On July 18, 2009, plaintiff John Nigra, 78, a retired banking officer, complained of leg pain following a lumbar spine decompression surgery and asked to speak with his orthopedic surgeon. Nigra was previously found to be positive for chronic lower back pain and, in the recent months, his discomfort began to significantly interfere with his daily functional activities. He had also been diagnosed with an ischemic optic neuropathy and was found to be legally blind, but his visual impairment did not interfere with his ability to live and function independently. On Feb. 7, 2009, Nigra underwent an L4 decompression surgery without any complications by an orthopedic surgeon, Dr. Roy Ashford. The following day, when Nigra got out of bed to ambulate for the first time after the surgery, he was noted to develop atrial fibrillation. Prior to this event, he was without a cardiac history. As a result, Dr. Joseph Bornheimer Jr., the attending cardiologist, and Ashford agreed to place Nigra on Lovenox in order to decrease the likelihood of clot formation and an embolic stroke. On Feb. 10, 2009, Nigra was transferred from the medical surgery floor to the Rehabilitation Unit located on the Glendale Adventist Medical Center campus. At the time of transfer, the orthopedic surgeon documented that Nigra was stable and neurologically intact. Nigra eventually returned to Glendale Adventist Medical Center on July 7, 2009, to undergo the lumbar decompression surgery. Following the procedure, while on the Rehabilitation Unit on July 11, 2009, he began to complain of pain in both legs, which was greater in his left leg than in his right leg. His symptoms did not resolve over the course of the next few days and, on July 13, 2009, he asked to be seen by Ashford. The orthopedic surgeon subsequently ordered a Doppler Ultrasound study, which ruled out the presence of a deep vein thrombosis. He then ordered Nigra to be seen by a pain management physician, who, on July 15, 2009, administered an epidural injection at L4-5 after holding Lovenox for approximately 12 hours. Nigra was then seen by his neurologist following the nerve block, at which time he continued to complain of left leg pain. On July 16, 2009, a CT scan was ordered and completed, which revealed the presence of a fluid collection at L4-5, suggestive of a hematoma versus seroma. Nigra’s left leg pain persisted up to and through Saturday, July 18, 2009, and at times, was reported to be as high as a level 8 out of 10. In addition, Nigra asked again to be seen by his surgeon due to his persistent pain and his desire to discuss the CT scan results with him. The attending nurse subsequently phoned Nigra’s orthopedic surgeon and left a message with his service to report Nigra’s request. Approximately five hours later, the attending nurse placed a second call to Ashford, since he did not respond to the initial call. At that time, she spoke with the on-call surgeon, who advised her that he did not have staff privileges and, therefore, would not be able to come in to see Nigra. The on-call surgeon then recommended that Nigra wait until Monday, July 20, 2009, to be seen by Ashford. The next nurse on duty on July 18, 2009, noted for the first time Nigra’s complaint of left leg weakness. On July 19, 2009, the attending nurse contacted Nigra’s neurologist and reported that the patient wanted to be seen due to his persistent left leg pain. She left a message with the orthopedic surgeon’s answering service, reminding him that Nigra wanted to discuss his symptoms and CT scan study with him. On July 20, 2009, at approximately 9:30 am, a copy of the CT scan result was faxed to the office of Nigra’s orthopedic surgeon at the surgeon’s request. At about 1:15 p.m., the physical therapist treating Nigra reported that Nigra’s feet were numb and he demonstrated weakness in his left foot. This change in condition was reported to Nigra’s neurologist, who ordered a second CT scan and decreased the dose of Lovenox at this time. At approximately 7:40 p.m., the attending nurse reported to the attending physical medicine physician, Dr. Aaron Selzer, that Nigra was too weak to stand to urinate and had numbness in both feet. As a result, an order was issued to place a Foley catheter. At 8:40 p.m., the attending nurse contacted Nigra’s orthopedic surgeon and reported that Nigra was weak, experiencing numbness and was unable to feel the Foley catheter insertion. An MRI scan was ordered and orders were issued to place Nigra on a “nothing by mouth” status in anticipation of an exploratory surgery to be done the next day to evacuate a presumed spinal hematoma. Subsequently, on July 21, 2009, Nigra underwent surgery to evacuate a spinal hematoma and to further decompress the lumbar spine. Nigra remained in the hospital until Sept. 11, 2009, but he never regained full strength in his lower extremities, or regained control of either his bowel or bladder function. Nigra sued Glendale Adventist Medical Center, Ashford, Bornheimer and the attending physical medicine physician, Dr. Aaron Selzer. He alleged that the defendants failed to properly monitor his condition and that the medical center’s nurses failed to timely refer him to his orthopedic surgeon, and that these failures constituted medical malpractice. Ashford and Bornheimer ultimately settled prior to trial for confidential sums, and Selzer was dismissed from the case by way of an unopposed motion for summary judgment. Thus, the matter continued against Glendale Adventist. Plaintiff’s counsel contended that by July 18, 2009, there had been a sufficient enough change in Nigra’s condition, which included progressive left leg pain and an acute onset of left leg weakness, that the nursing staff should have been alerted to the importance of insuring that the patient was seen by his orthopedic surgeon. Counsel also contended that the fact that the nursing staff should have known that there was a “black box” warning for Lovenox when used for patients after undergoing acute spinal surgery should have further heightened their concern. Thus, plaintiff’s counsel argued that the standard of care, under the circumstances, required that the attending nurse on July 18, 2009, go up the chain of command to insure that Nigra’s surgeon was advised of Nigra’s change in condition. In the event his surgeon could not be located, another spinal surgeon needed to be consulted, counsel added. In addition, counsel argued that, in the face of changing neurological status in a patient at risk of an epidural hematoma, the attending nurse should not have given Lovenox without first clearing it with the surgeon or an attending physician. Plaintiff’s counsel also contended that, had the surgeon been advised of Nigra’s status on July 18, 2009, the appropriate imaging studies would have been ordered and surgical intervention would have occurred prior to the onset of bladder impairment. The plaintiff’s nursing expert testified that the nurse attending Nigra on July 18, 2009, fell below the standard of care by failing to go up the chain of command to contact Nigra’s surgeon when there was a change in condition and a request by Nigra to see his surgeon. The expert was also critical of the same nurse for failing to check with the patient’s surgeon or the attending physician before administering Lovenox on July 18, 2009, since she knew or should have known of the “black box” warning that this medication can result in a spinal hematoma in patients with recent spine surgery. The plaintiff’s neurosurgeon opined that the change in Nigra’s condition post-lumbar laminectomy was due to the development of a lumbar epidural hematoma that was compressing the spinal cord and the nerve roots at lumbar levels 4 and 5. The expert added that, in general, the sooner the surgeon evacuates the hematoma, the greater the chances are to prevent permanent nerve damage and that certainly by the time Nigra developed bowel and bladder impairment, it was too late to prevent permanent nerve damage. In addition, the expert asserted that if the nurse had been able to contact the surgeon on July 18, 2009, he would have evacuated the hematoma and prevented the onset of Caudia Equina syndrome, but that Nigra was not seen by the surgeon until July 20, 2009. Glendale Adventist’s counsel argued that the nursing care on July 18, 2009, was reasonable and within the standards of care under the circumstances, and that such care was not a substantial factor in causing the permanent nerve damage that Nigra sustained. The defense’s expert neurosurgeon opined that there was no evidence of a significant change in Nigra’s neurologic condition until the early afternoon of July 20, 2009, when the patient demonstrated objective changes in his lower extremity strength and numbness in his feet. In addition, the expert did not believe that there was any indication to surgically intervene on July 18, 2009, when Nigra requested to see his surgeon and complained of persistent pain and weakness. The defense’s nursing expert opined that the nursing care over the weekend of July 18, 2009, and July 19, 2009, was well within the standard of care. She testified that there was no significant change in Nigra’s neurologic condition on the weekend in question and, therefore, she opined that there was no need for the attending nurse to go up the chain of command and no indication to hold the Lovenox therapy., On July 21, 2009, Nigra underwent surgery to evacuate a spinal hematoma and to further decompress the lumbar spine. Nigra never regained full strength in his lower extremities, or control of either his bowel or bladder function. Plaintiff’s counsel contended that, to a reasonable medical probability, had the hematoma been evacuated prior to the onset of bladder impairment, Nigra would not have suffered any permanent neurologic impairment. Nigra, now 81, claimed that he currently resides in his home, but that his future options include either staying in his home or, if he could not manage, move into an assisted living facility. The plaintiff’s physical medicine and rehabilitation expert examined Nigra on two occasions and testified to his future life care needs in terms of medical care and equipment. She opined that Nigra would need to have skilled nursing help for his bowel and bladder care, an electric wheelchair, home modifications, and ongoing assessments by a urologist, internist and surgeon, as well as physical and occupational therapy. The plaintiff’s expert life care planner prepared a life care plan designed to address Nigra’s future care needs in conjunction with the plaintiff’s physical medicine and rehabilitation expert. The life care plan primarily consisted of the costs for the services required in the future. The plaintiff’s expert economist calculated the present cash value of the cost of Nigra’s future life care needs to be in the range of $995,900 to $1,375,837, depending on the various options for Nigra’s living situation, such as residence versus facility. The defense’s expert neurologist performed a medical examination of Nigra and provided his recommendations for future medical care needs based on his examination findings and review of the medical records. The defense’s expert life care planner, along with the defense’s expert neurologist, developed a life care plan to address all of Nigra’s future medical care needs and assigned a cost to each item. The defense’s expert forensic economist opined that the present value costs for Nigra’s future care needs were in the range of $285,000 to $420,000 depending on where Nigra would reside. The expert also calculated an offset figure based on the costs of care that would have been required due to Nigra’s pre-existing visual impairment.