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Wright v. United States

United States District Court, S.D. California

July 14, 2017

ANNABELLE WRIGHT, an individual, Plaintiff,


          Hon. Gonzalo P. Curiel, United States District Judge

         Plaintiff Annabelle Wright (“Plaintiff or “Ms. Wright”) brings this medical malpractice action against Defendant United States of America (“Defendant”) under the Federal Tort Claims Act (“FTCA”). (Dkt. No. 1, Compl.) Plaintiff s action arises from heart surgery that healthcare providers at the Naval Medical Center San Diego (“NMCSD”) performed on her husband, Wilbur Wright III (“Decedent” or “Mr. Wright”) on September 20, 2012. (Id.) Plaintiff alleges that NMCSD healthcare providers negligently caused Mr. Wright's death on September 21, 2012. (Id.)

         On September 30, 2016, the Court conducted a motion in limine hearing. (Dkt. No. 78.) On October 3, 4, 5, 6, 11, and 12, 2016, the Court held a bench trial. (Dkt. Nos. 79, 80, 81, 82, 83, 84.) Steven Poliakoff, Esq. and Daniel Butcher, Esq. appeared on behalf of Defendant United States of America, and Suzanne Mindlin, Esq., Beth Golub, Esq., and Robert Weisenburger, Esq. appeared on behalf of Plaintiff Annabelle Wright. (Id.) Having carefully reviewed the evidence and the arguments of the parties, as presented at trial and in their written submissions, the Court makes the following findings of fact and conclusions of law pursuant to Rule 52 of the Federal Rules of Civil Procedure. As discussed below, the Court finds that the healthcare providers at NMCSD acted with the appropriate standard of care and concludes that Defendant is not liable for medical malpractice.


         Decedent Wilbur Wright III was born on December 15, 1969. Mr. Wright served in the United States Navy from June 19, 1989 to June 30, 2009, when he was honorably discharged. From June 30, 2009 to early December 2010, Mr. Wright did not work. From approximately early December of 2010, until approximately mid-July of 2012, Mr. Wright worked as a supply utility man in the Military Sealift Command. Mr. Wright died at age 42 and had a life expectancy of 62.79 years per stipulation of the parties. Mr. Wright and Plaintiff were married for ten years.

         In May 2012, Mr. Wright was diagnosed with a 5.0 cm aneurysm of his ascending aorta, which is a circumscribed dilation of the large blood vessel that first takes oxygenated blood from the heart to the rest of the body, as well as an abnormal aortic valve. A 5.0 cm ascending aortic aneurysm carries an approximately 10-12% per year risk of a rupture or dissection. Instead of having the usual three cusps in his aortic valve, Mr. Wright only had two. A bicuspid valve like Mr. Wright's can cause blood flow turbulence, which may increase the size of the aneurysm.

         Mr. Wright's heart was twice the normal size for an individual of Mr. Wright's size, and his left ventricle was hypertrophied, meaning that the muscle was enlarged and thickened to the point that blood vessels did not extend all the way into the heart muscle. These abnormalities meant that the vessels might not effectively carry cold cardioplegic solutions, which protect heart tissues during surgery, into the inferior wall of Mr. Wright's heart. In addition, Mr. Wright's heart had a left-dominant coronary system, meaning that the left main coronary artery, which branches off into the left anterior descending artery and the circumflex artery, supplied about four-fifths of his heart. In turn, Mr. Wright's circumflex artery supplied both the inferior (primarily via the posterior descending artery) and lateral (via an obtuse marginal branch) walls of Mr. Wright's heart. Any kinking of the left circumflex artery would have affected both the inferior and lateral walls of Mr. Wright's heart.

         CDR Theodore Pratt, M.D., a board-certified cardiothoracic surgeon and then-Chief of Cardiothoracic Surgery at NMCSD, evaluated Mr. Wright in 2012 and recommended that Mr. Wright undergo a modified Bentall procedure to remove and replace both his aortic heart valve and the diseased portion of his aorta. A modified Bentall procedure is one of the most complex heart surgeries and carries an approximately 5% risk of dying. During his pre-operative evaluations, Dr. Pratt informed Mr. Wright of the risks of this surgery, and Mr. Wright signed a consent form acknowledging that these risks included, inter alia, bleeding, heart attack, and death.

         During a modified Bentall surgery, the diseased portion of the aorta and the abnormal valve are removed and replaced with a mechanical heart valve connected to a tube of woven Dacron, a synthetic fabric. The combined valve and tube of woven Dacron are referred to collectively as a valve conduit or, more simply, a conduit. In order to remove the portion of the aorta with the aneurysm, the surgeon detaches the left and right coronary arteries, which supply blood to the heart, from the aorta within a circular “button” of adjacent aortic tissue. At the center of each button is the coronary artery ostium, the opening of the artery itself. Each coronary artery ostium is surrounded by aortic tissue from the sinus of Valsalva. The left and right coronary artery buttons are then reattached, or anastomosed, to the conduit after the conduit has been attached to the heart.

         A patient is placed on a heart-lung machine, or cardiopulmonary bypass (“CPB” or “bypass”), during a modified Bentall procedure. Bypass is necessary to circulate oxygenated blood to the brain and rest of the body while the surgeons remove the diseased heart valve and aorta, replace them with the conduit, and then reattach the coronary arteries. Once a patient is placed on bypass, the surgeon arrests the heart, or stops it from beating, by administering cardioplegia, a cold solution containing high levels of potassium, and by placing a clamp across the aorta. CPB lowers the temperature of blood. Components of the blood, such as platelets and clotting factors in the blood plasma, are damaged during bypass. Extended time on CPB can result in a medical coagulopathy, or a medical bleeding disorder, wherein the blood loses the ability to clot properly. Coagulopathy is treated by administering transfusions of blood and blood products, such as platelets and cryoprecipitate.

         On September 20, 2012, Mr. Wright underwent a modified Bentall procedure. Mr. Wright's September 20, 2012 surgery was performed by Dr. Pratt, who was assisted by CDR Alfredo Ramirez, M.D., a board-certified cardiothoracic surgeon who is now the Chief of Cardiothoracic Surgery at NMCSD. Since 2003, Dr. Pratt performed approximately thirty Bentall procedures as the primary surgeon and was the assistant surgeon in approximately thirty Bentall procedures. Prior to September 20, 2012, Dr. Ramirez personally performed an estimated five to seven Bentall procedures as the primary surgeon and was the assistant surgeon in approximately seventy to eighty Bentall procedures.

         The operation began at approximately 8:39 a.m. Mr. Wright was given a powerful blood-thinning agent, Heparin, and was placed on CPB beginning at approximately 9:15 a.m. Mr. Wright's heart was arrested, and Mr. Wright's blood was run through plastic tubing and a cardiopulmonary bypass machine to oxygenate the blood before returning the blood to Mr. Wright's body.

         Dr. Pratt removed the aneurysmal portion of Mr. Wright's aorta and the bicuspid aortic valve, and created the right and left coronary artery buttons. The operative report states that Mr. Wright's left “coronary button was noted to be large and the tissue thinned from the patient's enlarged sinus.” (Jt. Ex. 4-003.) When creating the right and left coronary artery buttons, Dr. Pratt and Dr. Ramirez assessed the integrity of Mr. Wright's aortic tissue by how it appeared, how it felt when the tissue was being cut and the coronary artery buttons were created, how the tissue handled when picked up with surgical forceps, and how the tissue held sutures when the stitches were done. Dr. Ramirez testified that the tissue consistency for the left and right coronary artery buttons was similar, and that while the tissue used for the buttons “was thinner than normal, ” it was “by no means . . . thinner than anything else [he] had seen before, ” and he “didn't feel . . . that it was not a suitable cuff to be able to use as a coronary button.” (Tr. 1031:09-16.)

         Dr. Pratt then performed four anastomoses in the following order: the proximal suture line, the left coronary artery button, the distal suture line, and right coronary artery button. Dr. Pratt attached the conduit to Mr. Wright's heart at the proximal suture line using interrupted horizontal mattress sutures with small pledgets of Teflon felt “all the way along the aortic annulus.” (Jt. Ex. 4-003.) A thin layer of BioGlue was placed along the suture line. (Id.)

         Dr. Pratt then anastomosed the left coronary button to the conduit using a single layer of sutures. To avoid twisting or kinking the arteries when he anastomosed the buttons to the conduit, Dr. Pratt placed orienting sutures on the buttons so that “twelve o'clock” on the buttons corresponded to “twelve o'clock” on the conduit.

         Dr. Pratt then performed the distal suture line anastomosis, using two layers of Teflon felt pledgets for reinforcement and running continuous sutures to connect the conduit to the aorta. A thin layer of BioGlue was placed along the suture line. Finally, Dr. Pratt performed the right coronary artery button anastomosis in the same manner as the left coronary artery button anastomosis, using a single layer of sutures. All of Mr. Wright's anastomoses, whether they were to the heart, the remaining aorta, or between the coronary artery buttons and conduit, were pressure-tested twice to ensure, as best as possible before the bypass was discontinued, that they would not leak.

         After the procedure was completed, a period of time was allowed for the heart to recover from being kept cold and not beating, and Mr. Wright's heart was gradually weaned from bypass. The surgery, up until attempted weaning, proceeded uneventfully.

         In attempting to wean Mr. Wright from CPB at approximately 12:04 p.m., Dr. Pratt observed bleeding coming from the area behind the conduit in the region of the left coronary artery button. Dr. Pratt attempted to identify the precise source of the bleeding, but was unsuccessful. The precise source of the bleeding could not be identified without placing undue traction on the aorta and the newly created anastomoses between the conduit graft, the aorta, and the coronary artery buttons. In order to identify the specific site of bleeding, it was necessary to place Mr. Wright back on bypass, reapply the cross clamp, and re-arrest the heart, so that the conduit could be opened and the anastomoses inspected directly.

         Accordingly, Mr. Wright was placed back on CPB. Dr. Pratt cross-clamped the aorta, arrested the heart, opened the conduit transversely, and inspected the left coronary artery button anastomosis.[1] The left coronary artery button suture line was checked for tension, and Dr. Pratt placed additional sutures where needed to adjust the tension of the suture line.[2] Dr. Pratt examined the outside of the graft as well while he made these repairs. Dr. Pratt then closed the conduit with sutures and removed the aortic cross-clamp.

         Another attempt at weaning from bypass was undertaken. In this second attempt to wean Mr. Wright from CPB, Dr. Pratt observed bleeding from the inferior edge of the left coronary artery button, where it appeared that the tissue of the coronary button had begun to tear along the suture line. (Jt. Ex. 4-004.) Dr. Pratt then placed a single stitch over a pledget of pericardium to stop the bleeding. (Id.) After Dr. Pratt made this repair, no further bleeding was observed from the left coronary artery button. Mr. Wright was taken off CPB at 3:05 p.m, and the blood-thinning agent Heparin was reversed. Following separation from bypass, Mr. Wright's heart was noted to have a stable rhythm, and his vital signs, including pulmonary artery pressures, were noted to be stable.

         Dr. Pratt and Dr. Ramirez testified that at no point during the surgery did they observe or detect bleeding from the proximal suture line. Because bleeding in the proximal suture line area is difficult to visually detect, Dr. Pratt tested for bleeding by using white gauze pads and a white hemostatic powder, so that any bleeding would stain the white gauze or powder. The left coronary artery button was the only site of bleeding Dr. Pratt and Dr. Ramirez observed, and no bleeding was observed from the left coronary artery button after Dr. Pratt's second repair.

         Mr. Wright had been on bypass from 9:15 a.m. until 3:05 p.m. (Jt. Ex. 2:004, 2:010.) While modified Bentall procedures normally take between four and a half to six hours, Mr. Wright's case was prolonged by the bleeding that was encountered and the procedures that were necessary to stop the bleeding. Dr. Stuart W. Jamieson, Defendant's designated expert in cardiothoracic surgery, testified that “[b]leeding is a major risk in heart surgery” that “[e]very experienced surgeon” has encountered in a Bentall procedure, and the fact that bleeding occurs does not indicate that there was a breach in the standard of care. (Tr. 1089:17-1090:01.)

         After Mr. Wright was taken off CPB at around 3:05 p.m., a transesophogeal echocardiography (“TEE” or “echo”) probe was placed, and a scan of Mr. Wright's heart was performed. The TEE scan noted that a portion of the inferior wall of Mr. Wright's heart appeared to be hypokinetic, or have decreased contractility. Decreased contractility after cardiac surgery can have many causes, such as the patient being on bypass, the length of time on bypass, the length of time that the aorta is cross-clamped, the heart being cold, and air remaining in the heart's circulation. Hypokinesis may also take any time between minutes to hours to resolve. Mr. Wright's heart was accordingly given time to recover. During this recovery period, the surgeons and anesthesiologists adjusted Mr. Wright's medications and inserted an intra-aortic balloon pump (“IABP”) at 3:41 p.m. to offload some of the strain off of the left ventricle, mechanically reduce cardiac work, and increase cardiac perfusion pressures. (Jt. Ex. 2:013; Jt. Ex. 4:004.)

         Mr. Wright's heart function was observed for a period of time. Mr. Wright's cardiac outputs-the stroke volume, or the amount of blood being pumped out of the heart in liters per minute-improved during this observation period. From 3:53 p.m. to 4:08 p.m., Mr. Wright's cardiac output was 4.2; from 4:53 p.m. to 5:08 p.m., it was 4.5;[3]and from 5:38 p.m. to 5:53 p.m., it was 5.3, a cardiac output which Dr. Robert L. Shuman, Plaintiff's designated expert in cardiothoracic surgery, agreed was within normal limits for a man Mr. Wright's age, and which Dr. Jamieson characterized as “high.” (Jt. Ex. 2:014, 2:017; Tr. 342:13-16, 1132:17-18.) Dr. Jamieson testified that even while the heart is assisted by an IABP, medications, blood, blood products, and fluids, the cardiac output is ultimately generated by the heart: “You cannot improve cardiac output or heart function merely on the basis of fluids and drugs.” (Tr. 1133:07- 16.) Accordingly, Mr. Wright's improving cardiac outputs reflected actual improvement in his cardiac function. (Id.)

         Dr. Ramirez and Dr. Pratt also observed that the strength and contractility of Mr. Wright's left ventricle continued to improve over time. Mr. Wright's pulmonary artery pressures were stable, signifying improvement. Mr. Wright's electrocardiogram (“EKG”) showed no evidence of ST segment changes, meaning that the EKG readings did not reflect ischemia or a lack of oxygen to a section of the heart, and did not indicate a myocardial infarction. Given the improvement in contractility and ventricular function, Dr. Pratt did not believe that Mr. Wright needed to undergo the stresses of another major cardiac surgery, such as a coronary artery bypass grafting (“CABG”) procedure, which would necessitate further anticoagulation and time on bypass. Dr. Pratt therefore continued to watch Mr. Wright in the operating room.

         Beginning at approximately 6:00 p.m., Mr. Wright began to require increased dosages of medication, such as norepinephrine, which was first administered at about 6:06 p.m., to support his blood pressure. (Jt. Ex. 2:016.) Mr. Wright's blood pressure dropped significantly;[4] his need for pressor medications and inotropic support increased; and the decreased contractility in his inferior left ventricle possibly persisted. (Jt. Ex. 4:004.) Dr. Pratt hypothesized in the operative report that these changes in Mr. Wright's condition may have possibly resulted from the stitch that was placed at the left coronary artery button to stop the bleeding at that site. (Id.) Regardless of the specific cause, Dr. Pratt and Dr. Ramirez determined that Mr. Wright needed to undergo a CABG procedure to augment the blood supply to his inferior left ventricle.[5]

         In order for Dr. Pratt to perform a CABG procedure, the blood-thinning agent Heparin was administered to Mr. Wright at approximately 6:30 p.m., (Jt. Ex. 2:016), and bypass was initiated at 6:46 p.m., (Jt. Ex. 7:004).[6] Dr. Pratt performed Mr. Wright's CABG procedure by harvesting a vein from Mr. Wright's leg and performing two coronary artery bypass grafts. Dr. Christopher Cornelissen, the attending cardiac anesthesiologist, testified that the procedure proceeded “expeditiously.” (Tr. 868:01-05.) Following the CABG procedure, Mr. Wright was removed from CPB at approximately 9:05 p.m. The hypokinesis in Mr. Wright's left ventricular inferior wall decreased, and the contractility of Mr. Wright's heart appeared to improve between 9:05 p.m. and 10:48 p.m., based on readings from the TEE probe.

         Mr. Wright was observed in the operating room between 9:05 p.m. and 11:13 p.m. During this period of time, Dr. Pratt and Dr. Ramirez observed Mr. Wright's open chest and did not observe, visually or through repeated testing with white gauze and hemostatic powder, evidence of surgical bleeding at the anastomoses. Mr. Wright was clinically stable and transported from the operating room at 11:13 p.m. to the ICU. Dr. Pratt accompanied Mr. Wright to the ICU and remained with him throughout the night.

         Mr. Wright arrived in the intensive care unit at approximately 11:20 p.m. on September 20, 2012. After three runs on bypass and the modified Bentall and CABG procedures, Mr. Wright's cardiac outputs were low, and he required a significant amount of inotropic and vasopressor medications to maintain his blood pressure. Mr. Wright exhibited elements of cardiogenic shock, or heart pump failure, and medical coagulopathy. Cardiogenic shock causes leakage of fluid from the blood vessels into tissue spaces. Dr. Kenneth Serio, Defendant's expert in critical care medicine and pulmonary medicine, noted that Mr. Wright “had dysfunction of multiple elements of the clotting system, ” including platelet dysfunction, fibrinogen deficiency, and lack of fibrinolysis. (Tr. 926:21-25, 929:17-24.) In accordance with the appropriate treatments for shock and medical coagulopathy, Mr. Wright received aggressive inotropic and vasopressor support, and he received blood, blood products, and platelets. Dr. Serio testified that the “significant amount of blood product replacement, to the point that [Mr. Wright] had his entire blood volume replaced once with that regimen, ” was an appropriately aggressive treatment measure, given the level of clotting system dysfunction involved. (Tr. 931:08-15.)

         At approximately 12:27 a.m. on September 21, 2012, the morning following surgery, Dr. Pratt removed Mr. Wright's dressing in the ICU because Mr. Wright's blood pressure abruptly decreased. After removal of the dressing, Mr. Wright's blood pressure increased and stabilized. Dr. Pratt observed bleeding from all tissue surfaces as a result of Mr. Wright's medical coagulopathy, and continued to treat Mr. Wright with transfusions of blood, fresh frozen plasma and platelets, and by keeping Mr. Wright in a warm room.

         Shortly before 2:00 a.m., Mr. Wright's vital signs deteriorated, and his cardiac rhythm changed to ventricular fibrillation. A cardiac arrest code was called. Dr. Pratt attempted to resuscitate Mr. Wright for over an hour. At 3:08 a.m. on September 21, 2012, Mr. Wright was pronounced dead.

         An autopsy was performed on Mr. Wright's body. The Chief of Pathology, CAPT Scott Luzi, M.D., examined Mr. Wright's heart and found a myocardial infarction, or heart attack, in the posterior wall of the left ventricle. Dr. Luzi testified that Mr. Wright's heart weighed 750 grams, among the largest he had seen. Dr. Luzi initially believed there was a “defect” in the back of the graft conduit as it anastomosed to the heart.

         On November 17, 2014, Plaintiffs designated experts in cardiothoracic surgery and pathology (Robert L. Shuman, M.D. and John C. Hiserodt, M.D., respectively) and Defendant's experts in cardiothoracic surgery and pathology (Stuart W. Jamieson, M.D. and Christopher L. Swalwell, M.D., respectively) inspected Mr. Wright's heart. The examination was video-recorded. Mr. Wright's heart was examined for anastomotic defects, as well as the “defect” initially identified by Dr. Luzi. Dr. Hiserodt, Dr. Swalwell, and Dr. Jamieson all concluded that there were no defects in any of the anastomoses, and that the “defect” identified by Dr. Luzi was not present. Dr. Shuman also testified that Dr. Luzi “was incorrect, ” and that the “defect” was in fact “just a piece of redundant aortic tissue that hadn't been cut away.” (Tr. 318:21-319:01.)

         The video-recorded examination from November 17, 2014 was reviewed by Dr. Luzi prior to his deposition on December 12, 2014. Dr. Luzi testified that being unfamiliar with the conduit used in the procedure, he had mistakenly identified as a “defect” the area between the conduit and the native aortic tissue that remained after the aneurysm was removed. After reviewing the recorded examination and listening to both parties' pathologists and cardiothoracic experts discuss the anatomy of Mr. Wright's heart and the procedure performed, Dr. Luzi realized that his probe had merely passed easily into a “blind space” between the graft and Mr. Wright's native tissue that remained following removal of the aneurysm, and that no actual defect was present. (Tr. 580:13-23, 581:16-24.)

         Plaintiffs allegations of medical malpractice rely on the opinion of Dr. Robert L. Shuman, who testified that Dr. Pratt and his surgical team breached the standard of care in the following six ways:

1. Failing to reinforce the left coronary artery button;
2. Performing a single-layer closure at the proximal suture line;
3. Making two attempts to repair the left coronary artery button;
4. Failing to stop Mr. Wright's bleeding;
5. Delaying Mr. Wright's CABG procedure for three hours; and
6. Failing to insert a left ventricular assistive device (“LVAD”) while Mr. Wright was still in the operating room.

(Tr. 189:22-190:21.)

         Defendant's expert in cardiothoracic surgery, Dr. Stuart W. Jamieson, testified that Dr. Pratt and his surgical team did not breach the standard of care in any of the six ways enumerated above. Dr. Jamieson supported his analysis with facts, his extensive knowledge of the standard of care, and his work throughout the United States and the world.

         Dr. Jamieson is a preeminent cardiothoracic surgeon. He is currently the Endowed Chair and Distinguished Professor of Surgery as well as the Dean of Cardiovascular Affairs at University of California San Diego (“UCSD”). (Tr. 1075:1-5; Ex. 395.) Dr. Jamieson was formerly a professor and the director of the heart and lung transplantation program at Stanford University, where he was involved in the first successful heart and lung transplant in the world. (Tr. 1078:16-21.) Dr. Jamieson was also formerly a professor and the chief of heart surgery at the University of Minnesota, where he performed the first heart and lung, double lung, and single lung transplants in the Midwest. (Tr. 1078: 22-1079:11.)

         Dr. Jamieson has performed heart surgery for forty-five years, worked in major training institutions, lectured throughout the United States and the world, established heart surgery programs throughout the world, and done demonstration surgeries in many countries. (Tr. 1084:23-1085:23.) He is very familiar with the standard of care in the United States, the world, and locally. (Id.) Dr. Jamieson has performed or supervised approximately 50, 000 heart surgeries and has performed or supervised several hundred Bentall procedures. (Tr. 1082:12-15.) Dr. Jamieson participates as the senior surgeon in critical stages of multiple heart surgeries and trains cardiovascular surgeons in California, the United States, and throughout the world. (Tr. 1082:18-22, 1085:15-1086:3.) He has authored or co-authored over 500 publications regarding heart surgery and trained approximately fifty cardiovascular surgeons. (Tr. 1081:17-20, 1082:4-11.)


         The Federal Tort Claims Act directs the Court to apply the law of the State of California, which is where the alleged tort occurred. See 28 U.S.C. § 1346(b)(1); Daly v. United States, 946 F.2d 1467, 1469 (9th Cir. 1991). Plaintiff has the burden of establishing by a preponderance of the evidence all of the facts necessary to prove the negligence of Defendant and that such negligence was the cause-in-fact of the complained-of injury. Johnson v. Superior Court, 143 Cal.App.4th 297, 305 (Cal.Ct.App. 2006); Fein v. Permanente Med. Grp., 38 Cal.3d 137, 152 n.9 (Cal. 1985).

         The elements for medical malpractice are: “(1) a duty to use such skill, prudence, and diligence as other members of the profession commonly possess and exercise; (2) a breach of the duty; (3) a proximate causal connection between the negligent conduct and the injury; and (4) resulting loss or damage.” Johnson, 143 Cal.App.4th at 305. California courts require “only that physicians and surgeons exercise in diagnosis and treatment that reasonable degree of skill, knowledge, and care ordinarily possessed and exercised by members of the medical profession under similar circumstances.” Mann v. Cracchiolo, 38 Cal.3d 18, 36 (Cal. 1985) overruled on other grounds by Perry v. Bakewell Hawthorne, LLC, 2 Cal. 5th 536 (Cal. 2017); see also Landeros v. Flood, 17 Cal.3d 399, 408 (Cal. 1976); Meier v. Ross Gen. Hosp., 69 Cal. 2d 420');">69 Cal. 2d 420, 429 (Cal. 1968); Allen v. Leonard, 270 Cal.App. 2d 209, 215 (Cal.Ct.App. 1969). Ordinarily, the standard of care is a matter solely within the knowledge of experts and can only be proven through expert testimony unless the negligence is obvious to a layperson. Johnson, 143 Cal.App.4th at 305; Landeros, 17 Cal.3d at 410.

         The law further acknowledges that there may be more than one recognized method of diagnosis or treatment, and a physician is not negligent if, in exercising his best judgment, he chooses a method which, in hindsight, turns out to be the wrong choice, or one not favored by other physicians. Lawless v. Calaway, 24 Cal. 2d 81');">24 Cal. 2d 81, 87-89 (Cal. 1944); Barton v. Owen, 71 Cal.App.3d 484, 501-02 (Cal.Ct.App. 1971); Vandi v. Permanente Med. Grp., Inc., 7 Cal.App.4th 1064, 1070 (Cal.Ct.App. 1992). “A difference of medical opinion concerning the desirability of one particular medical procedure over another does not, however, establish that the determination to use one of the procedures was negligent.” Clemens v. Regents of Univ. of Calif., 8 Cal.App.3d 1, 13 (Cal. 1970) (citing Meier, 69 Cal. 2d at 420).

         To prove causation, the plaintiff must establish “‘that the defendant's breach of duty . . . was a substantial factor in bringing about the plaintiffs harm.'” Mayes v. Bryan, 139 Cal.App.4th 1075, 1092-93 (Cal.Ct.App. 2006), as modified (June 21, 2006) (quoting Leslie G. v. Perry & Assocs., 43 Cal.App.4th 472, 481 (Cal.Ct.App. 1996)). The traditional “but for” test of causation is necessarily subsumed under the “substantial factor” test. Viner v. Sweet, 30 Cal.4th 1232, 1239 (Cal. 2003); Mitchell v. Gonzales, 54 Cal.3d 1041, 1052 (Cal. 1991) (“‘If the conduct which is claimed to have caused the injury had nothing at all to do with the injuries, it could not be said that the conduct was a factor, let alone a substantial factor, in the production of the injuries.'” (quoting Doupnik v. Gen. Motors Corp., 225 Cal.App.3d 849, 861 (Cal.Ct.App. 1990))).

         Moreover, in a medical malpractice action, causation must be proven to a reasonable medical probability, rather than a reasonable medical possibility, based upon competent expert testimony. Jones v. Ortho Pharm. Corp., 163 Cal.App.3d 396, 403 (Cal.Ct.App. 1985) (emphasis added); Morgenroth v. Pac. Med. Ctr., Inc., 54 Cal.App.3d 521, 533-34 (Cal.Ct.App. 1976). “A possible cause only becomes ‘probable' when, in the absence of other reasonable causal explanations, it becomes more likely than not that the injury was a result of its action.” Miranda v. Bomel Const. Co., Inc., 187 Cal.App.4th 1326, 1336 (Cal.Ct.App. 2010). Accordingly, “[c]ausation is proven when a plaintiff produces sufficient evidence to allow the jury to infer that in the absence of the defendant's negligence, there was a reasonable medical probability the plaintiff would have obtained a better result.” Mayes, 139 Cal.App.4th at 1093 (internal citations and quotation marks omitted).

         Plaintiff has failed to meet her burden to prove by a preponderance of the evidence that Dr. Pratt and his surgical team breached the standard of care. Each alleged ...

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