On Oct. 12, 2011, plaintiff Karla Carrillo, 17, a student, was brought by her mother, Norma Carrillo, to Valley Medical Group, in Bakersfield, with complaints of headaches over the prior three days. Karla described her headaches as occurring approximately 15 times per day and lasting approximately 15 to 30 seconds each time. She was seen and evaluated by a licensed physician assistant of approximately 20 years, Carlos Flores, and a student trainee from the physician assistant educational program at Touro University, Alfred Tobias. Karla’s history and exam were initially obtained by Tobias, and a second, independent history and exam were later obtained by Flores. As part of her medical history, it was disclosed that Karla had previously been diagnosed with diabetes earlier in her childhood, but she had not required medication for her diabetes for several years and she reportedly had not been checking her blood sugar for a number of years since her diabetic status had resolved. During the exams at Valley Medical Group, it was determined that Karla’s vital signs were normal in all respects, except for a mild, elevated heart rate of 105. Flores did not consider the heart rate to be significant in the overall picture, and Karla was diagnosed with tension headaches. Karla was discharged and told to take Tylenol and return to the clinic if her headaches worsened and/or became constant. For most of the next 18 days, Karla attended her regular class schedule at Ridgeview High School. On Oct. 30, 2011, Karla complained to her mother at church that she felt badly and was experiencing double vision. The family left church and went to the emergency room of Bakersfield Memorial Hospital, where Karla’s initial physical exam was within normal limits. However, according to the history given by the family at the emergency room, Karla had been experiencing headaches on and off for approximately two weeks and had experienced ongoing headaches and a fever over the past two or three days. They also reported that Karla had been experiencing neck pain and stiffness, light sensitivity, double vision, and sleepiness. The emergency room physician, Dr. Peter Ellis, ordered a CT scan. However, while awaiting the CT scan procedure, Karla severely deteriorated and began demonstrating seizure-like activity. When the CT scan was normal, a lumbar tap was performed, which indicated a brain infection in the nature of meningitis, later determined to be disseminated coccidioidomycosis (Valley Fever), which included vasculitis and resulted in Karla experiencing multiple strokes. An MRI taken at the emergency room, after the CT scan, demonstrated structural damage to Karla’s brain. As a result, she was transferred to Valley Children’s Hospital, in Madera, for a higher level of care. Karla, through her mother, sued Flores; Tobias; the university that was in charge of Tobias’ educational program, Touro University Inc.; Flores’ supervising physician, Dr. Carlos Alvarez; Flores and Alvarez’s employer, Valley Medical Group Inc. (initially sued as “Valley Medical Group and Diabetic Center”); Bakersfield Memorial Hospital; Ellis; and Ellis’ medical group, Pinnacle Emergency Physicians of Bakersfield. Ellis and Bakersfield Memorial Hospital were ultimately dismissed from the case, and Touro University settled out. Thus, the matter went to trial against Flores, Alvarez and Valley Medical Group. Plaintiff’s counsel contended that Karla was misdiagnosed with a tension headache and that because the headache complaints were so unusual and atypical, she should have been referred for some kind of imaging study, a CT scan and MRI, or a referral to an emergency room for the imaging studies. Counsel also contended that if the imaging studies were negative, a lumbar tap should have been performed and that such studies would have resulted in a correct diagnosis of coccidioidal meningitis. Plaintiff’s counsel argued that if the correct diagnosis was obtained sooner, Karla would have obtained immediate treatment, which would have avoided the events of Oct. 30, 2011 and Karla’s profound disabilities associated therewith. The plaintiff’s treating infectious disease specialist, a nationally prominent expert on Valley Fever, opined that the standard of care required the defendants to refer Karla to an emergency room on Oct. 12, 2011. The expert also opined that if the cocci had been diagnosed sooner, fluconazole (an antifungal medication) would have been prescribed and given by Oct. 17, 2011, and avoided the devastating effects of Karla’s strokes that occurred on Oct. 30, 2011. The expert further opined that as a result, Karla would have gone on to live, on a probability basis, what was described as a normal life. Plaintiff’s counsel argued that had a physician been present, rather than Flores, the physician would have recognized that the headache complaints required further work-up. However, the court refused to allow plaintiff’s counsel to argue that California law required a physician to precept a student trainee and that Alvarez had a non-delegable duty to make certain that he was present with reference to any patient seen by Tobias, including Karla. The court also refused to allow plaintiff’s counsel to present evidence that California Law and a contract between the Touro University and Valley Medical Group did not permit Alvarez to delegate to Flores the authority to proctor a student trainee. Defense counsel contended that the standard of care had permitted, for many years, a licensed physician assistant to precept a student trainee. Defense counsel, in a motion in limine, argued that regardless of the statutory and/or regulatory provisions outlining the scope of a physician assistant’s practice, the law did not confer on Karla’s cause of action, including a theory of recovery, premised on statutory violations of that sort. Multiple 402 hearings were held, and Judge David Lampe ruled, in limine, that no expert would be allowed to testify that California law had either been violated or not violated, nor would any expert be allowed to testify that the interpretation of the contract between Touro University either permitted or did not permit the precepting of a student trainee by a licensed physician assistant, as opposed to a physician. Thus, Lampe disallowed any questioning of any witness about either the law or the contract, even for impeachment. Defense counsel contended that Karla had a potentially fatal and lethal version of coccidioidal meningitis as of Oct. 12, 2011, before she even entered the lobby of Valley Medical Group, and that even if a diagnosis had been made and a treatment had been initiated, the outcome would have been the same since fluconazole does not prevent vasculitis, which is why Karla experienced multiple strokes beginning on Oct. 30, 2011. The defense’s infectious disease specialist, who was also a nationally renowned expert on cocci, agreed with the causation position advocated by defense counsel., Karla suffered a brain infection in the nature of meningitis, later determined to be disseminated coccidioidomycosis (Valley Fever), and included vasculitis. As a result, Karla experienced multiple strokes, and an MRI demonstrated structural damage to Karla’s brain. She was ultimately transferred to Valley Children’s Hospital, in Madera, for a higher level of care, and remained hospitalized there until late December 2011. Karla has been unable to speak, move, or eat since Oct. 30, 2011. She was initially described as a patient in a vegetative state, but over the next two years, it was determined that her cognitive level was substantially better than originally thought. However, Karla remains quadriplegic and requires a feeding tube for all of her nutritional needs. She also requires, without dispute, 24-hour per day care from either a registered nurse and/or a licensed vocational nurse. Plaintiff’s counsel contended that Karla was an excellent student and had planned to be the first in her family to go to college. However, counsel contended that Karla now needs 24/7 care for the rest of her life, which has a normal life expectancy of approximately 58 to 61 additional years. The plaintiff’s expert life care planner outlined care needs with a present value of approximately $29 million to $34 million, plus an additional $1.9 million for Karla’s loss of earnings, based on the assumption that Karla would have been a college graduate. Thus, plaintiff’s counsel asked the jury to award Karla $50 million in total damages, including approximately $15 million in general damages for Karla past and future pain and suffering. Defense counsel argued that Karla had a life expectancy of approximately eight to 13 years, based on Karla’s immobility, but agreed that Karla required nursing care on a 24/7 basis. Thus, counsel argued that with a reduced life expectancy, the present value of Karla’s care needs, on a cash basis, was approximately $22 million. Defense counsel cross-examined the plaintiff’s expert life care planner about the application of the Affordable Care Act, relative to the future medical and hospital needs of Karla, but counsel agreed that the Affordable Care Act did not provide for in-home nursing care and/or permanent admission to a skilled nursing facility for the rest of Karla’s life.