On Dec. 11, 2004, plaintiff Alberto Flores, Jr., 14, was involved in an accident involving an all-terrain vehicle, his right foot and ankle. Alberto also fell in a puddle of water with green film on the top and got dirt in his wound. He treated at the Doctors Hospital emergency room in Perris, where he was diagnosed with multiple abrasions of his right leg, ankle and foot, and a severe ankle sprain. Alberto was told to follow up with his primary care physician, which he did on Dec. 14, 2004. The doctor requested that Alberto have an immediate consultation with an orthopedist or podiatrist. On Dec. 17, 2004, Alberto was seen by John Santoro, D.P.M., a podiatric surgeon, who thought there was a questionable fracture of the third cuneiform. An MRI revealed diffuse bone marrow edema, involving the anterior 50 percent of the talus, mid to anterior aspect of the calcaneus, and subjacent portion of the cuboid. It was also noted that Alberto had soft-tissue swelling over the dorsal aspect of his mid foot, extending distally. Alberto underwent a second MRI on Dec. 20, 2004, which showed a non-displaced fracture at the proximal metaphyseal-diaphyseal junction of the second metatarsal, a diffuse nonspecific bone marrow edema involving the second through fifth metatarsals, a mild to moderate bone marrow edema of the second and third cuneiforms, and a cuboid without evidence of a frank fracture, and an intact tarsometatarsal articulation. Santoro subsequently admitted Alberto to Ranch Springs Medical Center for local wound care and antibiotics. On Dec. 21, 2004, Dr. Thuan Le, a consulting infectious disease specialist, saw Alberto and noted in his initial consultation that the patient had an abrasion over the dorsum of his ankle that had an exudative discharge. He also noted Alberto’s very necrotic, soft and fluctuant lesion on his lateral malleolus, which was also odorous. As a result, Le recommended antibiotics and surgical debridement. Two days later, Santoro performed the surgical debridement on all necrotic tissue. He also did another surgical debridement the following day, and a third debridement on Dec. 26, 2004. On the day of the third procedure, a culture taken during the second debridement was reported to show evidence of a fungal infection, so Le started Alberto on Ambisome, a broad-spectrum antifungal agent. The Ambisome was briefly discontinued between Jan. 2, and Jan. 4, 2005, due to Alberto developing a renal toxicity, and was then restarted at a lower dose. Le then used several different antibiotics at different times to treat Alberto’s bacterial infections, which included an Enterobacter cloacae infection. On Jan. 3, 2005, Alberto underwent another MRI, which showed inflammatory changes of the anterior talus and calcaneus, suspicious for osteomyelitis. Two days later, Santoro performed a fourth debridement and explored the bone for infection. After Santoro claimed he found no infectious invasion of bone, Alberto was discharged from Rancho Springs on Jan. 7, 2005, but was instructed to continue his Ambisome treatment at Le’s infusion center on a daily basis and treat with hyperbaric oxygen as an outpatient. On Feb. 8, 2005, Alberto developed hypokalemia and profound nausea as a result of the infusions. Le tried to readmit Alberto to the hospital, but his mother refused. Alberto returned to the hospital the following day and his hypokalemia was reversed. On Feb. 10, 2005, Santoro performed an aspiration of Alberto’s right ankle joint. Alberto was then discharged on Feb. 14, 2005, and continued to treat with Le until March 13, 2005. Dr. William Bunnell, an orthopedic surgeon, later evaluated Alberto on March 10, 2005. He noted that Alberto had significant swelling around the right foot and ankle. As a result, Bunnell ordered X-rays, which showed evidence of talar dome avascular necrosis with an evident talar neck fracture, as well as an evident calcaneal fracture. Thus, Bunnell assessed Alberto with right ankle osteomyelitis of the calcaneus and talus, with avascular necrosis of the talus. Alberto was subsequently admitted to Loma Linda University Medical Center on March 15, 2005, and over the next week, underwent two surgical debridements performed by Bunnell. On March 23, 2005, Alberto underwent a below-the-knee amputation to prevent further complications from the infection, as well as renal compromise. Alberto, through his guardian ad litem, Maria Flores, sued Santoro and Le. He alleged that the doctors failed to properly treat the infection and that this failure constituted medical malpractice. The matter subsequently proceeded to a bench trial. Plaintiff’s counsel contended that during Alberto’s care and treatment with Santoro and Le, what started as a superficial skin infection ultimately ate away Alberto’s Achilles tendon and destroyed the calcaneus and talus, leading to the amputation of his lower right leg. Counsel contended that Santoro knew, or should have known, that the area where Alberto’s ATV crash took place was rife with bacteria and fungus, which would subject Alberto to serious injury. Plaintiff’s counsel further contended that when Santoro performed a primary repair of the wound, he cut-off the route for the infection to escape Alberto’s foot and ankle, thus trapping the infection inside the foot and ankle, which contributed to the subsequent need for the amputation. Plaintiff’s counsel contended that Santoro failed to perform adequate aggressive debridements, claiming there should have been a complete debridement of all dead necrotic tissue and bone. Counsel also argued that Santoro should not have completed the debridements until he was satisfied that all the dead tissue and bone were removed. However, counsel noted that Santoro went on vacation on Dec. 27, 2004, without providing surgical coverage for Alberto. Plaintiff’s counsel argued that Le had an obligation to make sure that Santoro knew of the importance of complete and deep removal of necrotic tissue. Counsel contended that Le was concerned about the deterioration of Alberto’s foot on Dec. 31, 2004, and ordered an MRI to be performed on Jan. 1, 2005, but it was not done until Jan. 3. Plaintiff’s counsel contended that during that time, Le also did not call for an orthopedic or podiatry consult. In addition, plaintiff’s counsel argued that if the aggressive and complete debridements had been completed, Alberto’s infection would have been eradicated. Counsel further contended that Alberto would have then received a bone graft to those areas of bone that were debrided, which would have preserved his leg and prevented the amputation. Santoro and Le claimed that, at all times, they completely met the standard of care in treating plaintiff’s crush injury, infection and wounds. Santoro claimed that he was appropriately and timely advised by Le that surgery was the key to the infection’s resolution. He alleged that he removed all infected necrotic tissue during the five surgeries he performed on the patient, and appropriately placed drains to allow for the drainage of the infection out of the foot and ankle. Le claimed he timely and appropriately provided Alberto with Ambisome. He also claimed that when the patient developed significant side effects and hypokalemia from the medication, he appropriately readjusted the dose. Defense counsel contended that, as a result of the ATV crash, Alberto suffered a significant crush injury to his foot and ankle, as well as a fracture of the talus bone. Counsel also contended that the fungus and bacteria spread from the skin to the deep tissues and structures of the foot/ankle prior to Alberto first seeing either Santoro or Le. Counsel further contended that Alberto’s talus was dead three days after the accident and that in order to properly treat the infection, the talus had to be removed. Defense counsel argued that as a result of their care and treatment of the patient, Alberto’s fungal infection never spread beyond his foot and ankle. Counsel also argued that amputation was the only way to stop the infection at that point, and contended that there has never been a reported case of traumatic inoculation of the Mucor infection that did not result in an amputation., Alberto was ultimately diagnosed with right ankle osteomyelitis of the calcaneus and talus, with avascular necrosis of the talus. He was subsequently admitted to Loma Linda University Medical Center, where he underwent two surgical debridements over the next two weeks. On March 23, 2005, Alberto ultimately underwent a below-the-knee amputation to prevent further complications from the infection, as well as renal compromise. Alberto claimed difficulty with ambulation and all physical activities/sports, due to his amputated limb. Thus, he sought recovery of damages, including $375,659 in future medical costs for prosthetic care and replacements, and $250,000 for his past and future pain and suffering. His past medical costs were paid by his insurance. Defense counsel argued that the cost of Alberto’s prosthetic care and replacements was $109,726.