A. Non Steroidal Anti-inflammawry Drugs: Adverse Reactions.
       Drug Protocol 4 (2): 1989

Bl1imji S. Lacrimal Disorders. Can.l Diagnosis 6 (11): 1989

Shear N, Bhimji S. Pharmaeugcnelics and Cutaneous Drug Reacti om.
       Sem1,par in Dermatology. 8 (.1): 219-226, 1989

Bhjlllji S. Adhesive Capsulilis. Annals (Canadian) 22 (2): 1989


Rbimji S, Hurwitz, 1 OCllloplastic Surgery. Annals (Canadian). 22(6): 1989


Bbimji S, Godin D, McNeill JH. lsllprotereno] lnducec.J Myocardial
       UluBstrucl\ll'al i\lte1'8lion ill Alloxan Diabetic Rabbits. Oen Pharmacol 20(4)
       479-85,1989                                                                       I
                                                                                    15
Cruneron H, Bbimji S. Design Ratiunale in Early Clinical Trials with a
       Hemispherical Threaded AC(;1.abular Component J Arthroplasty 3(4) 299-304,
       1998

Bhimji S. Pearle Mason. Cansda's First Otolaryngologist. J Otology 177,1988

I3birnji S Helen M~cMurchy University of Toronto Medical Journal, April 1988

Bbimji S. Wombs for Rent. Canadlan Medical Assoc. J 137(12): 1132-5,1987

Bbimji S. Aphrodisiacs Univer,ilY on'oronto Medical School Journal. 65 (J)
      November 1987

Bhimji S, Godin D. Effect of Allopurinol on Myocardial Ischemic Injury
       Following Reperfusion Biochem Pharmaco136 (13): 2101-7, 1987


Agrawal D, Bhimji S, McNeill JH Effects of Chronic Experimental Diabetes
       On Vascular Smooth Ml\scle FUDClion in Rabbit Carotid Artery J Cardiovas
       PhmnacoI9'584-593,1987


BhiI1lji S, Godin D, McNeill JI-1. Coronary Anery Ligation and Reperfl.lsion m
       Rabhits Made Dia.bdi<; with Alloxan, J Endocrinel ]] 243--49,1987


Bhimji S, Gedin D, McNeill JH. hoprolerenollnduced Ultrastructural
       Alterations in Rabbits, Acta Anatomica 8:452-457, 1986


Godin D, Bhilllji S, McNeill JR Eff~cts of Allopurinol Pretreatment on
      Myocardial Ultrastructure and Arrhythmias Following Coronary Artery Occlusion
      and Reperfusion, Virchows Arch (Cell Pathol) 52:327-341, \986

Bhimji S, Godin D, McNeill HI. The SlJltus of Magnesium in Rabbits with
      Experimentally Induced Dial'etcs Mellitus. J-lor Me Res 18:734-73 8, 1986

Bhimji $, Godin D, McNeill lB, Coronary Aru:ry Ligation and Repcrfusion in
      Alloxan Diabetic Rabbits; Ultrastructural and Hemodynamic Changes. Br J Expt
      Palhol67: 851-863, 1%6

Bhimji S, Godin D, McNeill JH ln~uhn Reversal of Biochemical Changes in
      Hearts from DiabeLic RfilS Am J Physiol 25] :1-J670-675, 1986
                                                                                       t
                                                                                       r
                                                                                       ,
Bhitnji S, Godin 0, McNeill JH. Isoproterenol Induced Myocardial Alterations


                                                                                  16
                                                                                                     •
       in Alloxan Diabetic Rnbhi1s Can.l Cardiol 2;313-319, 1986

Bhirnji S, Godin D, McNeill .11-1. Myoc:)j'dia] UhrasLructura1 Alterations in
       Diabetic Rabbit }karls. Acta Anatomicil 125'195-200, 1986

Bllimji S, Uodin D, McNeill J}1. \soprc.tcrenollnduced Myocardial Ischemic
       Injury Biochemical and Chemical Alterations. Can J Cardiol 1:282·287,1985

Bbimji S, Godin D, McNeill    m,Biochemical and Chemical Alterations in
      Hearts of Diabetic Rabbits. DiabelOlogia. 28:452-457,1985

Bbimji 13, McNeill JR. Cateclwlllrnine Induced Hearl Injwy. In Stress and the
      Heart Ed: Dhulla NS_ Elsevier Press, pp 282-306,1985

Bbimji S, Godin D, McNeill JH. ]soproterenol Induced Myocardial lschemic
      Injury, Proc Wes1 Pham1ilco] Soc27:210-213,1984

Bhimji S, Godin D, McNeill J!-i Biochemical Alterations in Diabetic Hearts.
      Proc Western Pharmacol Soc 27:185-7,1984

lssekutz A, 13himji S, Effect of Immune Serum Or Polymyxin Bon E coli
       Induced Inflarmnatiolj aIJd Vascular Jnjury. Infect Immunity 36(2):      548~557, 1982


Issekutz A, Bhimji S. QljMtificmion of f'oIymorphonuc]eocyte Immigration
        under Agarose by Enzyme AS;<ay, J Immuno! Me\hods 59:19-28, 1983

lssckmz A, Bbim.ii S, Effect of Non-steroidal Anti-inflammatory Agents on
      [mmunB      Complex       and   Chemotactic      Factor  Induced Inflammation.
       Immunopharmacol 4:251-266, 1982

lssekut( A, Ehimji S. The ffTect afNon-steroidal Anti-inflammatory Agents on
       E coli Induced Inflarrtm,\tion. Imrrnmopharmaco14: J1-22, \982

lss.::kL\tz A, Bhimji S. Role of Endot()xin in the Leukocyte Inllltration
          Accompanying E ellI; Inflarnmalionlnfect lmmun 36'558-566,1982

A.RTICLES ('ME

Bhimji S, Post Infarct Left Ventricular Rup1ure

Bhimji S Takayasu's Disease

Bhimji S, Superior Vena Cava Syndrome

Bhimji S. Mediastinal Non Seminolnas
                                                                                                 t
                                                                                                 i
                                                                                                 ,
Bhimji S. MediasLinal Seminoma


                                                                                            17
Bhimji S. Transmyoc&rdial Laser Revascularizalion

Bbimji S Tetralogy of Fallot

Bhirnji S. Intra Aortic Balloon Punl?

BhiIllji S An approacll to Bone Tumors

Bbimji S. Cardiac   Myxom~s


Bllimji S. A11laurosi:s Fugax

Bllimji S. Sinus of Valsalva Aneurysms

Pre~.ntJ>ti"n"


Diabetic Foot. World Diabetic Day, Nov 15,2005. KFMC, Riyadh.




                                                                     ~
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                                                                     I
                                                                18
        t




TAB 7
                                                                         FILED
                                                                                 DEC 10 2009
                                                                         CAROL ANNE FLORES CLERK
                                                                            COURT OF APPEALS
                                                                             NINTH DisTRICT
                                   Court ofAppeals                             Beaumont, Texas


                      Ninth District of Texas at Beaumont

                                   NO. 09-09-00363-CV


                       JUAN MANUEL GONZALEZ, Appellant

                                             V.
PAUL SEBILE, SR., INDIVIDUALLY AND AS RElRAND REPRESENTATIVE
       OF THE ESTATE OF LAURA SEBILE, PAUL SEBILE, JR.,
LAWRENCE C. SEBILE, ERIC SEBILE, DON C. SEBILE, CLARA J. SEMIEN,
         FRANKIE L. COBB AND SHARON K. DEAN, Appellees


                        On Appeal from the 60th District Court
                              Jefferson County, Texas
                             Trial Cause No. B-182,575


                              MEMORANDUM OPINION

       Appellees Paul Sebile, Sr., individually and as heir and representative of the estate of

Laura Sebile, deceased; Paul Sebile, Jr., Lawrence C. Sebile, Eric Sebile, Don C. Sebile,

Clara J. Semien, Frankie L. Cobb and Sharon K. Dean, as children of the deceased, brought

a healthcare liability claim against appellant Juan Manuel Gonzalez, M.D. and other
                                                                                                   t
                                                                                                   i
                                                                                                   ,
defendants. Gonzalez appeals the denial of his motion challenging the expert reports. See

TEX. ClY.    PRAC. & REM. CODE ANN. § 74351(l) (Vernon Supp. 2009). We reverse and
                                                                                                     ,
render.

                                           BACKGROUND

          In their petition, appellees alleged that after Laura Sebile went to Baptist Hospital on

October 22, 2006, complaining of shortness of breath and pain, chest x-rays suggested

congestive heart failure, and Sebile was referred to a surgeon, Dr. Gordon, and booked for.

a thoracoscopy to biopsy her lymph nodes. Appellees contended that the physicians failed

to el iminate congestive heart failure as the cause of Sebile's symptoms and, despite the fact

that Sebile had previously had open heart surgery, did not call for a cardiology consult to

clear Sebile for surgery. According to appellees, Gordon placed Sebilc under general

anesthesia "without a single medical consultation[,)" and the anesthesiologist, Gonzalez,

"failed to read the history and physical which revealed [Sebile] as not fit for surgery."

Appellees contended that during the procedure, Gordon punctured Sebile's heart with an

instrument, which resulted in massive bleeding, and Sebile developed multiorgan failure and

died thirteen days later. AppeHees asserted numerous ways in which Gonzalez allegedly fell

below the standard of care in his treatment ofSebile, including "[b]y failing to note [Sebile]

was at very high risk for surgery and general anesthesia[.]" Appellees also asserted that



                                                  2
                                                                                                      •

Gonzalez should have consulted with a cardiologist to clear Sehile for surgery, and that

Gonzalez breached his duty to properly oversee the care provided by Baptist's nursing staff.

       Appellees attached to their petition the expert report of Dr. Shabir Bhimji, a hoard-

certified cardiothoracic and vascular surgeon. Gonzalez filed a motion to dismiss, in which

he contended that the expert report by Bhimji was insufficient. Appellees also later provided

a report by Dr. Hector Herrera, an anesthesiologist. Gonzalez also objected to the sufficiency

of Herrera's report and filed another motion to dismiss. The trial court found the reports

deficient and gave appellees thirty days in which to. file amended reports. See TEX. ClV..

PRAC. &   REM. CODE ANN. § 74.351(c) (Vernon Supp. 2009). Appellees subsequently filed

an amended report by Bhimji, hut did not provide an amended report from Herrera.

Gonzalez again moved to dismiss appellees' claims. After conducting a hearing, the trial

court denied Gonzalez's motion to dismiss. Gonzalezthen filed this accelerated interlocutory

appeal. See id.

                                     GONZALEZ'S ISSUE


       In his sole appellate issue, Gonzalez contends that the trial court erred by refusing to

dismiss appellees' claims "for failure to produce an expert report that provided a fair

summary [of) the standard ofcare germane to Dr. Gonzalez, how he breached said standard,

and how that breach allegedly caused Mrs. Sebile's death[.)"



                                                                                                  t
                        STANDARD OF REV1EW AND PERTINENT LAW

       We review a trial court's decision regarding the adequacy of an expert report under

an abusc of discretion standard. Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46
                                                                                                  r
                                               3
                                                                                                     i
                                                                                                     ,
                                                                                                     ~




S.W.3d 873,877 (Tex. 2001). "A trial court abuses its discretion ifit acts in an arbitrary or

unreasonable manner without reference to any guiding rules or principles." Bowie Mem 'I
                                                                                                     I
Hasp. v. Wrighi, 79 S.W.3d 48,52 (Tex. 2002). A trial court also abuses its discretion if it

fails to analyze or apply the law correctly. Walker v. Packer, 827 S.W.2d 833, 840 (Tex.

1992).

         A plaintiff who asserts a healthcare liability claim must provide each defendant

physician and healthcare provider with an expert report no later than the 120th day after.

filing suit. TEX. ClY    PRAC. &   REM. CODE ANN. § 74.351 (a) (Vernon Supp. 2009). The

statute defines "expert report" as

         a written report by an expert that provides a fair summary of the expert's
         opinions as ofthe date ofthe report regarding applicable standards ofcare, the
         manner in which the care rendered by the physician or health care provider
         failed to meet the standards, and the causal relationship between that failure
         and the injury, harm, or damages claimed.

Jd. § 74.351 (1')( 6). If a plaintiff furnishes the required report within the time permitted, the

defendant may file a motion challenging the report. Id. § 74.35 J(I).

         The statute provides that the trial court "shall grant amotion challenging the adequacy

of an expclt report only if it appears to the court, after hearing, that the report does not

represent an objective good faith effort to   ~f)mpJy   with the definition of an expert reDort in

Su bsection (r)(6)." Id. When determining whether the report represents a good- faith effort,

the trial court's inquiry is limited to the four comers of the report. Wright, 79 S.W.3d at 53;      t
                                                                                                     !
                                                                                                     ,
                                                4
                                                                                                       ,
                                                                                                       i
                                                                                                       i



Palacios,46 S.W.3d at 878; Eichelbergerv. Mulvehill, 198 S.W.3d487, 490-91 (Tex. App.--

Dallas 2006, pet. denied). To constitute a good-faith effort, the report "must discuss the
                                                                                                       I
                                                                                                       !

standard of care, breach, and causation with sufficient specificity to inform the defendant of

the conduct the plaintiff has called into question and to provide a basis for the trial court to

conclude that the claims have merit." Palacios, 46 S.W.3d at 875. The expert report must

set forth the applicable standard of care and explain the causal relationship between the

defendant's acts and the injury. See TEX. CIV. PRAC. &REM. CODE ANN. § 74351(a), (r)(6).

(A claimant must provide each defendant with an expert report that sets forth the manner in

which the care rendered failed to meet the standards of care and the causal relationship

between that failure and the injuries claimed.); Doades v. Syed> 94 S.W.3d 664, 671-72 (Tex.

App.--San Antonio 2002, no pet.); Rittmer v. Garza, 65 S.W.3d 718, 722-23 (Tex. App.--

Houston [14th Dist.] 2001, no pet.). Although an expert report need not marshal and present

all afthe plaintiffs proof, a report that omits any ofthe elements required by the statute does

not constitute a good-faith effort. Palacios, 46 S.W.3d at 878-79.

                          ApPLlcA110N OF THE LAW TO THE FACTS

       With respect to Gonzalez, Bhimji's report states as follows, in pertinent part:

       In brief, the cause of death of Laura Sebile was due to .             [the] gross
       negligence of the anesthesiologist, Dr. Gonzalez ....



       Based on the review of Laura Sebile's medical records fTom Memorial
                                                                                                   t
                                                                                                   I
                                                                                                   ,
       Hermann Baptist Hospital, it is my professional opinion that the surgeon, and

                                               5
                                                                                        •



the Anesthesiologist (Dr[.J Gonzalez) at [theJ facility have failed to adhere to
the barest minimum of standards of medical practice in their management of
                                                                                        !
the patient.



It is my opinion that "in all reasonable medical probability" the below standard
of care actions [sic] andlor omissions of both the surgeon, Dr. Fallon Gordon
and Dr[.] Gonzalez caused the injuries suffered by Laura Sebile as well as her
death[.J (usc of all capsin original omitted).



[I.] According to the Texas Administrative Standards of Physician Practice
is it not reasonable to ask the anesthesiologist to evaluate the patient for
surgery, especially one who is at very high risk for surgery? [TJhe
anesthesiologist in this case is just as culpable of gross negligence for putting
this patient under general anesthesia without appropriate cardiac workup[.]

[m.] According to the Texas Administrative Standards of Physician Practice
prior to any surgery, is it not reasonable for both physicians and nurses to
check blood work for a patient going to surgery? This is not some obscure
fancy or exotic blood work up but a standard laboratory test used by millions
everyday in the USA. It is vital that all surgeons and anesthesiologists check
blood work prior to surgery. This patient had [the first set ofINR obtained at
13:25 p[.]m[.] reveals that the patient had twice the nonnalINR.] (emphasis
deleted).



It is shocking to see that the anesthesiologist took such an ill patient to the
 [o]perating room without checking the most basic blood work. The INR (a
profile of the ability of the blood to clot) was abnormal. First of all, it is
unheard of that a patient with such [a] complex medical disorder would be
rushed to the OR without a set of proper blood work. Moreover, this blood
work must be checked. Laura Sebile's coagulation profile was so high that no
-reasonable doctor would ever take her to the [0]perating room. Even in dire

                                       6
                                                                                    f
                                                                                    !
emergency cases, such cases are turned down because the patient can bleed to
death. The responsibility for checking the blood work is on both the surgeon
and the anesthesiologist. It is shocking that this patient was even allowed to
come to the [o]perating room, with such abnormal blood coagulation
parameters.... [I]t is the absolute responsibility ofDr[.] Gonzalez to check
these numbers before allowing the surgeon to operate. (emphasis in original
deleted).

. . . [I)t is vital that all patients who are at high risk for surgery get proper work
up and are cleared for surgery. Anesthesiologists grade patients based on their
medical illness. The higher the grade, the more the risk of surgery. Laura
Sebile hald] bypass surgery 20 years ago, she was being worked up for a
hypothetical cancer, she was obese, had multiple medical problems and yet
Drr.] Gonzalez agreed to put this patient to sleep. There is a vast amount of
literature that says patients need to be worked up if they have any type of
serious medical disorder and the anesthesiologist must demand this work up.
Dr[.] Gonzalez failed in this most basic duty to ask for a proper work up before
putting the patient to sleep. (emphasis in original deleted).

The patient had already had prior ... surgery and was now going for another
thoracic procedure. There is no procedure in thoracic surgery that is
considered safe, especially when the patient has already had one prior thoracic
procedure. So one would think that the surgeon and anesthesiologist would
make sure that the patient would have blood ready just in case there was a
problem. Apparently, Dr[.] Gonzalez, like Dr[.) Fallon, scems to have been
grossly negligent. It is shocking that an anesthesiologist would put a patient
to sleep and not have any blood on stand by in case it was needed. Laura
Sebile had no blood ready when she had a complication in the OR. (emphasis
in original deleted).

. . . Dr[.] Gonzalez has performed way beyond [sic] the accepted standard of
care. Any reasonable anesthesiologist would have check[ed] blood work prior
to putting the patient to sleep, any reasonable anesthesiologist would have
demanded that the surgeon properly work up the patient prior to any elective
surgery[,] and any reasonable anesthesiologist would have made sure that the
patient has blood available in case there was a complication. Dr[.]
Gonzalez['s] performance is shocking and ... falls well beyond accepted
standards ofcare for patients not only in Texas but also anywhere in the world.
(emphasis in original deleted).                                                          f
                                                                                         !



                                          7
       None ofBhimji 's statements explain how, if Gonzalez had ordered a cardiac consult,

Sebile's death would have been prevented. See Jones v. King, 255 S.W.3d 156, 159 (Tex.
                                                                                                  !
                                                                                                  ,
App.--San Antonio 2008, pet. denied). Moreover, the purported causallinkBhimii attemnts

to establish in his report (i.e., that SebiIe would not have been injured if GC)llzalez had not

cleared her for surgery) is tooJiltenuated to set forth evidence of causation with sufficient

specificity to inform Gonzalez of the conduct that appellees have called into question, and

to provide a basis for the trial court to conclude that appellees' claims have merit. See

Palacios, 46 S.W.3d at 875; see also IHS Cedars Treatment Or. of DeSoto, Tex, Inc. v.'

Mason, 143 S.W.3d 794, 800 (Tex. 2004). In addition, Herrera's report contains only a

conclusory statement about causation; that is, his report does not link his conclusion to the

facts and docs not explain how Gonzalez's alleged negligence contributed to Sebile's death.

       We sustain Gonzalez's issue. Accordingly, we reverse the trial court's order denying

Gonzalez's motion to dismiss and remand the case to the trial court for entry ofajudgment

dismissing appellees' claims against Gonzalez with prejudice and to award Gonzalez

reasonable attorney's fees and court costs. See TEX. ClY.        PRAC. &    REM. CODE ANN.

§ 74.351(b) (Vernon Supp. 2009).

       REVERSED AND REMANDED.


                                                           STEVE McKEITHEN
                                                              Chief Justice
Submitted on October 22, 2009
Opinion Delivered December J 0,2009
Beforc McKeithen, C.J., Gaultney and Kreger,      n.

                                              8

				
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