ÿWPC" 6# UN %] 0ccU<Æw@4BVU<e¡ 0§© AQP {¡ 0Dº 0Jþ 0TH 0^œ 0hú 0rb 0|Ô 0†P 0Ö 1uf 0dÛ B? Æ\ 0D" 0@f 0D¦ D/ê B D36U>iB)§DCÐ AMU*`^ŠèèôÐv~ÄvÓB˜HP LaserJet 4SiHPPCL5MS,ü,,,,,ü0nLhÎ(ÈhH  Z 6Times New Roman RegularX(;cW$¡¡Ò°ÒÒ„°ÒÔ€XaBXXXÔ-šBu Z‹$Arrus BT Roman 1E23U4U5U6î7Ó€8Ó€DGn~<$3|xG)LÀÄ  Z $Arrus BT Roman(W(3Ï€$¤¤Ý ƒcW!ÝÒ°ÒÒ„°ÒÔ€X4XXXÔÝ  Ýà ` àòòÚ  Ú0Ú  Úóó !"%Cþÿ<< Cÿÿ(ñ&8$¡¡Ò°ÒÒ„°ÒÑ7€ ¡XXdðXXdð7ÑÑ  ÑÔ‡ Xn>XXXÔÑTR[  AØ'ÿ Legal[  AØ'ÿ Legal AØ'ÿ Legal AØ'ÿ LegalTÑÓÓÓ  Ó($$””ò òÚ  Ú1Ú  Úó ó2 ÿÿ0Indent1Ô2ÔÔ3  Ô2" ÿÿ0Indent2à0 àÔ2ÔÔ3  Ô2, ÿÿ0Indent3à0 àà0 àÔ2ÔÔ3  Ô26 ÿÿ0Indent4à0 àà0 àà0 àÔ2ÔÔ3  Ô2@ ÿÿ0Indent5à0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô2J ÿÿ0Indent6à0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô2T 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 dƒLevel 1Level 2Level 3Level 4Level 5(3¯$¢¢Ý ƒ!ÝÝ  Ý("ÿÿ$££Ò  ÒÒ  Ò(#Ã$òòÚ  Ú0Ú  Úóó'''÷ÿ dxdüÿP Pd'ÿÿdxd< Œ 9p`(&Times New Roman% Line 7 d----7Border 1dd ".Cþÿ << Gÿÿ< Œ 9p`(Arial TÝ ƒ!ÝÑ  ÑÑ#€d#ÑÔ€,ÔÒ  ÒÒ „ ÒÔ€ÔÝ  ÝÝ ƒ!"ÝÝ  ÝÔ€0ÔÔ€0ÔÓ  ÓÔ YYY ÔFILEDÔ€0XÔÌÌò òJuneÏ12,Ï1998ÌÌCecilÏCrowson,ÏJr.ÌÔ€0ôÔAppellateÏCourtÏClerkó ó ÞÝ ƒ!ÝÑ#€d#ÑÔ€,ÔÒ  ÒÒ „ ÒÔ€ÔÝ  ÝÝ ƒ $Ýà àòòÚ  ÚÚ  ÚóóÝ  ÝÓÔÓ€€Relevant€portions€of€this€text€state:ÌÌà8 àà8 à€€€€€Antibiotics€are€administered€preoperatively€toÏhelp€control€any€local€or€generalized€sepsis€that€mayÏbe€present€and€to€reduce€the€incidence€ofÏpostoperative€wound€infection.€€Although€theÏprophylactic€administration€of€antibiotics€continuesÏto€be€a€matter€of€controversy,€the€evidence€that€hasÏaccumulated€over€approximately€the€past€decade€isÏclearly€in€favor€of€antibiotic€administration.€ÏAntibiotics€probably€are€of€minor€benefit€unless€theÏappendix€is€gangrenous€or€has€perforated.€.€.€.€Hence,Ïwe€administer€antibiotics€to€all€patients€suspected€ofÏhaving€appendicitis€but€continue€administrationÏintraoperatively€and€postoperatively€ò òòòonlyó óóóin€thoseÏpatients€demonstrated€to€have€complicatedÏappendicitis.Ìà8 àà8 ààH¸ ¸ ¸ ààH¸ ¸ ¸ àà àà àà àò ò*à à*à à*Ìà8 àà8 àó ó€€€€€Antibiotic€therapy€should€not€be€continued€post„operatively€unless€the€appendix€is€gangrenous€orÏperforated.€€The€patient€may€be€discharged€as€early€asÏthe€third€postoperative€day€provided€there€is€noÏundue€wound€tenderness€or€fever€and€antibiotics€haveÏnot€been€administered€for€48€hours€prior€to€discharge.Ìà àà àà àà àà àò ò*à à*à à*Ìà8 àà8 àó ó€€€€€Infection€of€the€subcutaneous€tissues€is€the€mostÏcommon€complication€following€appendectomy.€.€.€.ÏSince€wound€infections€in€cases€of€appendicitis€areÏcaused€by€fecal€organisms,€the€classic€signs€ofÏinfection€(calor,€dolor,€rubor,€tumor)€often€are€notÏpresent.€€The€early€signs€of€a€fecal€wound€infection€areÏundue€pain€and€modest€edema€around€the€wound.ÌÌTextbook€of€Surgery€974,€978,€980€(David€C.€Sabiston,€Jr.,€M.D.€et€al.€eds.,€13thÏed.€1986)€(emphasis€added).Ì êÝ ƒ!ÝÑ#€d#ÑÔ€,ÔÒ  ÒÒ „ ÒÔ€ÔÝ  ÝÝ ƒ $Ýà àòòÚ  ÚÚ  ÚóóÝ  Ý€€As€quoted€from€Dr.€Koonceððs€testimony.ÌPtPtHHØ(ÿáÿâùFG(üHHØ(d'`Styl{WP}01•ÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃà Ãà Ãà Ãà Ãà ÃÃÃÃÃÃÃÃÃÃÃÐ ÐÐHHÐÐ  ÐÐ2ÐÐÿÿ¸æ$ÿÐÐHHÐÐÐÐÐÐÐÐ  ÐÐ ÐÐ ÐÑÑÑGenevaÑÑ ÑÑ € ÑÑ<Px–ÈÑÒÒÒ443!#4ÒÒ$ *$ÒÒ$*$ÒÒ ÿKK ÒÒ  Geneva ÒÒ  Geneva ÒÓ.,ÓÓÓÓ6ÓÓ ÓßßßßßßßßßßßßßßßßßßÑGenevaÑÑ ÑÒ  ellan Geneva ÒÒ  ellan Geneva ÒÝ ƒ!ÝÔ . ÔÔ€,ÔÒ  ÒÒ „ ÒÔ€ÔÝ  ÝÑ\R AØ'\ÑÑ7€ŒïXXdðdÈ7ÑÑ  ÑÓ  ÓÞ ÞÌà@ àIN€THE€COURT€OF€APPEALS€OF€TENNESSEEÌà@ àAT€JACKSONÌà àà à€€€€______________________________________________ÌÙ€ ÙßR€/1.A1-j|„Ì` à. `€€@ÿRßÌò òBARBARA€PIERCE,€ó óÌÌà àClaimant„Appellant,Ìà àà àà àà àà àà àà àTennessee€Claims€CommissionÌà àà àà àà àà àà àà àNo.€96„015ÌVs.à àà àà àà àà àà àà àC.A.€No.€02A01„9710„BC„00245ÌÌò òSTATE€OF€TENNESSEE,€ó óÌÌà àDefendant„Appellee.Ì____________________________________________________________________________ÌÌà@ àFROM€THE€TENNESSEE€CLAIMS€COMMISSIONÌà@ àTHE€HONORABLE€MARTHA€B.€BRASFIELD,€COMMISSIONERÌÌÌÌÌÌà@ àL.€L.€Harrell,€Jr.;€Harrell€&€Harrell€of€TrentonÌà@ àFor€AppellantÌÌà@ àBeauchamp€E.€Brogan,€General€CounselÌà@ àJoAnn€C.€Cutting,€Assistant€General€CounselÌà@ àof€Memphis,€For€AppelleeÌÌÌÌÌÌà@ àò òòòAFFIRMEDó óóóÌÌà@ àOpinion€filed:ÌÌÌÌÌÌÌÌÌà àà àà àà àà àà àà àà àò òW.€FRANK€CRAWFORD,Ìà àà àà àà àà àà àà àà àPRESIDING€JUDGE,€W.S.ÌÌÌÌCONCUR:ÌÌALAN€E.€HIGHERS,€JUDGEÌÌHOLLY€KIRBY€LILLARD,€JUDGEó óÌÌÌÓÓÔT€Ôà àThis€is€a€medical€malpractice€case€tried€by€the€Tennessee€ClaimsÏCommission.€€Claimant€Barbara›€Pierce€(Pierce)€œappeals€from€the€judgment€ofÏthe€Claims€Commision€for€defendant,€State€of€Tennessee.€€Pierce€filed€thisÏcomplaint€alleging€that€while€a€patient€at€the€Regional€Medical€Center€inÏMemphis,€Tennessee,€she€had€surgery€for€removal€of€her€appendix.€€She€aversÏthat€she€was€under€the€care€and€treatment€of€Dr.€Kenna€Williams€and€Dr.ÏRobert€Howell,€medical€residents€and€employees€of€the€State€of€TennesseeÏthrough€the€University€of€Tennessee€School€of€Medicine.€€She€basically€allegesÏthat€the€defendant,€University€of€Tennessee,€through€its€employees,€breachedÏthe€recognized€standard€of€acceptable€professional€practice€in€its€medicalÍtreatment€thus€resulting€in€a€severe€infection€that€necessitated€furtherÏhospitalization,€expense,€pain,€and€suffering.Ìà àThe€Commissionerððs€excellent€order€provides€a€thorough€statement€of€theÏfacts€as€developed€from€the€testimony,€and€we€quote€those€pertinent€parts€ofÏthe€order:ÌÓÔÓà8 àà8 à€€€€€At€approximately€3€p.m.€on€May€16,€1988,€theÏclaimant,€a€41„year„old›€woman,€presented€herself€inÏthe€emergency€room€of€the€Regional€Medical€œCenter,›Ïcomplaining€of€pain€in€the€lower€right€section€of€herÏabdomen,€accompanied€by€nausea,€vomiting€and€aÏfever€of€approximately€101€F.€€her€white€blood€cellÏcount€œat›€19,800.€€She€was€diagnosed€withÏappendicitis,€and€at€approximately€10€p.m.,€anÏappendectomy€was€performed€by€Dr.€Robert€Howell,€aÏmedical€resident€and€an€employee€of€the€State€ofÏTennessee€thorough€the€University€of€TennesseeÏMemphis€Health€Science€Center€(UT).€€ImmediatelyÏprior€to€surgery,€the€claimant€was€given€intravenousÏantibiotics,€Gentamycin€and€Clindomycin.€€In€surgery,Ïthe€claimantððs€obesity€(her€weight€was€approximatelyÏ275„280€pounds)€necessitated€a€generous€incision€toÏexpose€her€appendix.€€Dr.€Howell€reported€seeing€noÏgross€pus€or€blood€around€the€appendix.€€TheÏappendix,€itself,€appeared€red€and€swollen,€but€showedÏno€evidence€of€gangrene€or€perforation.€€Both€theÏappendix€and€a€swab€of€the€fluid€surrounding€theÏappendix€were€sent€to€the€laboratory€for€analysis.€€TheÏincision€was€irrigated€and€closed,€and€the€claimantÏwas€sent€to€the€recovery€room€and€then,€during€theÏearly€hours€of€May€17,€1988,€transferred€to€herÏhospital€room.ÌÌà8 àà8 à€€€€€Initial€laboratory€reports€received€by€theÍphysicians€on€May€18,€1988,€indicated€no€activeÏbacteria€in€the€fluid€specimen.€€The€microscopicÏexamination€of€the€appendix€and€the€culture€of€theÏfluid€specimen€took€several€days€to€complete.ÌÌà8 àà8 à€€€€€Throughout€her€hospital€recuperation,€theÏclaimant€was€examined€and/or€treated€by€variousÏphysicians€and€medical€students€from€UT.€€TheÏclaimant€was€primarily€treated€by€Dr.€Keena€Williams,Ïa€medical€resident€who€first€saw€the€claimant€on€MayÏ17,€1988,€and€continued€to€provide€care€to€her€untilÏshe€was€discharged€from€the€hospital€on€May€20,Ï1988.€€The€claimant€was€also€examined€daily€by€BryanÏL.€Woods,€who€was€a€third„year€medical€student€atÏUT.ÌÌà8 àà8 à€€€€€Following€her€surgery,€the€claimant€experiencedÏfever€which€peaked€near€œ103.5ð$ð›€at€6€p.m.€on€May€17,Ï1988€but€declined€to€œ99.4ð$ð›€by€the€time€of€herÏdischarge€from€the€hospital€on€May€20,€1988.€€AmongÏtests€administered€during€this€period€were€a€chest€x„ray,€a€urinalysis,€a€vaginal€smear,€and€several€bloodÏtests,€the€results€of€which€were€normal.€€By€the€date€ofÏher€discharge€from€the€hospital,€her€white€blood€cellÏcount€had€fallen€to€approximately€8,000,€a€rangeÏwhich€is€somewhat€high€but€which€is€generallyÏconsidered€to€be€within€the€normal€range€limits.ÌÌà8 àà8 à€€€€€During€her€hospital€stay,€the€claimant€receivedÏseveral€doses€of€Tylenol€3€for€pain,€and€two€doses€ofÏregular€Tylenol€for€fever.€€She€received€œno›€antibioticsÏexcept€those€administered€immediately€prior€toÏsurgery.ÌÌà8 àà8 à€€€€€Treatment€notes€and€nurses€notes€reflect€that€theÏexaminations€of€the€claimantððs€incision€revealed€aÏnormally„healing€wound,€with€one€exception;€on€MayÏ19,€1988,€a€nurse€[Nurse€Mary€Alice€Anderson]€notedÍthat€the€area€around€the€staples€in€the€claimantððsÏincision€was€ð ðred€and€hot€with€[a]€red€streak€up€toÏ[the]€umbilicus.ðð€€Physiciansðð€œnotes›€written€just€priorÏto€the€claimantððs€discharge€on€May€20,€1988€describedÏthe€wound€as€healing€normally,€and€stated€that€theÏð ðwound€look[ed]€good.ððÌÌà8 àà8 à€€€€€On€May€19,€1988,€the€claimantððs€physiciansÏreceived€€via€telephone€the€final€results€of€theÏmicroscopic€examination€of€the€appendix€and€theÏculture€of€he€fluid€specimen€which€were€taken€duringÏsurgery.€The€written€report€followed€on€May€20.€ÏNotes€made€by€Bryan€L.€Woods€on€May€19,€1988,Ïstate€that€the€laboratory€had€diagnosed€the€appendixÏas€having€ð ðacute€suppurative€appendicitis€withÏmultiple€areas€of€microscopic€purulent€perforation,ððÏwhich,€defined€in€laymenððs€terms,€is€an€appendix€withÏmicroscopic€perforations€(tears€œor›€holes)€andÏmicroscopic€amounts€of€pus.€€With€regard€to€theÏcultured€specimen,€the€laboratory€reported€that€ð ðfewÏe„coli€bacteriaðð€were€present€in€the€cultured€specimen.€ÏœThese›€e„coli€bacteria€were€sensitive€to€all€antibiotics.ÌÌà8 àà8 à€€€€€The€claimant€was€released€from€the€hospital€onÏMay€20,€1988,€with€routine€instructions€on€woundÏcare,€follow„up€visits,€and€symptoms€which€wouldÏrequire€immediately€medical€attention.€€She€was€givenÏa€prescription€for€pain€medication,€but€noÏprescription€for€antibiotics.ÌÌà8 àà8 à€€€€€On€May€25,€1988,€the€claimant€returned€to€theÏhospital€complaining€that€her€wound€had€burst€openÏand€was€œseeping›€a€purulent€discharge.€€Dr.€KeenaÏWilliams€examined€the€claimantððs€incision€andÏdetermined€it€to€be€infected.€€The€claimant€wasÏreadmitted€to€the€hospital.€€The€claimantððs€initialÏtemperature€was€recorded€as€œ97ð$ð›€degrees€and€laterÏrose€to€œ101ð$ð.›€€Her€white€blood€cell€count€was€in€theÍrange€of€18,000.€€Her€surgical€incision€was€opened,Ïdrained€and€cleaned.€€It€was€left€open€for€healingÏð ðfrom€the€inside€out.ðð€€Antibiotics€were€administered.€ÏShe€was€released€from€her€second€hospitalÏconfinement€on€June€4,€1988.€€It€took€approximatelyÏthree€months€for€the€incision€to€heal€completely.ÌœÌà àà àà à*à àà à*à àà à*à àà à*›Ìà àœà8 àà8 àÌà8 àà8 à€€€€€The€partiesðð€expert€witnesses€agreed€that€the€mostÏcommon€complication€of€appendectomies€is€infectionÏof€the€surgical€wound€(incision),€and€that€suchÏinfections€are€most€often€the€result€of€bacteria€havingÏleaked€into€the€wound€from€the€infected›€appendix,Ïeither€before€or€during€surgery€(while€the€infectedÏappendix€is€being€removed€œfrom›€the€abdominal€cavityÏthrough€the€surgical€incision).€€The€partiesðð€expertÏwitnesses€agreed€that€the€risk€of€wound€infectionÏincreases€with€the€severity€of€the€inflammation€of€theÏappendix.€€(There€are€four€stages€of€appendicitis:€(1)ÏIn€the€first€stage,€the€outside€of€the€appendix€appearsÏmildly€red€with€bright€blood€vessels;€(2)€In€the€secondÏstage,€the€entire€appendix€is€inflamed,€red€and€swollen;Ï(3)€In€the€third€stage,€the€appendix€developsÏmicroscopic€perforations;€and€(4)€in€the€fourth€stage,Ïthe€appendix€develops€visual€spots€of€gangrene€(pus)Ïand€visual€perforations€or€ruptures.€€The€risk€ofÏinfection€increases€with€each€stage€of€appendicitisÏbecause€the€bacteria€are€more€likely€to€escape€fromÏthe€perforations€and€the€pus.)€€The€partiesðð€expertÏwitnesses€also€agreed€that€the€pre„operativeÏantibiotics€lessen€the€risk€of€surgical€wound€infection,Ïalthough€the€experts€disagreed€as€to€the€level€andÏduration€of€the€effectiveness€of€the€pre„operativeÏantibiotics.€€Also,€based€on€the€fact€that€the€claimantÏdid€develop€an€infection€in€the€surgical€wound,€theÏexperts€agreed€that€the€claimant€was€ð ðbrewing€anÏinfectionðð€when€she€was€released€from€the€hospital.ÌÌà8 àà8 à€€€€€The€parties€primary€differences€arise€over€whetherÏor€not€the€claimant€should€have€been€administeredÏantibiotics€post„operatively.ÌÌà8 àà8 à€€€€€Pursuant€to€œTenn.€Code€Ann.€ðð€29„26„115(b),€bothÏparties€presented€medical€experts€who€testified€on€theÏissues€of€the€standard€of€acceptable€professionalÏpractice€and€whether€or€not€the€defendantððsÏemployees€committed€malpractice€in€failing€toÏadminister€post„operative€antibiotics€to€the€claimant.›ÌÌà8 àà8 à€€€€€The€claimantððs€expert€witness,€Dr.€Marshall€L.ÏKoonce,€is€a€semi„retired€physician€licensed€toÏpractice€in€the€State€of€Tennessee.€€His€area€ofÏexpertise€lies€in€internal€medicine€and€rheumatology.€ÏHe€graduated€from€medical€school€in€1964,€andÏcompleted€his€medical€residency€in€1967€at€theÏUniversity€of€Tennessee.€€He€trained€in€rheumatologyÏfrom€1967€through€1969,€and€went€into€privateÏpractice€in€1969.€€Dr.€Koonce€practiced€medicine€full„time€until€1986,€when€he€underwent€hip€surgery€andÏwas€unable€to€return€to€active€practice.€€He€has,Ïhowever,€continued€to€see€a€few€patients€on€a€limitedÏbasis,€and€has€maintained€subscriptions€to€severalÏrespected€medical€journals.€€Dr.€Koonce,€himself,€didÏnot€perform€appendectomies,€but€he€did€provide€post„surgical€care€to€many€appendectomy€patients.€€Dr.ÏKoonce€stated€that€he€is€familiar€with€the€standardsÏof€care€in€Memphis€and€Shelby€County€for€treatingÏphysicians.ÌÌà8 àà8 à€€€€€Dr.€Koonce€testified€that,€based€on€his€experienceÏwith€other€doctors€and€surgeons€at€Baptist€HospitalÏand€his€own€knowledge,€the€recognized€standard€ofÏacceptable€professional€practice€with€regard€toÏappendectomy€patients€is€to€administer€pre„operativeÏantibiotics€and,€in€most€cases,€to€administer€post„operative€antibiotics,€especially€to€patients€whoÏexhibit€symptoms€of€infection€and€to€those€deemed€toÏbe€at€high€risk€for€infection.€€He€testified€thatÏpatients€should€be€observed€for€elevated€œbody›Ïtemperatures,€wound€inflammation,€elevated€whiteÏblood€cell€counts,€and€any€other€obvious€indicators€ofÏinfection.ÌÌà8 àà8 à€€€€€According€to€Dr.€Koonce,€the€pre„operativeÏantibiotics€administered€to€the€claimant€were,€byÏthemselves,€insufficient€to€combat€the€risk€ofÏinfection,€especially€in€light€of€her€obesity€which,€inÏhis€opinion,€placed€her€at€a€higher€risk€of€contractingÏan€infection.€€He€stated€that€he€would€haveÏadministered€antibiotic€drugs€to€the€claimant€ð ðfor€aÏfew€days€after€surgeryðð€as€a€preventative€measure.€€InÏsupport€of€his€position,€he€stated€that€ð ðone€shot€ofÏantibiotics€has€very€little€effect,ðð€and€pointed€out€thatÏthe€fluid€specimen€obtained€during€the€surgeryÏeventually€cultured€e„coli€bacteria;€He€maintained€thisÏwas€a€clear€indication€that€the€pre„operativeÏantibiotics€had€been€inadequate€to€destroy€bacteriaÏand€prevent€infection.€€He€stated€that€he€would€haveÏð ðgiven€her€antibiotics€straight€through€[herÏhospitalization],ðð€and€that€he€believed€the€UTÏphysicians€deviated€from€the€standard€of€care€in€notÏdoing€so.ÌÌà8 àà8 à€€€€€Dr.€Koonce€further€opined€that€(1)€the€claimantððsÏelevated€body€temperatures,€(2)€the€red€streak€in€herÏsurgical€wound,€and,€(3)€the€lab€report€which€showsÏthat€her€appendix€was€microscopically€perforated€andÏthat€e„coli€bacteria€grew€in€the€specimen€of€the€fluidÏoutside€the€appendix€were€indicators€of€infection€andÏwarranted€the€administration€of€post„operativeÏantibiotics€to€combat€the€infection.€€He€testified€thatÏduring€an€infectious€process,€body€temperatures€oftenÏelevate€then€drop,€and€stated€that,€in€his€opinion,€theÍclaimantððs€body€temperature€readings€were€consistentÏwith€the€pattern€often€seen€during€an€infectiousÏprocess.€€He€stated€that€her€symptoms€would€haveÏprompted€him€to€prescribe€antibiotics,€keep€her€inÏthe€hospital€for€a€few€more€days,€and,€if€conditionsÏwarranted,€possibly€to€have€opened€and€cleaned€theÏsurgical€wound.ÌÌà8 àà8 à€€€€€(Dr.€Koonceððs€first€deposition€was€taken€JanuaryÏ30,€1991€and€was€marked€as€Exhibit€3.€€Having€readÏthe€records€from€the€hospital,€it€was€his€opinion€thatÏthe€claimantððs€infection€in€the€appendix€(which€wasÏthe€reason€for€the€surgery),€the€microscopicallyÏruptured€appendix,€her€obesity,€her€fever,€her€redÏstreak€and€the€wound€culture€which€showed€e„coliÏbacteria€were€all€indications€that€antibiotics€shouldÏhave€been€administered€post„operatively.€€In€thisÏdeposition€Dr.€Koonce€determined€that€the€woundÏculture€was€a€culture€of€the€actual€surgical€incisionÏtaken€by€Bryan€L.€Woods,€then€a€third„year€medicalÏstudent,€on€May€18,€1988.€€The€proof€indicates€thatÏno€culture€was€made€of€the€surgical€incision€afterÏsurgery.€€On€May€18,€1988,€Dr.€Woods€was€recordingÏwhat€the€laboratory€had€reported€to€him€by€telephoneÏconcerning€the€culture€taken€by€Dr.€Howell€duringÏsurgery€on€May€16,€œ1988.)›ÌÌà8 àà8 à€€€€€The€defendantððs€expert€witness,€Dr.€Hiram€C.€Polk,ÏJr.,€is€a€medical€instructor€and€is€chairman€of€theÏDepartment€of€Surgery€at€Louisville€School€ofÏMedicine.€€He€received€his€medical€degree€fromÏHarvard€University€in€1960,€and€completed€hisÏresidency€at€Barnes€Hospital€in€St.€Louis,€Missouri,€inÏ1965.€€Since€that€time,€Dr.€Polk€has€taught€at€schoolsÏof€medicine€in€Florida,€Missouri€and€Kentucky.€€HeÏhas€authored€approximately€300€articles€in€theÏmedical€field,€and€has€contributed€chapters€to€variousÏmedical€textbooks.€€His€areas€of€surgical€specializationÍare€the€esophagus€and€certain€kinds€of€cancer,€but€hisÏlifetime€research€interest€has€been€matters€related€toÏinfection€in€surgery.€€Many€of€his€articles€pertain€toÏwound€care.€€He€has€been€a€practicing€surgeon€for€28Ïyears,€has€supervised€thousands€of€appendectomies€inÏhis€capacity€as€an€instructor,€and€has€personallyÏrendered€care€to€hundreds€of€private€appendectomyÏpatients.ÌÌà8 àà8 à€€€€€Dr.€Polk€advised€that€it€is€virtually€impossible€toÏremove€an€appendix€without€contaminating€theÏsurgical€wound,€and€reported€that€10%„30%€ofÏappendectomy€patients€develop€surgical€woundÏinfections€despite€the€most€strict€precautions.€€(Dr.ÏKoonce€opined€that€Dr.€Polkððs€figures€were€high.€ÏAlthough€Dr.€Koonce€did€not€have€the€statistics,€heÏtestified€that€he€had€seen€the€infection€reports€fromÏBaptist€Hospital€and€that€infection€rates€were€lowerÏthere.)€€Dr.€Polk€described€the€standard€of€care€ofÏappendectomy€patients€as€follows:ÌÌà8 àà8 à€€€€€First,€appendicitis€should€be€timely€diagnosed€toÏenable€the€surgeon€to€remove€the€appendix€as€soon€asÏpossible.€€The€surgical€incision€should€be€long€enoughÏto€allow€the€appendix€to€be€brought€straight€upÏthrough€the€œwound›€with€as€little€manipulation€asÏpossible.€€Secondly,€antibiotic€treatment€should€beÏadministered€to€reduce€the€risk€of€infection.€€Thirdly,Ïpost„surgical€patients€should€be€closely€monitored€forÏsymptoms€of€infection.€€Fourth,€pathological€studiesÏshould€be€performed€to€determine€whether€bacteriaÏfrom€the€infected€appendix€had€contaminated€theÏabdominal€cavity.€€Finally,€the€wound€should€beÏcarefully€closed.ÌÌà8 àà8 à€€€€€Dr.€Polk€opined€that€the€claimantððs€appendicitisÏwas€timely€diagnosed,€and€that€her€appendectomy€wasÏperformed€as€soon€as€was€practicable.€€Based€upon€theÍsurgeonððs€notes,€Dr.€Polk€found€no€evidence€that€theÏsurgeon€had€breached€the€accepted€standards€of€careÏduring€the€claimantððs€surgery€or€during€closure€of€theÏsurgical€wound.€€In€his€opinion,€the€properÏpathological€testing€was€performed.ÌÌà8 àà8 à€€€€€With€regard€to€antibiotic€drug€treatment€inÏgeneral,€Dr.€Polk€testified€that€the€accepted€standardÏof€care€dictated€the€administration€of€antibioticsÏprior€to€appendectomies,€but€stated€that€post„operative€antibiotics€should€be€prescribed€on€a€case„by„case€basis,€depending€on€the€severity€of€theÏpatientððs€appendicitis€and€the€likelihood€of€bacterialÏcontamination€from€the€appendix.€€The€pre„operativeÏantibiotics€given€to€the€claimant,€Gentamycin€andÏClindomycin,€were,€according€to€Dr.€Polk,€the€mostÏcommonly„used€combination€of€antibioticsÏadministered€prior€to€appendectomies.€Dr.€PolkÏtestified€that€although€he,€personally,€preferred€aÏdifferent€antibiotic€combination,€he€felt€he€was€in€aÏminority€and€found€no€fault€with€the€types€ofÏantibiotics€sued€or€the€dosages€administered€by€theÏdefendant,€deeming€them€ð ðsufficient€for€her€stage€ofÏappendicitis.ððÌÌà8 àà8 à€€€€€Dr.€Polk€stated€that€research€indicated€thatÏantibiotics€ð ðdo€a€great€deal€of€good€prior€toÏcontamination,ðð€but€that€they€are€ð ðmeasurably€lessÏeffective€once€contamination€occurs.ðð€€Dr.€PolkÏtestified€that,€in€cases€such€as€the€claimantððs€where€aÏvisual€inspection€of€the€appendix€reveals€noÏperforations€or€gangrene,€his€personal€preference€is€toÏadminister€antibiotics€prior€to€surgery,€and€ð ða€dose€orÏtwoðð€during€the€hours€immediately€following€theÏsurgery.€€However,€Dr.€Polk€advised€that€there€is€aÏgreat€deal€of€medical€evidence€that€a€single€pre„operative€dose€of€antibiotics€is€enough€to€preventÏinfection,€and€that€he€would€not€take€issue€with€aÍphysician€who€chose€not€to€administer€post„operativeÏantibiotics€as€a€matter€of€course€following€the€removalÏof€an€apparently€un„perforated€appendix.€€Dr.€PolkÏopined€that€the€defendant€did€not€deviate€from€theÏstandard€of€care€in€choosing€not€to€administer€post„operative€antibiotics€to€the€claimant€as€a€routineÏcourse€of€action.ÌÌà8 àà8 à€€€€€With€regard€to€post„operative€symptoms,€Dr.€PolkÏtestified€that€physicians€generally€look€to€the€followingÏareas€to€determine€an€appendectomy€patientððsÏprogress:€€(1)€Does€the€patient€feel€better?€€(2)€AreÏhis/her€intestines€working?€(3)€Has€his/her€bodyÏtemperature€declined?€(4)€Has€the€white€blood€cellÏcount€declined?€€Dr.€Polk€stated€that€satisfactoryÏanswers€to€all€four€questions€in€concert€would€lead€aÏphysician€to€determine€that€a€patient€was€doing€OKÏand€that€the€course€of€treatment€should€not€beÏaltered.ÌÌà8 àà8 à€€€€€Dr.€Polk€testified€that,€according€to€the€claimantððsÏmedical€records,€she€was€feeling€better€by€the€date€ofÏrelease€from€her€initial€hospitalization€and€hadÏcommented€to€the€nurses€that€she€wanted€to€goÏhome.€€By€the€date€of€her€discharge,€she€was€walkingÏand€receiving€visitors.€€Her€intestines€were€œworking.€ÏHer›€blood€count€had€returned€to€a€normal€level.€€Dr.ÏPolk€advised€that€he€would€have€felt€some€concernÏthat€the€claimant€ran€a€fever€of€œ101ð$ð›€the€night€beforeÏher€discharge.€€However,€he€stated€that,€since€all€ofÏher€other€symptoms€were€essentially€normal,€he€wouldÏhave€worried€about€her€a€little€bit,€but€would€haveÏkept€her€[in€the€hospital]€for€another€day€or€sent€herÏhome€and€asked€her€to€be€sure€and€call€[him]€if€sheÏhad€any€trouble.€€Additionally,€on€the€date€of€herÏdischarge,€her€temperature€had€dropped€to€œ99.4ð$ð,›Ïwhich€could€be€considered€a€normal€temperature.€€TheÏclaimant€had€received€Tylenol€and€Tylenol€3€(whichÍcontains€codeine€and€is€generally€prescribed€as€a€painÏreliever)€in€the€24„hour€period€prior€to€her€discharge,Ïbut€not€enough,€according€to€Dr.€Polk,€to€haveÏmasked€a€high€fever€or€an€infection.€€Dr.€Polk€testifiedÏthat€her€fever€showed€an€overall€pattern€of€decline,Ïand€that€he€would€not€have€administered€furtherÏantibiotics€based€on€the€fever€alone.€€He€furtherÏtestified€that€one€more€day€in€the€hospital€might€haveÏresulted€in€an€earlier€diagnosis€of€the€wound€infection,Ïbut€would€not€have€prevented€the€infection,€nor€wouldÏit€have€altered€the€eventual€treatment€of€the€infectionÏ(in€other€words,€if€the€wound€infection€had€beenÏdiscovered€prior€to€her€release€from€the€hospital,€theÏtreatment€of€the€wound€infection€at€that€time€wouldÏhave€been€the€same€as€the€treatment€she€receivedÏduring€her€second€hospitalization).ÌÌà8 àà8 à€€€€€With€regard€to€the€issue€of€the€claimantððs€obesityÏand€the€additional€risk€it€posed,€Dr.€Polk€testifiedÏthat€there€is€arguable€data€on€the€impact€of€obesityÏwith€operative€wound€infections.€€He€stated€that€mostÏphysicians€believe€obesity€makes€one€more€prone€toÏinfection.€€Nevertheless,€Dr.€Polk€advised€that€theÏclaimantððs€obesity€would€not€have€prompted€him€toÏorder€post„operative€antibiotics.€€He€stated€that€whenÏclosing€the€surgical€wound,€he€might€have€used€anÏantibiotic€spray,€but€added€that€the€data€on€theÏeffectiveness€of€such€sprays€is€ð ðshaky,ðð€and€that€theÏUT€surgeon€could€not€be€faulted€for€not€œusing›€anÏantibiotic€spray.ÌÌà8 àà8 à€€€€€With€regard€to€the€red€streak€noted€by€NurseÏAnderson,€Dr.€Polk€stated€that€he€would€haveÏð ðworried€about€itðð€and€would€have€ð ðwondered€what€itÏwas.ðð€€He€testified€that€redness€around€surgical€staplesÏis€common,€but€a€red€streak€would€be€unusual.€€HeÏadvised€that€he€would€have€examined€the€wound,Ïhimself,€and€if€he€had€seen€nothing€unusual,€he€wouldÍhave€discharged€the€claimant€with€instructions€to€callÏhim€or€return€to€the€hospital€if€trouble€arose.€€HeÏtestified€that€he€would€not€have€administeredÏantibiotics€based€upon€the€nurseððs€observation.ÌÌà8 àà8 à€€€€€Finally,€with€regard€to€the€pathology€report€thatÏthe€appendix€was€microscopically€perforated€and€thatÏthe€fluid€specimen€had€cultured€e„coli€bacteria,€Dr.ÏPolk€testified€that€neither€of€these€findings€wouldÏhave€prompted€him€to€administer€additionalÏantibiotics.€€He€stated€that€by€the€time€the€laboratoryÏfindings€were€received,€the€claimantððs€recovery€seemedÏto€be€progressing€in€a€satisfactory€manner,€all€thingsÏconsidered.€€She€had€received€no€post„surgicalÏantibiotics€which€might€have€obscured€a€brewingÏinfection.€€Based€on€her€condition€at€the€time€of€herÏdischarge€on€the€fourth€post„operative€day,€hisÏopinion€would€have€been€that€the€pre„operativeÏantibiotics€had€successfully€eliminated€what€few€e„coliÏbacteria€had€escaped€from€the€appendix,€and€thus€heÏwould€have€released€the€claimant€with€instructions€toÏcall€him€should€any€troublesome€symptoms€arise.ÌÌà8 àà8 à€€€€€It€must€also€be€noted€that€many€of€Dr.€PolkððsÏopinions€were€supported€in€the€excerpt€from€theÏTextbook€of€Surgery,€filed€as€Exhibit€12.× ƒ2 ××  ×ÌÌà8 àà8 à€€€€€In€summary,€Dr.€Koonce€opined€that€the€UTÏphysicians€erred€in€(1)€failing€to€administer€post„operative€antibiotics€as€a€prevention€against€infection,Ïespecially€in€light€of€her€obesity,€(2)€failing€toÏadminister€post„operative€antibiotics€in€response€toÏher€symptoms€of€an€elevated€œbody›€temperature€andÏredness€at€the€incision€site,€and€(3)€failing€toÏadminister€post„operative€antibiotics€in€response€toÏthe€pathology€laboratoryððs€finding€of€e„coli€bacteria€inÏthe€fluid€specimen€and€microscopic€perforations€ofÏthe€appendix.ÌÌà8 àà8 à€€€€€Dr.€Polk€opined€that€the€treatment€given€to€theÏclaimant€by€UT€physicians€met€the€recognizedÏstandard€of€acceptable€professional€practice.€€HeÏdeemed€pre„operative€antibiotics€a€necessity,€butÏbelieved€that€post„operative€antibiotics€are€optional,Ïdepending€upon€the€patientððs€condition.€€According€toÏDr.€Polk,€he€saw€nothing€in€the€claimantððs€medicalÏrecords€which€would€have€caused€him€to€recommendÏadditional€antibiotics€or€to€alter€the€course€of€theÏtreatment€ordered€by€the€UT€physicians.€€Further,€Dr.ÏPolk€opined€that€the€treatment€given€to€the€claimantÏupon€her€return€to€the€hospital€was€the€correctÏtreatment€and€was€the€same€treatment€she€would€haveÏreceived€if€the€infection€had€been€discovered€duringÏher€first€hospitalization.€€€€€€Ìà8 àÌÓ©Óœ›à àœAfter€considering€the€evidence€presented,€the›€Commissioner€found€thatÏDr.€Polkððs€testimony€was€ð ðmore€compelling€than€Dr.€Koonceððs€testimony.ðð€€TheÏCommissioner€expressly€found€that€Dr.€Polkððs€credentials€were€superior€to€thoseÏof€Dr.€Koonce.€€In€addition,€the€Commissioner€stated:ÌÓÔÓœ›à8 àà8 àà àDr.€Koonceððs€testimony€cannot€be€given€asÏmuch€credence€as€Dr.€Polkððs€for€several€factualÏreasons.€€Dr.€Koonce€opined€that€the€claimant€shouldÏhave€received€post„operative€antibiotics€in€response€toÏher€symptoms€of€an€elevated€body€temperature€andÏredness€at€the€incision€site.€€With€regard€to€redness€atÏthe€incision€site,€he€especially€stressed€that€nurseÏMary€Andersonððs€note€of€May€19th€describing€theÏclaimantððs€surgical€wound€as€ð ðred€hot€with€[a]€redÏstreak€up€to€the€umbilicusðð€should€have€alerted€theÏUT€physicians€to€the€presence€of€infection€in€theÏclaimantððs€surgical€wound.€€Ms.€Andersonððs€note€is€theÏonly€indication€in€the€medical€records€that€the€staplesÏat€the€incision€site€were€red€or€that€the€claimant€hadÍa€red€streak€on€her€abdomen.€€After€nurse€AndersonððsÏobservation,€the€incision€was€examined€at€variousÏtimes€by€other€nurses€and€doctors,€with€the€followingÏnotes:€ð ð[N]o€evidence€of€drainage€or€puffiness,ðð€ð ðskinÏwarm,€dry,ðð€ð ðintact€and€dryðð€and€ð ðwound€lookedÏgood.ððÌÌà8 àà8 àà àDr.€Kenna€Williams€testified€that€she€receivedÏnurse€Andersonððs€message€concerning€the€red€streaksÏat€the€claimantððs€incision,€and€that€she€examined€theÏincision€on€May€19th€and€May€20th,€prior€to€theÏclaimantððs€discharge.€€According€to€Dr.€Williams,€theÏwound€appeared€to€be€a€normal€surgical€wound,€withÏno€signs€of€excessive€redness€or€fever.€€She€saw€no€redÏstreak€on€the€claimantððs€abdomen,€and€does€not€knowÏwhat€nurse€Anderson€may€have€seen,€with€the€possibleÏexception€of€a€stretch€mark,€or€a€mark€left€by€theÏsurgical€tape€which€had€held€the€dressing€in€place.€ÏAlso,€Dr.€Polk€testified€that€he€had€never€seen€a€streakÏas€described€by€nurse€Anderson.€€There€was€no€redÏstreak€at€the€incision€when€the€claimant€returned€toÏthe€hospital€on€May€25.€€It€must€be€concluded€thatÏthis€red€streak€was€not€an€indicator€of€infection€in€theÏsurgical€wound.ÌÌà8 àà8 àà àWith€regard€to€the€finding€of€e„coli€bacteria€inÏthe€fluid€specimen,€as€set€out€above,€Dr.€KoonceÏincorrectly€believed€that€the€fluid€specimen€wasÏobtained€and€analyzed€post„surgically€by€Bryan€WoodsÏwhen,€in€fact,€the€specimen€was€obtained€during€theÏsurgery€and€was€analyzed€by€the€pathology€laboratory.ÌÌÓ©ÓœConsequently,›€the€Claims€Commission€found€that€the€œUT€physicians›€adhered€toÏthe€standard€of€care€in€their€treatment€of€œPierce€and€dismissed€the€claim.Ìà àThis€is€a€direct€appeal€from€the€Tennessee€Claims€Commission€and€isÍgoverned€by€Tennessee€Rules€of€Appellate€Procedure,€T.C.A.€ðð€9„8„403€(a)(1)Ï(Supp.€1997).€€Since€this€is€a€nonjury€case,€it€is€reviewed€ò òòòde€novoó óóó€upon€theÏrecord€with€a€presumption€of€correctness€of€the€Commissionerððs€findings€ofÏfact.€€T.R.A.P.€13(d),€ò òòòSanders€v.€Stateó óóó,€783€S.W.2d€948,€951€(Tenn.€App.€1989).›Ìœà àThe€sole€issue€on€appeal€is€whether€the€evidence€preponderates€againstÏthe€Claims€Commissionerððs€finding€that€the€claimant›€failed€to€show€that€theÏState€employees€did€not€conform€to€the€standard€of€care.€€œÌà àA€plaintiff€in€a€medical€malpractice€suit€carries€the€burden€of€proving€theÏfollowing:€€ÌÓÔÓà8 àà8 à(1)€The€recognized€standard€of€acceptable€professionalÏpractice€in€the€profession€and€the€specialty€thereof,€ifÏany,€that€the€defendant€practices€in€the€community€inÏwhich€he€practices€or€in€a€similar€community€at€theÏtime€the€alleged€injury€or€wrongful€action€occurred;ÌÌà8 àà8 à(2)€That€the€defendant€acted€with€less€than€or€failedÏto€act€with€ordinary€and€reasonable€care€inÏaccordance€with€such€standard;€€andÌÌà8 àà8 à(3)€As€a€proximate€result€of€the€defendant's€negligentÏact€or€omission,€the€plaintiff€suffered€injuries€whichÏwould€not€otherwise€have€occurred.€€ÌÌÓ©ÓT.C.A.€ðð€29„26„115€(a)€(1980).Ìà àPierce€contends€that€she€satisfied€her€burden€of€proof€in€the€instant€case.€ÏPierce€notes€that€her€expert€witness,€Dr.€Koonce,€opined€that€the€UT€physicians›Ídid€not€comply€with€the€standard€of€care.€€In€addition,€Pierce€stresses€that€evenÏDr.€Polk,€who€testified€as€an€expert€on€behalf€of€the€State,€stated€that€he€wouldÏhave€treated€Pierce€differently.€€For€instance,€Dr.€Polk€testified€that€he€wouldÏhave€administered€different€antibiotics€prior€to€surgery,€he€œmay›€haveÏadministered€additional€post„operative€antibiotics,€and€he€may€have€sprayed€theÏincision€cite€with€antibiotics.€€Moreover,€Dr.€Polk€stated€that€Pierce€may€haveÏbeen€more€prone€to€an€infection€in€light€of€her€obesity.€€Despite€crediting€Dr.ÏPolk€with€these€opinions,€Pierce,€nevertheless,€disparages€Dr.€Polk€by€labelingÏhim€as€a€practitioner€of€ð ðivory€tower€medicine,ðð× ƒ3 ××  ×€accusing€him€of€primarilyÏteaching€and€supervising€as€opposed€to€actually€practicing€medicine.Ìà àPierce€further€asserts€that€Nurse€Andersonððs€note,€œstating›€that€PierceððsÏincision€area€was€hot€with€a€red€streak,€indicates€that€the€œUT€physicians›€shouldÏhave€been€aware€that€the€area€was€infected.€€Pierce€claims€that€Dr.€WilliamsÏnegligently€failed€to€take€heed€of€the€implications€of€the€note.€€Pierce€alsoÏargues€that€the€œUT€physicians›€were€negligent€for€failing€to€react€to€theÏlaboratory€reports€that€demonstrated€the€presence€of€E.€Coli€in€the€wound€area.Ìà àWhen€the€resolution€of€the€issues€in€a€case€depends€upon€the€œcredibilityÏof›€witnesses,€the€trial€judge€who€has€the€opportunity€to€observe€the€witnesses€inÍtheir€manner€and€demeanor€while€testifying€is€in€a€far€better€position€than€thisÏCourt€to€decide€those€issues.€€ò òòòMcCaleb€v.€Saturn€Corp.ó óóó,€910€S.W.2d€412,€415Ï(Tenn.€1995);òòò ò€Whitaker€v.€Whitakeróóó ó,€957€S.W.2d€834,€837€(Tenn.€App.€1997).€ÏThe€weight,€faith,€and€credit€to€be€given€to€any€witnessððs€testimony€lies€in€theÏfirst€instance€with€the€trier€of€fact,€and€the€credibility€accorded€will€be€givenÏgreat€weight€by€the€appellate€court.€€òòò òIdó óóó.;€ò òòòIn€re€Estate€of€Walton€v.€Youngó óóó,€950ÏS.W.2d€956,€959€(Tenn.€1997).Ìà àAfter€a€review€of€the€record,€we€conclude€that€the€Commissioner€did€notÏerr€in€finding€that€the€Stateððs€expert,€Dr.€Polk,€was€a€more€credible€witness€thanÏPierceððs€expert,€Dr.€Koonce.€€It€appears€that€Dr.€Polk€retained€a€higher€level€ofÏexpertise€on€the€subject€matter€based€on€his€credentials.€€Pierce€takes€issueÏwith€œDr.›€œPolkððs€testimony›€that€the€œUT€physicians›€adhered€to€the€standard€ofÏcare€œwhile,›€nevertheless,€œstating€that›€he€personally€may€have€administeredÏœadditional›€precautionary€treatment.€€This€assertion€has€no€merit.€€As€an€expertÏwitness,€Dr.€Polk€fulfilled€his€role€of€characterizing€the€ð ðrecognized€standard€ofÏprofessional€practiceðð€in€the€community€or€similar€community.€€T.C.A.€ðð€29„26„115€(a)(1).€€The€fact€that€Dr.€Polk€may€have€administered€additional€antibioticÏtreatment€simply€means€that€he€would€have€acted€ò òòòbeyondó óóó€the€standard€of€care.€Ïò òòòLewis€v.€Hilló óóó,€770€S.W.2d€751,€754€(Tenn.€App.€1988)€(ð ðThe€testimony€of€aÍphysician€as€to€what€he€would€do€or€his€opinion€of€what€should€have€been€doneÏdoes€not€prove€the€statutory€standard€of€medical€practice.ðð)Ìà àBased€on€the€great€weight€of€evidence€presented€before€the€Commission,ÏPierceððs€post„operative€condition€appeared€to€be€within€normal€limits.€€NurseÏAndersonððs€note,€mentioning€that€Pierceððs€incision€area€was€ð ðred€hot€with€[a]Ïred€streak€up€the€umbilicus,ðð€appears€to€be€an€anomaly.€€None€of€the€otherÏhealth€care€professionals€who€examined€Pierce€during€the€period€of€time€inÏwhich€this€notation€was€made€observed€these€symptoms.€€Dr.€Polk€testified€thatÏthere€was€no€cause€for€concern€since€the€practitioners€who€examined€the€woundÏarea€several€hours€after€the€notation€was€made€and€repeatedly€the€next€day€didÏnot€notice€any€complications.€€In€his€deposition,€Dr.€Polk€stated:ÌÓÔÓœ›à8 àà8 àI€donððt€mean€to€downgrade€the€value€of€the€nurseððsÏnotes€in€there,€but€if€somebody€looked€after€that€andÏsaid€it€was€okay€and€thought€it€was€all€right,€then€„„ÏIððd€have€to€accept€that€as€sort€of€countermanding€herÏor€overruling€the€other€observation.ÌÌÓ©ÓœMoreover,›€Dr.€Howell€testified€that€infections€are€indicated€by€red€streaksÏrunning€from€the€wound€area€to€an€area€of€lymph€nodes.€€The€lymph€nodes€thatÏdrain€the€abdominal€area€are€located€in€the€groin€region€and€ò òòònotó óóó€the€areaÏaround€the€umbilicus.€€Thus,€any€visible€red€streak€that€ran€from€PierceððsÏincision€site€to€her€umbilicus€would€likely€not€be€indicative€of€an€infection.Ìà àPierce€also€failed€to€show€that€the€physicians€should€have€administeredÏadditional€antibiotics€in€light€of€the€laboratory€report€that€indicatedÏmicroscopic€perforations€of€the€appendix.€€Dr.€Howell€testified€that€at€the€timeÏof€the€appendectomy€on€May€16,€the€appendix€did€not€appear€to€be€perforated.€ÏThe€perforations€were€not€discovered€by€the€physicians€until€the€pathologyÏreport€was€released€on€May€19.€€The€culture€of€the€fluid€sample€extracted€fromÏPierceððs€incision€site€did€not€grow€any€organisms€until€ð ða€few€e„coliðð€wereÏobserved€on€May€19.€Since€these€E„coli€were€sensitive€to€the€pre„operativeÏantibiotics€and€since€Pierceððs€post„operative€condition€appeared€to€be€normal,ÏDr.€Polk€testified€that€it€was€reasonable€for€the€physicians€to€conclude€that€anyÏE„coli€that€may€have€passed€through€the€microscopic€perforations€in€theÏappendix€were€destroyed€by€the€pre„operatively€administered€antibiotics.€€Thus,ÏDr.€Polk€stated€that€the€presence€of€a€few€bacteria€would€not€necessitate€theÏadministration€of€additional€antibiotics.Ìà àSignificantly,€Dr.€Polk€also€testified€that€signs€of€an€infection€discoveredÏa€few€days€after€the€operation€would€not€necessarily€warrant€the€imposition€ofÏadditional€antibiotic€treatment.€€Noting€the€potential€for€dangerous€side€effects,ÏDr.€Polk€stated:ÌÓÔÓœ›à8 àà8 àWhen€you€come€on€after€the€fact,€they€[antibiotics]Ïare€measurably€less€effective,€and€often€then€only€leadÍto€what€we€call€superinfection,€the€development€ofÏinfection€by€organisms€that€are€resistant€to€thatÏantibiotic.€€So€I€think€if€you€can€get€them€there€aheadÏof€time,€itððs€wonderful,€but€if€youððre€brewing€anÏinfection,€I€almost€would€never€start€antibiotics€laterÏand€after€the€fact.€€Iððd€rather€let€it€play€its€course.€.€.€.ÌÌÓ©ÓœThus,›€Dr.€Polk€testified€that€the€appropriate€course€of€treatment,€had€PierceððsÏinfection€been€œdiscovered›€during€her€initial€visit,€would€likely€have€been€theÏidentical€treatment€that€was€eventually€administered€when€she€returned€on€MayÏ25,€1988:€€opening€the€incision,€draining€it,€and€cleaning€it.€€€€€Ìà àThe€preponderance€of€the€evidence€supports€the€Commissionerððs€finding.€ÏThe€œjudgment€of€the€Commisson€is€affirmed.€€Costs€on€appeal€are€assessedÏagainst€the€Appellant.ÌÓÔÓà àà àà àà àà àà àà à_________________________________Ìà àà àà àà àà àà àà àò òW.€FRANK€CRAWFORD,€Ìà àà àà àà àà àà àà àPRESIDING€JUDGE,€W.S.ó óÌÌò òCONCUR:ÌÌÌ____________________________________ÌALAN€E.€HIGHERS,€JUDGEó óÌÌò ò____________________________________ÌHOLLY€KIRBY€LILLARD,€JUDGEó óœÔ€Ô