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B"˜HP LaserJet 4Si/4SiMX PS 600dpiPSCRIPTÈÚØÚÚØÈÚ0nLLÎ(ÖÃ9 Z ‹6Times New Roman RegularX($¡¡C:\OFFICE\WPWIN\TEMPLATE\STANDARD.WPT- ù- ²³P´Iµ¶D·I¸¹ºÓ€ÄDÒ n3|xÄ«<þ6X9`("Courier NewTTXXxþ6X@ÉDQX@(ÈhH  Z 6Times New Roman Regular2 ÿÿ0Indent1Ô2ÔÔ3  Ô((2üÝ$¤¤Ý ƒ!ÝÝ  Ýà  àòòÚ  Ú0Ú  Úóó("Û×$Ô‡ Xh†XXXh†ÔòòÚ  Ú3Ú  Úóó2" ÿÿ0Indent2à0 àÔ2ÔÔ3  Ô2, ÿÿ0Indent3à0 àà0 àÔ2ÔÔ3  Ô26 ÿÿ0Indent4à0 àà0 àà0 àÔ2ÔÔ3  Ô2@ ÿÿ0Indent5à0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô2J ÿÿ0Indent6à0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  ÔH[2T ÿÿ0Indent7à0 àà0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô2^ ÿÿ0Indent8à0 àà0 àà0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô ÿÿ?AGMSYaioIndent0I.A.1.a.(1)(a)i)a)P ÿÿ8Mac DefaultMac DefaultÓ ` °šXÓ d< Œ 9p`(&Times New Roman% Line 7 d&&&&7Border 1dd€-'Cþÿ << Gÿÿ< Œ 9p`(Arial####'ÿÿdxd Ý ƒ!ÝÑ  ÑÑ#€d#ÑÔ€%ÔÝ  ÝÔ€)ÔÔ€)ÔÓ  Óò òÔ YYY ÔFILEDÔ€)XÔÌÌApril€25,€1997ÌÌCecil€W.€CrowsonÌAppellate€Court€ClerkÔ  Ôó ó >Ý ƒ!ÝÑ#€d#ÑÔ€%ÔÝ  ÝÝ ƒ$Ýà àòòÚ  ÚÚ  ÚóóÝ  ÝÔ€%ôÔMs.€Moon€was€substituted€for€the€original€plaintiff,€Ruth€F.€Garrett,€the€surviving€widow€of€€Ray€ElmerÏGarrett,€in€1990€following€Ms.€Garrett's€death.Ì("ÿÿ$££Ò  ÒÒ  Ò FÝ ƒ!ÝÑ#€d#ÑÔ€%ÔÝ  ÝÝ ƒ$Ýà àòòÚ  ÚÚ  ÚóóÝ  ÝÔ€%ôÔThe€endotracheal€tube€was€manufactured€by€Bivona,€Inc.€which€was€formerly€a€defendant€in€this€suit€untilÏthe€case€against€it€was€dismissed€by€summary€judgment.Ì ¶Ý ƒ!ÝÑ#€d#ÑÔ€%ÔÝ  ÝÝ ƒ$Ýà àòòÚ  ÚÚ  ÚóóÝ  ÝÔ€%ôÔNurse€Hoeflein€described€the€suctioning€procedure€as€follows:€€"we€use€the€bag,€which€is€hooked€up€to€100Ïpercent€oxygen€and€has€an€adapter€on€the€end€that€you€place€on€the€endotracheal€tube€and€you€bag€the€patient,€orÏpump€the€patient€several€times€to€give€him€quick€amounts€of€oxygen.€€You€take€that€off€and€you€have€a€sterileÏtechnique€and€you€slide€a€catheter€down€the€endotracheal€tube€and€as€you€pull€back€out€you€apply€suction€which€isÏhooked€up€to€the€wall€to€eliminate€mucous€from€the€patient's€trachea€and€lung€area."Ì kÝ ƒ!ÝÑ#€d#ÑÔ€%ÔÝ  ÝÝ ƒ$Ýà àòòÚ  ÚÚ  ÚóóÝ  ÝWe€point€out€that€the€evidence€was€not€that€Mr.€Garrett€was€biting€his€tube€at€12:45€a.m.Ïas€stated€in€all€three€experts'€opinions.€€€Rather,€Nurse€Hoeflein€testified€that€he€bit€his€tube€twoÏtimes€around€12:00€a.m.€€ÌPtPtHHÚ(ÿáÿâùFG(üHHÚ(d'hStyl{WP}01•ÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃà Ãà Ãà Ãà Ãà ÃÃÃÃÃÃÃÃÃÃÃÐ ÐÐHHÐÐ  ÐÐ2ÐÐÿÿ¸æ$ÿÐÐHHÐÐÐÐÐÐÐÐ  ÐÐ ÐÐ ÐÑÑÑGenevaÑÑ ÑÑ € ÑÑ<Px–ÈÑÒÒÒ443!#4ÒÒ$ *$ÒÒ$*$ÒÒ ÿKK ÒÒ  Geneva ÒÒ  Geneva ÒÓ.,ÓÓÓÓ6ÓÓ ÓßßßßßßßßßßßßßßßßßßÑGenevaÑÑ ÑÒ  h HD: Geneva ÒÒ  h HD: Geneva Ò€-‚ƒCþÿ<< CÿÿƒLevel 1Level 2Level 3Level 4Level 5($$””ò òÚ  Ú1Ú  Úó ó„„'÷ÿ dxdüÿP PdÝ ƒ!ÝÔ . ÔÔ€%ÔÝ  ÝÑ\R AØ'\ÑÑ\R AØ'\ÑÑ€ÑÑ7€†^XXdìdÈ7ÑÑ  ÑÓ#` Ü` ä œ ’X#Ó›Þ ÞÌFREDA€G.€MOON,€à à)Ìà àà à)Ìà àExecutor€of€theà à)Ìà àEstate€of€RUTH€GARRETT,à à)Ìà àà à)Ìà àPlaintiff/Appellant,à à)à àAppeal€No.Ìà àà à)à à01„A„01„9609„CV„00389Ìv.à àà à)Ìà àà à)à àDavidson€Circuit̜ـ€ÙßR€(+'A1-j|5€` ç `€€@ÿRß›ST.€THOMAS€HOSPITAL,à à)à àNo.à à87C„239Ìà àà à)Ìà àDefendant/Appellee.à à)ÌÌÌÓ  ÓCOURT€OF€APPEALS€OF€TENNESSEEÌÌMIDDLE€SECTION€AT€NASHVILLEÌÌÌAPPEAL€FROM€THE€CIRCUIT€COURT€FOR€DAVIDSON€COUNTYÌÌAT€NASHVILLE,€TENNESSEEÌÌÌTHE€HONORABLE€BARBARA€N.€HAYNES,€JUDGEÌÓ  ÓÌÌÌHARLAN€DODSON,€IIIÌANNE€C.€MARTINÌJULIE€K.€SANDINEÌDodson,€Parker€&€BehmÌ306€Gay€StreetÌ400€Realtors€BuildingÌP.€O.€Box€198066ÌNashville,€Tennessee€€37219Ìà àATTORNEYS€FOR€PLAINTIFF/APPELLANTÌÌÌMARY€MARTIN€SCHAFFNERÌHowell€&€FisherÌCourt€Square€BuildingÌ300€James€Robertson€ParkwayÌNashville,€Tennessee€€37201„1107Ìà àATTORNEY€FOR€DEFENDANT/APPELLEEÌÌÌÌÌÌÌÌÓ  ÓAFFIRMED€AND€REMANDEDÌÓ  ÓÌÌÌÌÌÌÌSAMUEL€L.€LEWIS,€JUDGEÌÌòòÓ  ÓÔ€%„ÔOPINIONóóÌÓ  ÓÌÓÓÔ€%¼ÔÑ7€†^XXdìXXdì7Ñò òà àó óThis€law€suit€arose€out€of€the€death€of€Ray€Elmer€Garrett€whichÏoccurred€while€he€was€a€patient€at€St.€Thomas€Hospital,€the€defendant€below.€ÏFinding€that,€as€a€matter€of€law,€the€events€surrounding€Mr.€Garrett's€death€wereÏnot€reasonably€foreseeable,€the€Davidson€County€Circuit€Court€granted€theÏdefendant€hospital€summary€judgment.€€Freda€Moon× ƒ, ××  ×,€the€decedent's€daughter,Ïhas€appealed€to€this€court€arguing€that€this€was€not€a€proper€case€for€summaryÏjudgment.€€We€disagree.€€Accordingly,€we€affirm€the€decision€of€the€trial€court.€€ÌÌà àOn€6€February€1986,€Mr.€Garrett€was€admitted€to€the€defendant€hospitalÏwhere€he€underwent€coronary€bypass€surgery€the€following€day.€€DuringÏsurgery,€Mr.€Garrett€was€orally€intubated€with€an€endotracheal€tube× ƒ. ××  ×€„„€a€tubeÏplaced€in€his€throat€leading€to€his€lung€area€which€was€used€to€provide€him€withÏthe€necessary€oxygen.€€After€€a€successful€surgery,€Mr.€Garrett€was€taken€to€theÍrecovery€room€where€his€condition€was€considered€stable.€òòÌóóÌà àAt€approximately€12:00€a.m.€on€the€morning€following€Mr.€Garrett'sÏsurgery,€the€nurse€assigned€to€him,€Patricia€Hoeflein,€observed€that€Mr.€GarrettÏbecame€agitated€and€restless€when€she€attempted€to€suction€his€lungs.× ƒ/ ××  ×€€She€statedÏthat€he€bit€on€his€endotracheal€tube€two€times€but€that€he€ceased€biting€when€sheÏwas€finished€suctioning.€€In€response€to€Mr.€Garrett's€fidgeting€with€the€wires€toÏwhich€he€was€hooked,€Nurse€Hoeflein€put€him€in€soft€arm€restraints€to€preventÏhim,€once€he€awakened,€from€pulling€at€these€wires.€€She€stated€that€this€was€aÏcommon€procedure€with€post„operative€patients.€€For€the€next€hours,€while€sheÏcontinued€to€care€for€him,€she€noticed€no€signs€of€agitation.€€Almost€two€hoursÏafter€Nurse€Hoeflein€suctioned€Mr.€Garrett,€she€left€his€room€for€approximatelyÏthirty€seconds€and€returned€upon€being€alerted€that€Mr.€Garrett€had€bitten€hisÏtube.€ÌÌà àAt€1:40€a.m.,€just€before€Mr.€Garrett€bit€his€tube,€Ronald€McKay,€aÏrespiratory€technician,€decreased€the€percentage€of€oxygen€that€Mr.€Garrett€wasÏreceiving.€€At€this€time,€Mr.€McKay€checked€the€condition€of€the€endotrachealÍtube€and€noticed€no€indication€of€chewing€or€biting.€€Ten€or€eleven€minutes€laterÏat€1:50€a.m.,€Mr.€McKay€responded€to€an€alarm€in€Mr.€Garrett's€room€andÏdiscovered€that€he€had€bitten€his€tube€almost€in€two.€€€Mr.€McKay€left€the€roomÏseeking€assistance€from€the€supervising€respiratory€technician.€€When€Mr.€McKayÏmomentarily€returned€with€another€respiratory€technician,€Byron€Kaelin,€and€theÏrespiratory€therapy€supervisor,€Gene€Emerson,€Mr.€Garrett€had€completelyÏbitten€the€tube€in€half.€€Though€Mr.€Garrett's€jaws€were€clamped€shut,€the€menÏwere€able€to€force€an€airway€tube€through.€€However,€they€could€not€remove€aÏpiece€of€the€severed€tube€from€Mr.€Garrett's€throat.€€A€physician,€Dr.€Lee,Ïarrived€and€extracted€the€severed€tube.€€Unfortunately,€Mr.€Garrett€suffered€aÏheart€attack€during€this€process€and€he€was€unable€to€be€revived.ÌÌà àBoth€Nurse€Hoeflein€and€Mr.€McKay€testified€at€depositions€that€theyÏhad€never€seen€a€patient€bite€through€an€endotracheal€tube€before,€and€Mr.ÏMcKay€added€that€this€was€the€first€time€he€had€ever€heard€of€such€an€incident.€ÏThough€Nurse€Hoeflein€was€familiar€with€the€use€of€bite€blocks€to€prevent€aÏseizing€patient€from€biting€on€his€endotracheal€tube,€she€testified€that€she€had€notÏfelt€that€it€was€necessary€to€use€a€bite€block€or€an€oral€airway€in€the€case€of€Mr.ÏGarrett.€€She€testified€that€in€her€six€and€a€half€years€of€critical€care€nursing,€sheÏhad€only€used€a€bite€block€for€one€type€of€patient€„„€one€who€was€continuouslyÏseizing.€She€stated€that,€in€her€experience,€the€only€patients€who€continuouslyÍchewed€on€their€tubes€were€those€who€were€seizing.€€For€the€majority€of€patientsÏwho€were€chewing€on€their€endotracheal€tubes,€Nurse€Hoeflein€testified€that€herÏapproach€would€be€to€calm€them€down€and€to€orient€them€with€regard€to€theÏtube.€€If€a€patient€were€chewing€on€a€tube€to€the€point€that€they€were€incoherentÏand€uncooperative,€she€might€sedate€them€with€medication.€€If€a€patient's€chewingÏwere€interfering€with€the€delivery€of€oxygen,€she€might€put€in€an€oral€airwayÏwhich€she€had€commonly€used€"to€prevent€patients€who€continually€bite€on€theirÏendotracheal€tube€to€the€point€they€are€preventing€the€air€line€delivering€theÏbreath€and€oxygen€they€need."€€ÌÌà àMr.€Emerson€testified€that€he€had€never€seen€nor€heard€of€a€patientÏcausing€a€defect€in€an€endotracheal€tube€by€gnawing€or€chewing€on€the€tube.€€HeÏstated€that€part€of€his€duty€as€a€respiratory€therapist€was€to€suction€patients€whoÏhave€endotracheal€tubes€and€that€it€was€"fairly€common"€for€these€patients€toÏgnaw€on€the€tubes€while€being€suctioned.€€He€added€that€if€a€patient's€gnawingÏwas€caused€by€the€suctioning€and€if€it€stopped€when€the€suctioning€stopped,€noÏprecautions€were€taken€to€prevent€the€patient€from€biting€the€tube.ÌÌà àNurse€Hoeflein€and€Mr.€Emerson€both€testified€that€they€did€not€recallÏpersonally€using€a€bite€block€before€the€incident.€€They€stated€that€though€St.ÏThomas€had€not€generally€used€bite€blocks€before€the€incident,€it€had€used€themÍwith€most€patients€since€that€time.€€Mr.€Emerson€testified€that,€following€theÏincident,€the€hospital€adopted€a€policy€to€use€a€bite€block€or€oral€airway€with€anyÏorally„intubated€patient€who€has€teeth.€€Mr.€Emerson€said€that€he€had€not€usedÏbite€blocks€or€oral€airways€for€patients€with€endotracheal€tubes€at€either€of€hisÏtwo€places€of€previous€employment.ÌÌà àIn€presenting€its€case,€the€defendant€relied€heavily€upon€the€affidavit€ofÏClifton€W.€Emerson,€M.D.,€an€anesthesiologist€with€CardiovascularÏAnesthesiologists,€P.C.,€and€one€of€the€doctors€directly€responsible€for€managingÏMr.€Garrett's€anesthesia€and€supervising€his€post„operative€care.€€Dr.€EmersonÏtestified€that€"patients€can€intermittently€bite€on€the€endotracheal€tube€andÏinterrupt€the€ventilatory€flow€[but€that€€s]uch€biting,€which€frequently€occursÏwhen€the€patient€is€being€suctioned,€is€not€considered€problematic€unless€theÏanesthesiologist€anticipates€the€patient€might€experience€seizures."€€Dr.€EmersonÏtestified€that€"[i]f€the€anesthesiologist€anticipates€the€patient€may€bite€down€on€theÏtube€sufficient€to€interrupt€air€flow,€he/she€will€order€a€bite€block€or€oral€airwayÏto€be€used€in€order€to€enable€the€endotracheal€tube€to€deliver€appropriateÏventilatory€support€to€the€patient."€€Such€a€decision€is€a€medical€decision€and€asÏsuch,€absent€an€emergency,€it€would€have€been€inappropriate€for€hospitalÏpersonnel€to€utilize€a€bite€block€or€oral€airway€for€Mr.€Garrett€without€an€orderÏfrom€one€of€the€anesthesiologists.€€He€added€that€"[b]iting€on€a€tube€duringÍsuctioning€is€an€ordinary,€everyday€event€and,€in€no€way€represents"€such€anÏemergency.ÌÌà àDr.€Emerson€stated€that€though€he€had€been€involved€in€over€20,000Ïopen€heart€procedures,€prior€to€Mr.€Garrettððs€surgery,€he€was€totally€unawareÏthat€€a€Fome„Cuf€endotracheal€tube€could€be€bitten€in€two€by€a€patient.€€He€"hadÏnever€known€nor€[had€he]€ever€heard€of€a€patient€completely€transecting€anÏendotracheal€tube€as€did€Mr.€Garrett."€€He€stated€that€based€on€his€experience€andÏtraining,€"it€was€not€reasonably€foreseeable€that€Mr.€Garrett€would€bite€hisÏendotracheal€tube€in€two."€€Indeed,€Dr.€Emerson€felt€that€the€incident€was€"such€aÏ'freak'€accident€that,€even€today,€[he€does]€not€routinely€use€bite€blocks€for€post„anesthesia€patients."ÌÌà àThe€defendant's€testimony€revealed€certain€disadvantages€of€oralÏairways€and€bite€blocks.€€Nurse€Hoeflein€testified€that€an€oral€airway€was€not€onlyÏuncomfortable€but€that€it€had€the€potential€to€make€a€patient€gag€which€mightÏlower€his€heart€and€blood€pressure.€€As€for€a€bite€block,€it€also€is€uncomfortableÏfor€a€patient.€€Additionally,€prolonged€use€of€a€bite€block€can€cause€ulceration€ofÏthe€mouth.€òòÌóóÌà àTo€support€her€position,€the€plaintiff€relies€upon€the€affidavits€of€JosephÍWilliam€Rubin,€M.D.,€C.M.,€a€cardiovascular€surgical€specialist,€as€well€as€thoseÏof€two€critical€care€nurses,€Nell€S.€George€and€Veronica€Varallo.€€While€both€Dr.ÏRubin€and€Nurse€George€were€contacted€through€an€expert€witness€service,€NurseÏVarallo,€who€actually€worked€at€St.€Thomas€in€the€critical€care€unit€from€1992€toÏNovember€of€1994,€was€contacted€through€a€former€employer.€All€three€of€theseÏexperts€opined€that€the€bedside€care€of€Mr.€Garrett€fell€below€the€recognizedÏstandard€of€acceptable€professional€practice€in€the€profession€and€the€specialty€ofÏthe€critical€care€of€patients.€€Each€one€stated€in€his€affidavit€that,€after€reviewingÏthese€records,€it€was€his€opinion€that€"[w]hen€the€bedside€nurse€observed€Mr.ÏGarrett€biting€his€endotracheal€tube€at€[12:45€a.m.],€she€should€have€either€used€aÏbite€block€or€repositioned€the€tube€to€keep€him€from€further€biting€or€contactedÏthe€treating€physician€so€that€he€could€make€that€decision."€ÌÌà àDr.€Rubin's€second€affidavit€stated€that€"[t]he€medical€records€in€thisÏcase€indicate€that€the€bedside€nurse€knew€Mr.€Garrett€was€biting€his€endotrachealÏtube€during€his€recovery€from€surgeryò ò€ó ó[and€that€b]ased€on€the€records,€it€wasÏforeseeable€that€the€endotracheal€tube€could€become€occluded€or€impaired."€€InÏhis€third€and€final€affidavit,€Dr.€Rubin€again€stated€that€his€opinion€was€based€onÏmedical€records€"which€indicate€that€€the€bedside€nurse€knew€Mr.€Garrett€wasÏagitated€and€biting€his€endotracheal€tube€during€his€recovery€from€surgery."€€InÏaddition,€he€stated€that€attending€medical€personnel€have€a€duty€to€ensure€that€aÍpatient's€endotracheal€tube€is€not€blocked€or€damaged€and€that€when€a€patientÏdisplays€agitated€and€biting€behavior,€there€exists€a€further€duty€to€preventÏdamage.€€€"One€such€preventive€measure€is€repositioning€of€the€endotrachealÏtube,€which€decreases€the€extent€of€damage€to€one€specific€part€of€the€tube€byÏteeth€biting,€thereby€decreasing€the€likelihood€of€the€tube€being€severed€in€two.€ÏAnother€preventive€measure€is€the€use€of€a€bite€block."€€He€testified€that€theÏdecision€of€whether€or€not€to€use€a€protective€device€or€whether€or€not€toÏreposition€a€tube€is€an€appropriate€decision€for€a€critical€care€nurse.€€InÏconclusion,€it€was€Dr.€Rubin's€opinion€that,€"[u]nder€the€circumstances€of€thisÏcase,€it€was€reasonably€foreseeable€that€Mr.€Garrett€would€lose€ventilatoryÏsupport€due€to€his€transection€of€the€endotracheal€tube€and,€as€a€result,€be€unableÏto€breathe€and€die."òòò òÌÌó óóóà àThe€plaintiff€submits€that€her€evidence€directly€contradicts€that€of€theÏdefendant€and€that€it€expressly€demonstrates€that€inferences€and€conclusionsÏcontrary€to€those€of€the€defendantððs€expert€witnesses€have€been€reasonably€drawnÏfrom€the€facts€of€this€case.€€As€such,€the€plaintiff€asserts€that€this€is€not€a€properÏcase€for€summary€judgment€which€is€to€"be€rendered€forthwith€if€the€pleadings,Ïdepositions,€answers€to€interrogatories,€and€admissions€on€file,€together€with€theÏaffidavits,€if€any,€show€that€there€is€no€genuine€issue€as€to€any€material€fact€andÏthat€the€moving€party€is€entitled€to€a€judgment€as€a€matter€of€law.€"€€Tenn.€R.ÍCiv.€P.€56.03.€€In€other€words,€summary€judgment€is€appropriate€when€twoÏprerequisites€are€met.€€First,€there€must€be€no€genuine€issue€as€to€any€factÏnecessary€to€resolve€the€substantive€claim€or€defense€embodied€in€the€summaryÏjudgment€motion,€ò òòòByrd€v.€Hallóó,ó ó€847€S.W.2d€208,€210€(Tenn.€1993),€andÏsecond,€the€moving€party€must€be€entitled€to€a€judgment€as€a€matter€of€law.Ïœò òòòMansfield›€v.€Colonial€Freight€Sysóó.ó ó,€862€S.W.2d€527,€530€(Tenn.€App.Ï1993).€€As€our€supreme€court€has€stated€"[t]he€issues€that€lie€at€the€heart€ofÏevaluating€a€summary€judgment€motion€are:€€(1)€whether€a€òòfactualóó€dispute€exists;€Ï(2)€whether€the€disputed€fact€is€òòmaterialóó€to€the€outcome€of€the€case;€€and€(3)Ïwhether€the€disputed€fact€creates€a€òògenuineóó€issue€for€trial."€€ò òòòByrdóóó ó,€847€S.W.2d€atÏ214.€€€ÌÌà àThe€legal€principles€which€guide€an€appellate€court's€review€of€a€trialÏcourt's€grant€of€a€motion€for€summary€judgment€are€well€settled.€€€Because€theÏtrial€court's€decision€involves€only€a€question€of€law,€there€is€no€presumption€ofÏcorrectness€attached€to€this€decision.€€ò òòòHembree€v.€Stateóóó ó,€925€S.W.2d€513,€515Ï(Tenn.€1996).€€This€court€need€only€review€the€record€to€determine€whether€theÏrequirements€Rule€56€have€been€met.€€ò òòòCarvell€v.€Bottomsóóó ó,€900€S.W.2d€23,€26Ï(Tenn.€1995).€€In€so€doing,€we€must€view€the€evidence€in€the€light€most€favorableÏto€the€nonmoving€party,€allow€all€reasonable€inferences€in€favor€of€that€party,Ïand€discard€all€countervailing€evidence.€€ò òòòIdóó.ó ó€(citingò ò€òòByrdóóó ó,€847€S.W.2d€at€210„11).€€€Summary€judgment€should€be€granted€if€the€facts€and€conclusions€permit€aÏreasonable€person€to€reach€only€one€conclusion.€€ò òòòMcCall€v.€Wilderóóó ó,€913ÏS.W.2d€150,€152€(Tenn.€1995).€ÌÌà àOnce€it€is€shown€by€the€moving€party€that€there€is€no€genuine€issue€ofÏmaterial€fact,€the€nonmoving€party€must€then€demonstrate,€by€affidavits€orÏdiscovery€materials,€that€there€is€a€genuine,€material€fact€dispute€to€warrant€aÏtrial.€€ò òòòByrdóóó ó,€847€S.W.2d€at€211;€€ò òòòseeóóó ó€Tenn.€R.€Civ.€P.€56.05.€€For€Mr.€Garrett'sÏburden€in€this€case,€we€turn€to€the€substantive€law€regarding€medical€malpracticeÏwhich€is€outlined€in€Tennessee€Code€Annotated€section€29„26„115:ÌÓÓà8 à(a)€In€a€malpractice€action,€the€claimant€shall€have€the€burdenÏof€proving€by€evidence€as€provided€by€subsection€(b):Ìà8 à(1)€The€recognized€standard€of€acceptable€professionalÏpractice€in€the€profession€and€the€specialty€thereof,€if€any,€thatÏthe€defendant€practices€in€the€community€in€which€he€practicesÏor€in€a€similar€community€at€the€time€the€alleged€injury€orÏwrongful€action€occurred;Ìà8 à(2)€That€the€defendant€acted€with€less€than€or€failed€to€act€withÏordinary€and€reasonable€care€in€accordance€with€suchÏstandard;€€andÌà8 à(3)€As€a€proximate€result€of€the€defendant's€negligent€act€orÏomission,€the€plaintiff€suffered€injuries€which€would€notÏotherwise€have€occurred.Ìà8 à(b)€No€person€in€a€health€care€profession€requiring€licensureÏunder€the€laws€of€this€state€shall€be€competent€to€testify€in€anyÏcourt€of€law€to€establish€the€facts€required€to€be€established€byÏsubsection€(a)€unless€he€was€licensed€to€practice€in€the€state€orÏa€contiguous€bordering€state€a€profession€or€specialty€whichÏwould€make€his€expert€testimony€relevant€to€the€issues€in€theÏcase€and€had€practiced€this€profession€or€specialty€in€one€ofÏthese€states€during€the€year€preceding€the€date€that€the€allegedÍinjury€or€wrongful€act€occurred.€€This€rule€shall€apply€toÏexpert€witnesses€testifying€for€the€defendant€as€rebuttalÏwitnesses.€€The€court€may€waive€this€subsection€when€itÏdetermines€that€the€appropriate€witnesses€otherwise€would€notÏbe€available.ÌÓÓÌà àThe€outcome€of€this€case€is€contingent€upon€the€"recognized€standard€ofÏacceptable€professional€practice"€and€whether€the€defendant€hospital€acted€inÏaccordance€with€this€standard.€€ò òòòIdóó.ó ó€ðð€29„26„115(a)(1)€„€(a)(2).€We€note€thatÏabsent€a€finding€that€the€defendant€owed€Mr.€Garrett€a€duty€involving€theÏprotection€of€his€endotracheal€tube€from€being€bitten€in€two,€it€is€irrelevant€thatÏprotective€measures€such€as€a€bite€block€or€an€oral€airway€would€have€preventedÏthe€transection€of€the€tube.€€The€plaintiff€must€show€that,€under€these€facts,€theÏdefendant€hospital€owed€the€plaintiff€a€duty€of€care.€€As€in€all€negligence€cases,Ïthere€is€a€duty€to€exercise€reasonable€care€under€the€circumstances.€€ò òòòPittman€v.ÏUpjohn€Coóó.ó ó,€890€S.W.2d€425,€428€(Tenn.€1994)€(citing€ò òòòDoe€v.€LinderÏConstr.€Coóó.ó ó,€845€S.W.2d€173,€177€(Tenn.1992)).€€€In€ò òòòDoeóóó ó,€the€court€explained:ÌÓÓà8 àThe€term€reasonable€care€must€be€given€meaning€in€relation€toÏthe€circumstances.€€€Ordinary,€or€reasonable,€care€is€to€beÏestimated€by€the€risk€entailed€through€probable€dangersÏattending€the€particular€situation€and€is€to€be€commensurateÏwith€the€risk€of€injury.€€The€risk€involved€is€that€which€isÏforeseeable;€€a€risk€is€foreseeable€if€a€reasonable€person€couldÏforesee€the€probability€of€its€occurrence€or€if€the€person€wasÏon€notice€that€the€likelihood€of€danger€to€the€party€to€whom€isÏowed€a€duty€is€probable.€€€Foreseeability€is€the€test€ofÏnegligence.€€€If€the€injury€which€occurred€could€not€have€beenÏreasonably€foreseen,€the€duty€of€care€does€not€arise,€and€evenÏthough€the€act€of€the€defendant€in€fact€caused€the€injury,€thereÍis€no€negligence€and€no€liability.€€'[T]he€plaintiff€must€showÏthat€the€injury€was€a€reasonably€foreseeable€probability,€notÏjust€a€remote€possibility,€and€that€some€action€within€theÏ[defendant's]€power€more€probably€than€not€would€haveÏprevented€the€injury.'€€.€.€.€€The€pertinent€question€is€whetherÏthere€was€any€showing€from€which€it€can€be€said€that€theÏdefendants€reasonably€knew€or€should€have€known€of€theÏprobability€of€an€occurrence€such€as€the€one€which€caused€theÏplaintiff's€injuries.€ÌÌÓÓò òòòIdóó.ó ó€at€178€(citations€omitted).ò ò€€€òòSee€Pittmanóóó ó,€890€S.W.2d€at€431€(finding€thatÏdefendant€drug€company€was€entitled€to€summary€judgment€as€there€was€noÏgenuine€issue€of€disputed,€material€fact€with€regard€to€the€duty€of€care€it€owed€toÏwarn€in€this€case€and€that€its€warning€was€sufficient€as€a€matter€of€law).ÌÌà àIn€this€case,€the€risk€of€injury€was€the€risk€of€the€patient€biting€throughÏhis€endotracheal€tube.€€We€must€determine€whether€the€plaintiff's€evidence€in€theÏform€of€the€affidavits€of€Nurse€George,€Nurse€Varallo,€and€Dr.€Rubin€establishesÏthat€there€is€a€genuine,€material€fact€dispute€as€to€whether€the€defendantsÏreasonably€knew€or€should€have€known€of€the€probability€of€such€an€occurrence.€ÏWe€begin€by€an€examination€of€the€plaintiff's€experts'€opinions.€€All€three€expertsÏgave€their€opinions€that€the€bedside€care€of€Mr.€Garrett€fell€below€the€recognizedÏstandard€of€acceptable€professional€practice€in€the€profession€and€the€specialty€ofÏthe€critical€care€of€patients.€€Each€stated€that€"[w]hen€the€bedside€nurse€observedÏMr.€Garrett€biting€his€endotracheal€tube€.€.€.,€she€should€have€either€used€a€biteÏblock€or€repositioned€the€tube€to€keep€him€from€further€biting€or€contacted€theÍtreating€physician€so€that€he€could€make€that€decision."€€In€addition,€Dr.€RubinÏstated€that€attending€medical€personnel€have€a€duty€to€ensure€that€a€patient'sÏendotracheal€tube€is€not€blocked€or€damaged€and€that€when€a€patient€displaysÏagitated€and€biting€behavior,€there€exists€a€further€duty€to€prevent€damage€whichÏcan€be€satisfied€by€repositioning€the€tube€or€using€a€bite€block.€€Only€Dr.€RubinÏdirectly€addressed€the€issue€of€foreseeability€in€opining€that,€based€on€medicalÏrecords€which€indicate€that€the€bedside€nurse€knew€Mr.€Garrett€was€biting€hisÏendotracheal€tube€during€his€recovery€from€surgery,€it€was€foreseeable€that€theÏendotracheal€tube€could€become€occluded€or€impaired.€€òòÌÌóóà àWe€find€that€the€opinions€espoused€in€the€plaintiff's€experts'€Ô% € ÔaffidavitsÏare€inadequate€for€several€reasons,€the€first€of€which€is€their€failure€to€describeÏthe€standard€of€care€in€Nashville,€Tennessee.€€In€ò òòòMoore€v.€Walwynóóó ó,€No.Ï01A01„9507„CV„00295,€1996€WL€17143€(Tenn.€App.€1996),€this€court€upheldÏthe€grant€of€summary€judgment€to€a€defendant€doctor€basing€its€decision€in€partÏon€the€failure€of€the€plaintiff's€expert€"to€establish€a€material€dispute€as€toÏdeviation€from€the€standard€of€care."€€ò òòòIdóó.ó ó€at€*5.€€The€expert€stated€as€follows:€Ï"In€my€opinion,€intravenous€antibiotics€should€have€been€given€at€the€time€of€theÏoperation€of€5/2/93,€as€well€as€the€operation€of€5/5/93....€€In€my€opinion,€it€fellÏbelow€the€standard€of€care€for€a€surgeon€to€do€these€operations€without€standardÏantibiotic€prophylaxis."€€ò òòòIdóó.ó ó€at€*4.€€The€court€stated€that€the€doctor's€"statementÍdoes€not€describe€the€standard€in€Nashville€or€explain€that€it€is€the€standard€in€aÏsimilar€community.€€Moreover,€the€statement€does€not€even€describe€a€'standardÏof€acceptable€professional€practice.'"€€ò òòòIdóó.ó ó€€Dissenting€on€other€grounds,€JudgeÏKoch€agreed€that€"the€omission€of€any€reference€to€the€appropriate€recognizedÏstandard€of€professional€practice€in€Nashville€or€similar€communities€as€requiredÏby€Tenn.€Code€Ann.€Sec.€29„26„115(a)(1)"€was€a€"material€shortcoming"€in€theÏplaintiff's€expert€opinion.€€ò òòòIdóó.ó ó€at€*12€(Koch,€J.,€dissenting).ÌÌà àIn€the€case€at€bar,€the€plaintiff's€evidence€makes€no€reference€to€theÏappropriate€recognized€standard€of€professional€practice€in€Nashville.€€Instead,€allÏthree€experts€make€a€general€reference€to€the€recognized€standard€of€acceptableÏprofessional€practice€and€assert€their€views€of€what€actions€the€attending€nurseÏshould€have€taken€to€properly€care€for€Mr.€Garrett.€€This€court€has€stated€thatÏ"[t]he€testimony€of€a€physician€as€to€what€he€would€do€or€his€opinion€of€whatÏshould€have€been€done€does€not€prove€the€statutory€standard€of€medical€practice."€€Ïò òòòRoddy€v.€Volunteer€Med.€Clinic,€Incóó.ó ó,€926€S.W.2d€572,€578€(Tenn.€App.Ï1996)€(quotingò ò€òòLewis€v.€Hilló ó,€óó770€S.W.2d€751€(Tenn.€App.1988));€ò òòòseeó óÏò òGoodman€v.€Phythyonóóó ó,€803€S.W.2d€697,€700€(Tenn.€App.€1990)€(findingÏ"generalized€statements€concerning€the€deviation€from€the€standard€of€care€forÏmedical€practice"€inadequate€where€the€plaintiff's€expert€failed€to€address€theÏdefendant€doctor's€assertion€that€his€actions€complied€with€the€standard€of€care).ÌÌà àIn€comparison€to€the€plaintiff's€lack€of€evidence€on€the€acceptableÏstandard€of€care€in€Nashville,€the€testimony€of€the€defendant's€experts,€all€ofÏwhom€were€employed€in€the€Nashville€area,€indicates€that€acceptable€practice€didÏnot€mandate€they€take€any€further€protective€action€for€a€patient€who€had€becomeÏmomentarily€agitated€during€suctioning€and€bitten€down€two€times€on€hisÏendotracheal€tube.€€Nurse€Hoeflein€stated€that€in€her€six€and€a€half€years€as€aÏcritical€care€nurse,€she€had€only€used€a€bite€block€€for€a€patient€who€wasÏcontinuously€seizing.€€Neither€she€nor€Mr.€Emerson€could€recall€personally€usingÏone€of€these€devices€nor€did€the€defendant€hospital€generally€utilize€such€devicesÏprior€to€this€incident.€€Dr.€Emerson,€Nurse€Hoeflein,€and€Mr.€Emerson€were€inÏaccord€in€their€assertions€that€it€was€common€for€patients€who€were€beingÏsuctioned€to€gnaw€on€their€endotracheal€tubes€during€the€suctioning€process.€ÏBecause€this€gnawing€was€not€considered€problematic,€both€Dr.€Emerson€and€Mr.ÏEmerson€stated€that€no€precautions€were€taken€when€a€patient€displayed€suchÏbehavior.€€To€the€contrary,€Dr.€Emerson€considered€it€a€"freak€accident"€for€aÏpatient€to€bite€through€an€endotracheal€tube.€€Indeed,€the€transection€of€anÏendotracheal€tube€seems€to€have€been€an€unprecedented€occurrence.€€NeitherÏNurse€Hoeflein,€Mr.€McKay,€Mr.€Emerson€nor€Dr.€Emerson,€who€hadÏperformed€over€20,000€open€heart€procedures,€had€ever€experienced€or€heard€ofÏan€endotracheal€tube€being€completely€bitten€in€two.€ÌÌà àThus,€a€review€of€€the€defendant's€expert€proof€reveals€that€theÏrecognized€standard€of€professional€practice€did€not€necessitate€further€actionÏbecause€the€transection€of€the€tube€was€completely€unforeseeable.€€As€is€quotedÏabove€from€our€state's€supreme€court,€"[i]f€the€injury€which€occurred€could€notÏhave€been€reasonably€foreseen,€the€duty€of€care€does€not€arise€.€.€.€'[T]he€plaintiffÏmust€show€that€the€injury€was€a€reasonably€foreseeable€probability,€not€just€aÏremote€possibility.ðð"€€ò òòòDoeóóó ó,€845€S.W.2d€at€178.€€Here,€the€proof€does€not€evenÏestablish€that€the€defendant€medical€staff€should€have€considered€this€injury€aÏremote€possibility.€€Therefore,€we€conclude€not€only€that€the€plaintiff's€evidenceÏfails€to€describe€the€standard€of€care€in€Nashville,€Tennessee,€but€that€theÏdefendant's€uncontroverted€proof€demonstrates€that€no€duty€existed€because€noÏreasonable€person€could€have€foreseen€the€probability€of€Mr.€Garrett€biting€theÏendotracheal€tube€in€two.ÌÌà àIn€reaching€this€conclusion,€we€acknowledge€Dr.€Rubin's€assertion€thatÏbased€on€medical€records€which€indicate€that€the€bedside€nurse€knew€Mr.€GarrettÏwas€biting€his€endotracheal€tube€during€his€recovery€from€surgery,€"it€wasÏforeseeable€that€the€endotracheal€tube€could€become€occluded€or€impaired."€ÏHowever,€we€do€not€find€that€Dr.€Rubin's€opinion€substantiates€the€plaintiff'sÏburden€of€foreseeability.€€Indeed,€this€opinion€exemplifies€another€defect€in€theÍplaintiff's€evidence€€„„€the€inaccuracy€of€the€factual€predicate€upon€which€theÏplaintiff's€experts€drew€their€conclusions.€€ÌÌà àThe€undisputed€facts€in€this€case€show€that€Mr.€Garrett€briefly€displayedÏagitated€behavior€while€his€lungs€were€being€suctioned€at€which€time€he€bit€downÏon€his€endotracheal€tube€two€times.€€All€of€the€defendant's€experts€agree€that€suchÏagitation€is€a€common€reaction€for€patients€whose€lungs€are€being€suctioned.€€ÏThe€€proof€showed€that€Mr.€Garrett's€agitated€behavior€ceased€as€soon€as€theÏsuctioning€ceased€and€that€the€medical€personnel€noted€no€further€indication€ofÏsuch€behavior€until€he€bit€the€tube€in€half€almost€two€hours€later.€€ÌÌà àAs€stated€above,€all€three€of€the€plaintiff's€experts€opined€that€"[w]henÏthe€bedside€nurse€observed€Mr.€Garrett€biting€his€endotracheal€tube€at€[12:45Ïa.m.],× ƒ0 ××  ×€she€should€have€either€used€a€bite€block€or€repositioned€the€tube€to€keepÏhim€from€further€biting€or€contacted€the€treating€physician€so€that€he€could€makeÏthat€decision."€€In€addition,€Dr.€Rubin€stated€that€attending€medical€personnelÏhave€a€duty€to€prevent€damage€to€an€endotracheal€tube€when€a€patient€displaysÏagitated€and€biting€behavior.€€Indeed,€he€prefaced€his€opinion€in€his€thirdÏaffidavit€by€stating€that€it€was€based€on€Mr.€Garrett's€medical€records€"whichÍindicate€that€the€bedside€nurse€knew€Mr.€Garrett€was€agitated€and€biting€hisÏendotracheal€tube€during€his€recovery€from€surgery."€€According€to€the€opinionsÏespoused€by€these€experts,€the€actions€they€advocate€are€clearly€contingent€uponÏthe€patient€being€in€an€agitated€state.€€However,€the€facts€were€that€Mr.€GarrettÏwas€only€momentarily€in€an€agitated€state€almost€two€hours€before€the€incident.€ÏHis€agitation€was€induced€by€a€medical€procedure€which€typically€causedÏagitation,€and€when€the€procedure€was€completed,€Mr.€Garrett€showed€no€furtherÏsigns€of€agitation.ÌÌà àRule€of€Civil€Procedure€56.05€provides€in€part€that€"[e]xpert€opinionÏaffidavits€shall€be€governed€by€Tennessee€Rule€of€Evidence€703"€which€states€asÏfollows:ÌÓÓà8 àThe€facts€or€data€in€the€particular€case€upon€which€an€expertÏbases€an€opinion€or€inference€may€be€those€perceived€by€orÏmade€known€to€the€expert€at€or€before€the€hearing.€€If€of€aÏtype€reasonably€relied€upon€by€experts€in€the€particular€fieldÏin€forming€opinions€or€inferences€upon€the€subject,€the€factsÏor€data€need€not€be€admissible€in€evidence.€€The€court€shallÏdisallow€testimony€in€the€form€of€an€opinion€or€inference€ifÏthe€underlying€facts€or€data€indicate€lack€of€trustworthiness.ÌÌÓÓTenn.€R.€Evid.€703.€€In€this€case,€the€opinions€expressed€by€the€plaintiff's€expertsÏare€not€based€upon€the€facts€of€this€case.€€If€opinion€testimony€must€be€disallowedÏwhen€the€underlying€facts€indicate€a€lack€of€trustworthiness,€it€certainly€must€beÏdisallowed€when€the€underlying€facts€are€inaccurate.€€Moreover,€opinions€whichÍare€not€based€upon€the€facts€of€a€particular€case€are€inadmissible€as€irrelevantÏevidence.€€ò òòòSeeóóó ó€Tenn.€R.€Evid.€402.€€"'Relevant€evidence'€means€evidence€havingÏany€tendency€to€make€the€existence€of€any€fact€that€is€of€consequence€to€theÏdetermination€of€the€action€more€probable€or€less€probable€than€it€would€beÏwithout€the€evidence."€€Tenn.€R.€Evid.€401.€€Because€the€experts'€opinionsÏregarding€the€duty€owed€an€agitated€patient€have€no€bearing€on€the€determinationÏof€whether€there€is€a€duty€in€the€present€case,€this€evidence€is€irrelevant.€€ò òòòSeeÏState€v.€Campbellóóó ó,€904€S.W.2d€608,€616€(Tenn.€Crim.€App.€1995)€(upholding€Ïlower€court€exclusion€of€expert€testimony€where€"trial€court€correctly€found€thatÏthe€proposed€testimony€of€the€psychologist€would€not€substantially€assist€the€juryÏto€understand€the€proof€that€had€been€adduced€during€the€trial€or€to€resolve€anyÏfact€in€issue").€€€ÌÌà àIn€upholding€the€trial€court's€grant€of€summary€judgment€in€this€case,Ïwe€note€that€our€courts€have€long€espoused€the€view€that€summary€judgmentÏshould€be€entered€cautiously€in€particular€kinds€of€cases,€of€which€medicalÏmalpractice€is€a€prime€example.€€ò òòòSee€Bowman€v.€Henardóóó ó,€547€S.W.2d€527,Ï530€(Tenn.€1977);€€ò òòòLedford€v.€Moskowitzóóó ó,€742€S.W.2d€645,€649€(Tenn.€App.Ï1987);òò€€ò òsee€also€Blocker€v.€Regionalóó€òòMed.€Ctróó.ó ó,€722€S.W.2d€660,€662Ï(Tenn.€1987)€(reversing€the€summary€judgment€in€a€worker's€compensation€caseÏinvolving€the€commencement€of€the€statute€of€limitations€and€noting€that€suchÍcases€most€often€are€factual€in€nature).€€The€rationale€behind€this€notion€stemsÏfrom€the€fact€that€the€basic€elements€in€a€medical€malpractice€case€must€be€provenÏby€expert€medical€evidence€in€the€form€of€opinion€testimony.€€ò òòòSeeóóó ó€Tenn.€CodeÏAnn.€ðð€29„26„115(b);òò€€ò òPayne€v.€Caldwellóóó ó,€796€S.W.2d€142,€143€(Tenn.€1990);€Ïò òòòHartsell€v.€Fort€Sanders€Reg'l€Med.€Ctróó.ó ó,€905€S.W.2d€944,€950€(Tenn.ÏApp.€1995),€òòcert.€deniedóó,€116€S.€Ct.€1352€(1996).€€"Because€opinion€testimonyÏalways€is€subject€to€evaluation€by€the€fact€finder,€it€generally€has€been€held€not€anÏappropriate€basis€for€summary€judgment."€€ò òòòBowmanóóó ó,€547€S.W.2d€at€530.ÌÌà àHowever,€the€court€in€ò òòòBowmanóó€ó ónoted€an€exception€to€this€general€rule:€Ï"in€those€malpractice€actions€wherein€expert€medical€testimony€is€required€toÏestablish€negligence€and€proximate€cause,€affidavits€by€medical€doctors€whichÏclearly€and€completely€refute€plaintiff's€contention€afford€a€proper€basis€forÏdismissal€of€the€action€on€summary€judgment,€in€the€absence€of€proper€responsiveÏproof€by€affidavit€or€otherwise."€€ò òòòIdóó.ó ó€at€531.€€More€recently,€this€court€has€statedÏthat€grants€of€summary€judgment€"have€proven€particularly€useful€in€medicalÏmalpractice€cases€.€.€.€[w]hen€the€issue€is€properly€raised€and€it€is€shown€prior€toÏtrial€that€the€plaintiff€cannot€meet€that€burden€[imposed€on€the€plaintiff€by€theÏlegislature]."€€ò òòòWalker€v.€Bellóóó ó,€828€S.W.2d€409,€411€(Tenn.€App.€1991).€€WeÏbelieve€that€this€is€a€case€where€the€plaintiff€cannot€meet€the€burden€of€showingÏmedical€malpractice.€€ÌÌà àThe€plaintiff's€evidence€in€this€case€fails€to€demonstrate€a€genuineÏmaterial€fact€dispute€with€regard€to€whether€the€defendant€complied€with€theÏrecognized€standard€of€acceptable€professional€practice€in€Nashville,€Tennessee.€€ÏThe€expert€affidavits€presented€by€the€plaintiff€do€not€establish€that€theÏoccurrence€which€caused€Mr.€Garrett's€death€was€foreseeable€or€that€theÏappropriate€professional€practice€standard€mandated€further€action€in€an€effort€toÏprotect€Mr.€Garrett's€endotracheal€tube.€€Furthermore,€all€of€the€experts'Ïopinions€are€premised€upon€the€incorrect€fact€that€the€plaintiff€was€in€an€agitatedÏstate€following€surgery.€€Accordingly,€we€affirm€the€trial€court€and€tax€the€costsÏof€this€appeal€œto€the€plaintiff€Freda€G.€Moon.€Ô€%ôÔÌÓÓÔ€%¼ÔÌÔ€%XÔà à›à à____________________________________ÌœCONCUR:à àSAMUEL€L.€LEWIS,€JUDGEÌ›Ì_____________________________________ÌHENRY€F.€TODD,€P.J.,€M.S.ÌÌ_____________________________________ÌœWILLIAM€C.€KOCH,€JR.,€JUDGE