On Aug. 3, 2013, plaintiffs’ decedent Louise Lofton, 42, an elementary school teacher, awoke with pain on the left side of her upper back. After approximately 15 minutes of constant pain, Lofton decided to go to the Sutter Memorial Hospital’s Emergency Department, in Sacramento. Upon arrival, she complained of pain to her upper back and chest, and shortness of breath. She described the chest pain as being dull and in the center of her chest. Lofton underwent a CT scan of the chest, and a radiologist found a dissection distal to the origin of the left subclavian artery with an enlargement of the descending aorta, proximally to 5.4 centimeters. It tapered down to 3.2 centimeters at the mid-descending segment of the aorta. The radiologist also found two dissection flaps, one of which was less prominent within the descending portion, but then became evident in the distal descending thoracic aorta. However, the aorta was not fully evaluated on during that examination. The true lumen appeared to be the lumen between the two flaps. A limited evaluation of the abdominal aorta showed that the celiac axis appeared to be fed off the false lumen. The left renal artery was only seen on one image and appeared to be fed off the false lumen. There were irregularities at the origins of both the celiac axis and the superior mesenteric artery with poor visualization of the distal superior mesenteric artery. As a result, Lofton, who was nine weeks pregnant, was admitted to the intensive care unit. She completed a history and a physical, and it was determined that her upper back pain was accompanied by shortness of breath, diaphoresis, bilateral numbness, chest pressure, and abdominal pain. Her abdominal pain was in the pelvis and she also had a headache. At that time, the assessments were a Type B aortic dissection and accelerated hypertension. Thus, the plan was to place Lofton on a Nipride and Labetalol drip, intravenous fluids, and have cardiovascular and obstetrics/gynecology consultations. A cardiothoracic surgeon, Dr. James Longoria, also saw Lofton for a cardiovascular surgery consultation. Longoria was asked by Dr. Jody Gordon, a hospitalist in the Emergency Department, to evaluate Lofton regarding her aortic dissection. Longoria noted that a CT scan revealed a dissection involving the aorta from the level of the subclavian artery extending distally and that there was “some differential contrast enhancement in the ascending aorta.” The radiologist had confirmed it was a Type B aortic dissection beginning at the level of the subclavian artery extending distally to the celiac artery. A review of the systems was negative with the exception of what was previously noted. As a result, Longoria performed a physical examination and noted that Lofton’s blood pressure was 170/90 and that Lofton had 2+ palpable posterior bilateral tibial and femoral pulses. Longoria’s impressions were a Type B aortic dissection, hypertension, asthma, and nine weeks gestation. Base on his findings, Longoria’s plan was to treat Lofton medically with a beta-blockade and intravenous blood pressure control, including a Labetalol and Nipride drip. As a result, Lofton was to be admitted to the Intensive Care Unit. Given the differential diagnosis, Longoria recommended a repeat CT scan in 24 to 48 hours. At 9 a.m. on Aug. 4, 2013, Longoria saw Lofton for a follow-up visit, during which Lofton reported feeling better. Thus, Longoria’s plan was to have Lofton undergo an additional CT scan the next day. On Aug. 5, 2013, at 8:15 a.m., Longoria saw Lofton again for a follow-up visit, during which Lofton complained of mild pain in her left chest and upper back. Longoria requested to have an obstetrician/gynecologist see Lofton to review her medications. At 10:15 a.m., Lofton underwent a repeat CT scan of her chest and abdomen. Dr. Horacio Murillo, a radiologist, noted that Lofton’s heart size was within normal limits and that there was no pericardial effusion. Murillo found a Type B aortic dissection beginning immediately after the origin in the left subclavian artery without involvement of the cervical branches. He also found that Lofton’s left-sided aortic arch demonstrated a two vessel cervical branching pattern and that the “complex aortic dissection” extended to the right common internal iliac artery bifurcation and into the left proximal hypogastric artery. As a result, Murillo performed a series of aortic measurements and determined that the ascending aorta was 38 x 38 millimeters with the middle of the aortic arch measuring 32 millimeters. The aneurysmal dilatation of the distal arch and proximal descending aorta was found to be 59.4 millimeters, while it was previously 57.5 millimeters, and the descending aorta was found to be 37.5 x 37.7 millimeters, while it was previously 35 x 34.1 millimeters. Murillo noted that the celiac arteries straddled the dissection flaps and were perfused primarily by the pseudo-lumen. He also noted that the celiac artery was widely patent and that the superior mesenteric artery straddled the dissection flap and was primarily perfused by the true lumen with the dissection extending into the superior mesenteric artery, causing marked stenosis of its lumen and its proximal and mid segments. He also noted that the dissection flap extended to the distal subsegmental branch of the superior mesenteric artery and that there was no evidence of visceral ischemia. Murillo further noted that there was non-specific minimal wall thickening of the distal sigmoid colon and rectum and that the inferior mesenteric artery arose from the pseudo-lumen and was widely patent. In addition, he noted that the right renal arteries straddled the dissection plane and appeared to be perfused primarily by the true lumen and that the left renal artery arose entirely from the pseudo-lumen. Thus, Murillo’s impressions were that there was a limited CT angiogram, noted by the absence of a cardiac gating technique; a re-demonstration of a Stanford Type B aortic dissection starting just distal to the left subclavian artery and extending down to the right common internal iliac artery bifurcation and into the left proximal hypogastric artery; a distal arch and proximal ascending aorta aneurysmal dilatation measuring 59.4 millimeters (which was of uncertain significance and may have been related to measurement error/technique and pulsation phase of scanning); no CT angiography evidence of visceral ischemia; ectatic main pulmonary artery; vicarious excretion of I.V. contrast into the gallbladder; and enlarged heterogenous uterus compatible with a history of early pregnancy. Murillo added an addendum, indicating the sagittal anteroposterior diameter of the distal aortic arch was approximately 61 millimeters, but that it was “not significantly changed since the Aug. 3, 2013 examination.” On Aug. 6, 2013, at 7:32 a.m., Longoria saw Lofton for another follow-up visit. Longoria noted that the Aug. 5, 2013 CT scan was “essentially unchanged” from the Aug. 3, 2013 CT scan. As a result, he believed that Lofton “needed better blood pressure control” and requested a pharmacy consultation regarding the use of Hyrdalazine versus Metoprolol. On Aug. 7, 2013, the attending hospitalist saw Lofton, who reported that her headache was better. It was also noted that Lofton “still had significant constipation” and was having “blood pressure control issues.” At the time of the visit, Lofton’s blood pressure was 119/55 and then dropped to 105/70. Her heart rate ranged between 70 and 80 beats per minute. The assessments were: “hypertensive emergency – better;” a stable Stanford Type B aortic dissection; hypokalemia; nine week intrauterine pregnancy; and deep venous thrombosis prophylaxis. As a result, the hospitalist’s plan was for Lofton to remain on medical management of her aortic dissection and undergo potassium replacement. On Aug. 8, 2013, at 7:30 a.m., Longoria once again saw Lofton for a follow-up visit and noted that Lofton’s blood pressure had improved. He also noted that Lofton should undergo a follow-up CT scan in three months. Later that day, Lofton underwent a suction dilation and curettage to terminate the pregnancy and on Aug. 9, 2013, she was discharged from the hospital. Lofton’s discharge diagnoses were an aortic dissection, intrauterine pregnancy, hypertensive urgency, anemia, asthma and hypokalemia. Her discharge medications were Advair, Xopenex, Labetalol, Amlodipine, Hydralazine, Norco, and iron sulfate. It was also noted that Lofton was to follow-up with her primary care physician and vascular surgeon. Two days later, Lofton developed chest pain and was administered one tablet of pain medication. However, shortly after complaining of pain, she collapsed. When the paramedics arrived, Lofton was found to be in asystole, which is a cardiac arrest rhythm that has no discernible electrical activity on the ECG monitor. The paramedics subsequently administered routine advanced cardiac life support and were able to obtain brief pulseless electrical activity, but Lofton returned to asystole. Lofton was then emergently transported to Kaiser Permanente South Sacramento, but the Emergency Department physician was unable to revive her. Lofton’s cause of death was noted to be a massive left hemothorax due to a rupture of the thoracic aorta from an acute aortic dissection and hypertensive cardiovascular disease. The decedent’s husband, David Towey, and her three minor children, Savion Towey, Fragee Lofton IV and Kiara Lofton, sued Longoria; Murillo; Gordon; and the operator of Sutter Memorial Hospital, Sutter Health Sacramento Sierra Region. The decedent’s family alleged that the defendants failed to time treat the decedent’s condition, causing her wrongful death, and that this failure constituted medical malpractice. Gordon settled prior to trial, and Sutter Health was dismissed for a waiver of costs. Thus, the matter continued against Longoria and Murillo only. Plaintiffs’ counsel contended that Longoria was negligent for failing to surgically repair the aortic dissection while in the acute phase during the hospitalization. Counsel also contended that Murillo was negligent for failing to note the size increase of the dissection between the Aug. 3, 2013 and Aug. 5, 2013 CT scans, and for failing to recommend emergency surgery. Defense counsel argued that there was no actual size difference between the two CT scans of the dilatation and that the appropriate course was medical management and to consider operating in the subacute or chronic phase., Louise Lofton developed chest pain on Aug. 10, 2013, and was administered one tablet of pain medication. However, shortly after complaining of pain, she collapsed. Paramedics found that Lofton was in asystole and administered routine advanced cardiac life support. They were eventually able to obtain brief pulseless electrical activity, but Lofton returned to asystole and was emergently transported to Kaiser Permanente South Sacramento. However, the Emergency Department physician was unable to revive Lofton, and she died. Her cause of death was noted to be a massive left hemothorax due to a rupture of the thoracic aorta from an acute aortic dissection and hypertensive cardiovascular disease. The decedent was 42 years old at the time of her death. She was survived by her husband, David Towey; her minor son with David Towey, Savion Towey; her minor son from a prior marriage, Fragee Lofton IV, and her minor daughter from a prior marriage, Kiara Lofton. Thus, David Towey and the children sought recovery of wrongful death damages in excess of $1 million for the loss of the decedent’s financial support.