Salica v. Tucson Heart Hospital - Carondelet, L.L.C.

FILED BY CLERK
IN THE COURT OF APPEALS
STATE OF ARIZONA MAY 27 2010
DIVISION TWO
COURT OF APPEALS
DIVISION TWO
CAROL SALICA, the surviving wife of )
Louis Salica, individually and on behalf
)
of statutory beneficiaries, )
) 2 CA-CV 2009-0153
Plaintiff/Appellee, ) DEPARTMENT B
)
v. ) OPINION
)
TUCSON HEART HOSPITAL – )
CARONDELET, L.L.C., an Arizona )
corporation, )
)
Defendant/Appellant. )
)

APPEAL FROM THE SUPERIOR COURT OF PIMA COUNTY

Cause No. C-20072703

Honorable Virginia C. Kelly, Judge

AFFIRMED

Piccarreta Davis PC
By Barry M. Davis and Amy Hernandez Tucson
Attorneys for Plaintiff/Appellee

Humphrey & Petersen, P.C.
By Marshall Humphrey III and Andrew J. Petersen Tucson

and

Cooper & Scully, P.C.
By John A. Scully Dallas, Texas
Attorneys for Defendant/Appellant

E C K E R S T R OM, Presiding Judge.
¶1 This appeal by the defendant Tucson Heart Hospital – Carondelet, L.L.C.,

arises from a wrongful death action filed by Carol Salica, Louis Salica‟s widow. After a

twelve-day trial, a jury found Tucson Heart and other parties had negligently caused

Salica‟s death. The jury determined Tucson Heart was sixty percent responsible and

found it liable for damages totaling $600,000.1 On appeal, Tucson Heart argues there

was insufficient evidence that its negligence caused Salica‟s death and urges this court to

reverse the trial court‟s denial of its motion for judgment as a matter of law. For the

reasons set forth below, we affirm.

Factual and Procedural Background

¶2 “We view the evidence and reasonable inferences therefrom in the light

most favorable to upholding the jury‟s verdict.” Acuna v. Kroack, 212 Ariz. 104, ¶ 3,

128 P.3d 221, 223 (App. 2006). At approximately 4:15 a.m. on September 26, 2005,

fifty-year-old Louis Salica went to Tucson Heart‟s emergency room complaining of chest

pains and shortness of breath. After being examined, tested, and treated by emergency

room physicians, he was admitted to the hospital around noon in stable condition. The

emergency room doctors had given him differential diagnoses of acute coronary

syndrome (ACS), congestive heart failure (CHF), pneumonia, and hypoxia, or

insufficient oxygen.

1
The jury found Salica‟s cardiologist, Dr. James Myer, and the corporation with
which he was affiliated liable for forty percent of the damages. However, those
defendants satisfied the judgments against them and are not parties to the appeal.

2
¶3 While in the hospital that day, Salica was examined by an internist and a

pulmonologist. The internist believed that, although Salica had some type of “cardiac

component” to his illness, he was suffering primarily from pneumonia. The

pulmonologist who later examined Salica and reviewed his records disagreed. Having

detected a murmur in the mitral valve of Salica‟s heart, the pulmonologist believed Salica

was most likely suffering from a mitral-valve disease that was causing cardiac

decompensation. Salica was in stable condition when the pulmonologist examined him at

5:00 p.m., but the doctor characterized him as a “really sick guy” and expected him to be

cared for by a cardiologist.

¶4 Salica‟s own cardiologist and attending physician, Dr. James Myer, did not

examine Salica in the hospital until 9:00 p.m. Myer had been informed of Salica‟s status

over twelve hours earlier and originally had planned to visit him in the emergency room.

When Myer saw him, Salica was receiving supplemental oxygen, and Myer ordered that

he be given Lasix to reduce the fluid in his lungs and thereby ease his breathing. Because

it is a diuretic, Lasix also increases a patient‟s urine output.

¶5 During his examination of Salica, Myer detected mitral-valve regurgitation

and arranged for his partner, Dr. Charles Katzenberg, to perform a transesophageal

echocardiogram (TEE) the next morning to identify the defect more specifically.

Following Myer‟s visit with Salica, the on-call physician covering for Myer, Dr. Edward

Byrne-Quinn, would have received any overnight calls made to Myer regarding Salica.

¶6 That night, while Salica was in the care of registered nurse Diane LeBlanc,

his health deteriorated. His urine production was less than expected, indicating the Lasix

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was not having its intended effect, and his oxygen saturation consistently was below the

minimum level of ninety percent, even though he had been placed on a non-rebreathing

device and was receiving the maximum amount of supplemental oxygen possible without

intubation. Nurse LeBlanc consulted both her charge nurse and a respiratory therapist

about Salica‟s condition during this period. Yet she did not alert a physician about

Salica‟s status until approximately 6:00 the next morning during a telephone conference

initiated by Dr. Katzenberg.

¶7 The plaintiff‟s expert witness, Nurse Halina Orawiec, testified LeBlanc‟s

failure to call a physician between 9:00 p.m. and 6:00 a.m. fell below the standard of care

for registered nurses in several respects. Specifically, LeBlanc failed to report that Salica

had been placed on a non-rebreathing device at around 12:30 a.m. on September 27

without improvement;2 she failed to report that his oxygen levels were consistently below

the minimum level, despite the fact that he was receiving the maximum possible amount

of supplemental oxygen;3 and she failed to report Salica‟s poor response to Lasix, which

was evident two hours after it had been administered.

2
Nurse LeBlanc suggested and Salica‟s wife testified that Salica was already on
the non-rebreathing device when Dr. Myer was with him at 9:00 p.m. However, Myer
refuted this testimony, and the record from the respiratory therapist who placed Salica on
the device indicated it occurred several hours later. Viewing the evidence in the light
most favorable to sustaining the verdicts, we accept the latter version of events for
purposes of this appeal. See Warne Invs., Ltd. v. Higgins, 219 Ariz. 186, ¶ 15, 195 P.3d
645, 650 (App. 2008).
3
LeBlanc admitted at trial that Salica‟s oxygen saturation was below the minimum
level several times between 1:00 and 3:00 a.m.

4
¶8 Dr. Mark Perlroth, the plaintiff‟s expert-witness cardiologist, testified that

the standard of care for a cardiologist upon receiving a report about Salica‟s status during

LeBlanc‟s shift would have called for prompt action. This included admitting Salica to

the intensive-care unit (ICU), intubating him, performing a TEE, inserting an intra-aortic

balloon, increasing his medications, and consulting with a cardiothoracic surgeon.4

Another expert witness, Dr. Andrew Wechsler, testified that the lack of surgical

intervention during LeBlanc‟s shift, resulting in “hours of progression of the underlying

heart failure and difficulty in getting oxygen into the body in adequate amounts,” had

meaningfully decreased Salica‟s chance of survival.

¶9 The following morning, the pulmonologist who examined Salica after

Nurse LeBlanc‟s shift had ended found Salica was “significantly worse than when [he]

left him the day before.” The internist who previously had examined Salica ordered him

to the ICU at approximately 8:20 a.m. Dr. Katzenberg arrived at the hospital around

10:40 a.m., requested a consultation with a cardiothoracic surgeon about thirty minutes

later, and intubated Salica shortly thereafter. By noon, the TEE revealed Salica had

4
At oral argument, Tucson Heart claimed Dr. Perlroth did not testify about the
standard of care for a cardiologist upon receiving an overnight call from the nurse; rather,
his testimony only pertained to the treatment and interventions Dr. Myer should have
undertaken when he examined Salica around 9:00 p.m. Although Perlroth mentioned this
window of time in his testimony, he also clarified that a reasonably prudent cardiologist
would have implemented these measures upon learning “the most dramatic information
about how [Salica] was doing,” namely that his oxygen saturation levels had dropped into
the seventy-percent range and that his respiration rate had risen to thirty-six breaths per
minute when breathing room air. This “very critical point” came when Salica was being
placed on the non-rebreathing device and momentarily had to breathe without
supplemental oxygen. And despite the conflicting evidence about when this occurred, we
accept for purposes of this appeal that he was placed on the device after midnight, during
Nurse LeBlanc‟s shift, but well after Myer‟s visit had ended.
5
suffered a papillary muscle rupture that would require surgery. In preparation for the

surgery, Dr. Myer inserted an intra-aortic balloon pump. Doctors successfully repaired

Salica‟s mitral valve that day, but he ultimately died from complications and infections

resulting from the surgery. Dr. Paul Auwaerter, an infectious-disease specialist, testified

Salica‟s susceptibility to those complications was a consequence of his fragile,

significantly deteriorated condition at the time of the surgery.

¶10 At the close of the plaintiff‟s evidence, Tucson Heart moved for judgment

as a matter of law (JMOL) pursuant to Rule 50(a), Ariz. R. Civ. P., arguing the plaintiff

had failed to prove that the negligence of its employee, Nurse LeBlanc, had caused

Salica‟s death. The trial court denied the motion. Tucson Heart renewed its motion

under Rule 50(b) after the entry of judgment, and the court again denied the motion. This

appeal followed.

Discussion

¶11 Tucson Heart challenges the denial of its Rule 50 motion, an issue we

review de novo. See Felder v. Physiotherapy Assocs., 215 Ariz. 154, ¶ 36, 158 P.3d 877,

885 (App. 2007). “A motion for JMOL should be granted „if the facts produced in

support of the claim or defense have so little probative value, given the quantum of

evidence required, that reasonable people could not agree with the conclusion advanced

by the proponent of the claim or defense.‟” A Tumbling-T Ranches v. Flood Control

Dist. of Maricopa County, 222 Ariz. 515, ¶ 14, 217 P.3d 1220, 1229 (App. 2009),

quoting Orme Sch. v. Reeves, 166 Ariz. 301, 309, 802 P.2d 1000, 1008 (1990); see also

Ariz. R. Civ. P. 50(a)(1). When analyzing this issue, “we „review the evidence in a light

6
most favorable to upholding the jury verdict‟ and will affirm „if any substantial evidence

exists permitting reasonable persons to reach such a result.‟” Acuna v. Kroack, 212 Ariz.

104, ¶ 24, 128 P.3d 221, 228 (App. 2006), quoting Hutcherson v. City of Phoenix, 192

Ariz. 51, ¶ 13, 961 P.2d 449, 451 (1998).

¶12 As part of her wrongful death cause of action brought pursuant to A.R.S.

§ 12-611,5 the plaintiff had to establish medical malpractice in accordance with A.R.S.

§§ 12-561(2), 12-562(A), and 12-563. Pursuant to § 12-563, she was required to prove

that Salica‟s health care providers failed to comply with the accepted standard of care and

that “[s]uch failure was a proximate cause of the injury.” The sole issue raised in this

appeal is whether the evidence presented was legally sufficient to establish causation.

Specifically, the question is whether that evidence allowed the jury to conclude that the

actions of Tucson Heart‟s employee, Nurse LeBlanc, proximately caused Salica‟s death.

¶13 A “proximate cause” is defined as “that which, in a natural and continuous

sequence, unbroken by any efficient intervening cause, produces an injury, and without

5
The statute reads:

When death of a person is caused by wrongful act,
neglect or default, and the act, neglect or default is such as
would, if death had not ensued, have entitled the party injured
to maintain an action to recover damages in respect thereof,
then, and in every such case, the person who or the
corporation which would have been liable if death had not
ensued shall be liable to an action for damages,
notwithstanding the death of the person injured, and although
the death was caused under such circumstances as amount in
law to murder in the first or second degree or manslaughter.

7
which the injury would not have occurred.”6 Robertson v. Sixpence Inns of Am., Inc., 163

Ariz. 539, 546, 789 P.2d 1040, 1047 (1990). This definition includes the element of

causation in fact. Jefferson L. Lankford & Douglas A. Blaze, The Law of Negligence in

Arizona § 4.2 at 48 (1992).

¶14 However, when multiple tortfeasors are alleged to have created an

indivisible injury and each defendant‟s causal role is potentially indeterminable, such

causal uncertainty will not prevent a plaintiff from recovering altogether. E.g., Piner v.

Superior Court, 192 Ariz. 182, ¶¶ 3-4, 18, 26, 962 P.2d 909, 910-11, 913-14, 915-16

(1998) (sequential car accidents; extent of damage caused by each unknown); Holtz v.

Holder, 101 Ariz. 247, 248-49, 251, 418 P.2d 584, 585-86, 588 (1966) (sequential car

accidents; cause in fact and extent of damages caused by each defendant unknown);

Summers v. Tice, 199 P.2d 1, 3-4, 5 (Cal. 1948) (eye injury from one of two shotgun

blasts; cause in fact unknown). The test under such circumstances is whether the

defendant‟s actions were “a substantial factor” in producing the injury. See Barrett v.

Harris, 207 Ariz. 374, ¶¶ 24, 26, 86 P.3d 954, 960-61 (App. 2004); 65 C.J.S. Negligence

§ 216 (2010) (in concurrent negligence cases, “the proper cause in fact inquiry is whether

the conduct in question was a substantial factor in bringing about the accident”).

6
An “intervening cause” is defined as “an independent cause that intervenes
between defendant‟s original negligent act or omission and the final result and is
necessary in bringing about that result.” Robertson v. Sixpence Inns of Am., Inc., 163
Ariz. 539, 546, 789 P.2d 1040, 1047 (1990). An intervening cause qualifies as a
“superseding cause,” and thereby relieves a defendant of liability for his original
negligence, only if the “intervening force was unforeseeable and may be described, with
the benefit of hindsight, as extraordinary.” Id.

8
¶15 Arizona has adopted the “substantial factor” test from the Restatement

(Second) of Torts §§ 431, 433, and 435 (1965), in order to prevent inequities and serve

the remedial aims of tort law. See Piner, 192 Ariz. 182, ¶ 28, 962 P.2d at 916; Holtz, 101

Ariz. at 251, 418 P.2d at 588; Barrett, 207 Ariz. 374, ¶¶ 22-24, 86 P.3d at 960-61;

Restatement § 433A cmt. a. To avoid the “„unfairness of denying the injured person

redress simply because he cannot prove how much damage each [tortfeasor] did, when it

is certain that between them they did all,‟” tortfeasors are left to apportion damages

among themselves when causation is potentially indeterminable.7 Piner, 192 Ariz. 182,

n.3, 962 P.2d at 914 n.3, quoting Summers, 199 P.2d at 3. This approach is in keeping

with the modern common law, which evolved to place any financial loss upon culpable

defendants “whe[n] negligence on the part of both defendants [wa]s clear, and it [wa]s

only the issue of causation which [wa]s in doubt.” Id. ¶ 11, quoting W. Page Keeton et

al., Prosser & Keeton on the Law of Torts § 41, at 271 (5th ed. 1984). A plaintiff

therefore will be allowed to recover if he or she shows multiple defendants “contributed

to the final result,” in which case “the burden of proof on apportionment is on them.” Id.

¶ 30.

¶16 “Causation is generally a question of fact for the jury unless reasonable

persons could not conclude that a plaintiff had proved this element.” Barrett, 207 Ariz.

374, ¶ 12, 86 P.3d at 958. A party may prove proximate causation by presenting facts

7
Apportionment of fault is not called for when a plaintiff suffers separate injuries
and liability can be apportioned based only on causation. See A.R.S. § 12-2506(B)
(requiring calculation of percentage of fault only for those who “contributed to the
alleged injury”).
9
from which a causal relationship may be inferred, but the party cannot leave causation to

the jury‟s speculation. Robertson, 163 Ariz. at 546, 789 P.2d at 1047. “[U]nless a causal

relationship is readily apparent to the trier of fact,” expert medical testimony normally is

required to establish proximate cause in a medical negligence case. Gregg v. Nat’l Med.

Health Care Servs., Inc., 145 Ariz. 51, 54, 699 P.2d 925, 928 (App. 1985).

¶17 Here, LeBlanc‟s negligence in failing to alert a physician to Salica‟s

deteriorating status is not disputed on appeal. And, based upon the evidence presented

below, the jury reasonably could have concluded that LeBlanc‟s failure to act contributed

to Salica‟s worsened and weakened condition and was a substantial factor causing his

death. As Dr. Perlroth testified, there were a number of medical interventions that should

have been performed promptly had a physician been alerted to Salica‟s worsening

condition, including intubation, performing a TEE, inserting an intra-aortic pump, and

consulting a cardiothoracic surgeon. By the time these measures were taken, Salica‟s

oxygen saturation had declined drastically; he was in shock; and his chances of survival,

according to Dr. Wechsler, had fallen from over ninety percent to approximately twenty

percent. The jury reasonably could have inferred, given the testimony of Dr. Auwaerter,

that, had the various parties responsible for Salica‟s medical care not acted negligently,

Salica would not have been as susceptible to infection and would not have died from his

surgery.

¶18 Indeed, the present case is factually similar to Estate of Reinen v. N. Ariz.

Orthopedics, Ltd., 198 Ariz. 283, 9 P.3d 314 (2000). There, the plaintiff estate alleged

that the nurse responsible for Reinen‟s care had breached her duty by failing to obtain a

10
doctor for him and by not informing her supervisor of his deteriorating condition during

her overnight shift. Id. ¶¶ 1-4. The estate also claimed the on-call orthopedist was

negligent in failing to seek a consultation from the on-call internist and codefendant, Dr.

Thomas Henry. Id. ¶¶ 1, 4. Henry was a defendant in the case due to his failure to

examine Reinen or to make sufficient inquiries when contacted about his status. Id. ¶¶ 2,

4. At trial, Henry testified “he would not have altered [the] course of treatment if called

on to do an internal medicine consultation or take over the patient‟s care.” Id. ¶ 6. The

trial court consequently granted Henry‟s motion for a directed verdict on the ground that

evidence of causation was lacking. Id. ¶¶ 6-7. The court also concluded there could be

no proximate-cause finding against either the orthopedist or the nurse, even assuming

they had been negligent in their care, and it thus dismissed the case against both the

orthopedist and the hospital. Id.

¶19 Our supreme court reversed the trial court‟s rulings and remanded the case

for a new trial. Id. ¶ 28. As the court noted, the plaintiff‟s expert witness established

that, under the circumstances of the case, the standard of care for an internist required

that Henry personally examine the patient; had this occurred, the necessary treatments

then could have been instituted, giving the patient a seventy percent chance of avoiding

permanent injury. Id. ¶ 10. Because this expert testimony “provided evidence of a

breach of the standard of care . . . and a causal relationship to Reinen‟s injuries,” the

court concluded dismissing Henry from the case was erroneous. Id. The Reinen court

similarly concluded the trial court had erred in dismissing the orthopedist and the hospital

11
from the case, as the testimony of the plaintiff‟s expert was sufficient to show both a

breach of duty and the defendants‟ “causal relation to Reinen‟s injuries.” Id. ¶¶ 13-15.

¶20 None of Tucson Heart‟s arguments alters our conclusion that the evidence

presented below was sufficient to allow the jury to find the element of causation and,

consequently, that the trial court properly denied the appellant‟s JMOL motion. Tucson

Heart suggests the jury received no evidence from which to draw a conclusion about

causation in the absence of testimony from the on-call cardiologist, Dr. Byrne-Quinn, that

he would have initiated the necessary interventions had he been alerted to Salica‟s

deteriorating condition. But, as Reinen illustrates, testimony from this witness was not

essential. The jury is not obligated to believe the testimony of a treating physician, and

the testimony of qualified expert witnesses is sufficient to establish both a breach of the

standard of care and causation. See id. ¶¶ 12-13. Furthermore, as the court noted here in

denying the motion for JMOL, the evidence showed that a reasonably prudent

cardiologist would have followed up with the necessary interventions promptly upon

being informed of Salica‟s status, and “there was . . . testimony that a cardiothoracic

surgeon was on call 24 hours a day and could have assembled a surgical team at any time

during the nurse‟s night shift.”

¶21 In the same vein, Tucson Heart contends evidence of causation was

deficient because the plaintiff did not offer any specific proof that Nurse LeBlanc‟s

failure to call a physician was a “necessary condition for the occurrence of the injury.” It

alternatively asserts that the plaintiff was required to prove “the injury would not have

occurred without [Nurse LeBlanc‟s] act or omission.” But as Reinen demonstrates, these

12
are not the applicable standards in medical malpractice cases where multiple actors

contribute to an injury. Under such circumstances, a plaintiff is required to prove only

that each defendant‟s conduct was a “„substantial factor‟” in causing the injury. See

Ritchie v. Krasner, 221 Ariz. 288, ¶¶ 9, 23, 211 P.3d 1272, 1279, 1281-82 (App. 2009),

quoting Wisener v. State, 123 Ariz. 148, 150, 598 P.2d 511, 513 (1979).8 “The plaintiff

does not need „to introduce evidence to establish that the negligence resulted in the injury

or the death, but simply that the negligence increased the risk of injury or death.‟” Id.

¶ 23, quoting Thompson v. Sun City Cmty. Hosp., Inc., 141 Ariz. 597, 607, 688 P.2d 605,

615 (1984); see generally David A. Fischer, Causation in Fact in Omission Cases, 1992

Utah L. Rev. 1335, 1335-36, 1348 (1992) (explaining why problems of proof arising

from tortious failures to act best resolved by substantial-factor test).

¶22 Tucson Heart further suggests the evidence was deficient because the

plaintiff was required “to prove that Nurse LeBlanc‟s alleged breach of the standard of

care proximately caused Mr. Salica‟s death, not just some alleged pre-death injury.”

When viewed as a whole, however, the expert testimony admitted below was sufficient to

establish that LeBlanc‟s negligence substantially increased the likelihood of Salica‟s

death. According to those experts, the delay caused by that negligence substantially

compromised Salica‟s ability to endure and recover from surgery.

¶23 Although we find the evidence presented below sufficient to support a

finding that Nurse LeBlanc‟s negligence was a proximate cause of Salica‟s death, to the

8
This determination is informed by the considerations listed in Restatement § 433.
See Barrett, 207 Ariz. 374, ¶ 24, 86 P.3d at 960-61.

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extent the evidence of her causal role was unclear due to the acts of Dr. Myer and other

physicians or staff treating Salica, the trial court did not err in denying the JMOL motion

and submitting the case to the jury. Tucson Heart contends the “existence of multiple

defendants has no impact on plaintiff‟s burden to prove causation.” In light of Holtz,

however, this is an incorrect statement of the law.

¶24 In Holtz, our supreme court addressed the plaintiff‟s burden of proving

causation “where [the] plaintiff is unable to prove which defendant caused which injuries

or whether all were caused by one defendant or the other.” 101 Ariz. at 249, 418 P.2d at

586. In such circumstances, the court reasoned that public policy favored adopting the

so-called “„single injury‟ rule,” thereby relaxing the plaintiff‟s burden of proof. Id. at

251, 418 P.2d at 588. The court observed that

it is more desirable, as a matter of policy, for an injured and
innocent plaintiff to recover his entire damages jointly and
severally from independent tortfeasors, one of whom could
have to pay more than his just share, than to let two or more
wrongdoers escape liability altogether, simply because the
plaintiff cannot carry the impossible burden of proving the
respective shares of causation or because the tortfeasors have
not committed a joint tort.

Id.

¶25 Although joint and several liability subsequently was abrogated by A.R.S.

§ 12-2506, the rule from Holtz was reaffirmed in Piner. 192 Ariz. 182, ¶ 26, 962 P.2d at

915-16. After noting the interrelatedness of causation and apportionment of damages, id.

¶¶ 11-12, 18 & n.3, the Piner court held that, even under our present-day several-liability

system, which calculates defendants‟ damages based on percentages of fault, a plaintiff

14
may recover as long as he or she shows defendants “contributed to the final result,” in

which case “the burden of proof on apportionment is on them.” Id. ¶ 30. As these cases

demonstrate, the but-for test for causation is not strictly applicable when causation cannot

be determined between two defendants who may have created one injury. Otherwise, a

plaintiff could not prove the element of causation, and therefore could not recover any

damages, when the evidence failed to resolve whether one defendant caused all, or none,

of the injuries. See Summers, 199 P.2d at 3-4.

¶26 Tucson Heart also incorrectly suggests that apportionment of fault is wholly

separate from the determination of causation. The rule in Holtz, which was developed

from the Restatement § 433A, concerned the determination of both causation and

damages. Holtz, 101 Ariz. at 251, 418 P.2d at 588. As our supreme court has noted,

“„[t]he rules stated in §§ 430-453 [of the Restatement] as determining the causal relation

necessary to liability are as fully applicable to establish the extent of liability as to

establish its existence.‟” Thompson v. Better-Bilt Aluminum Prods. Co., 171 Ariz. 550,

554 n.5, 832 P.2d 203, 207 n.5 (1992), quoting Restatement (Second) of Torts § 454

(1965).

Disposition

¶27 Finding no error, we affirm the trial court‟s ruling and the judgment entered

against Tucson Heart.

/s/ Peter J. Eckerstrom
PETER J. ECKERSTROM, Presiding Judge

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CONCURRING:

/s/ J. William Brammer, Jr.
J. WILLIAM BRAMMER, JR., Judge

/s/ Garye L. Vásquez
GARYE L. VÁSQUEZ, Judge

16