Jackie Chalfant v. Carolinas Dermatology Group, PA

THE STATE OF SOUTH CAROLINA
In The Court of Appeals

Jackie Eadon Chalfant, Individually and as a Personal
Representative of the Estate of Michael Dallas Chalfant,
Appellant,

v.

Carolinas Dermatology Group, P.A., a South Carolina
Professional Association, and Mark G. Blaskis, M.D.,
Individually, Respondents.

Appellate Case No. 2019-001145

Appeal From Richland County
R. Keith Kelly, Circuit Court Judge

Opinion No. 5977
Heard June 15, 2022 – Filed April 12, 2023

AFFIRMED IN PART, REVERSED IN PART, AND
REMANDED

William T. Geddings, Jr., of Geddings Law Firm, PA, of
Manning, and Michael G. Fink, of Fort Myers, Florida,
both for Appellant.

Brandon Robert Gottschall, of Sweeny Wingate &
Barrow, PA, of Columbia, and Martin S. Driggers, Jr., of
Driggers Law Firm, of Hartsville, both for Respondents.

LOCKEMY, A.J.: In this medical malpractice action, Jackie Eadon Chalfant
(Appellant) appeals the trial court's grant of a directed verdict in favor of Carolinas
Dermatology Group, P.A. (CDG) and Dr. Mark G. Blaskis (collectively,
Respondents). Appellant argues (1) expert witness testimony was unnecessary
because the common knowledge exception applied to Respondents' failure to
provide after-hours contact information and post-operative instructions to her
husband, Michael Dallas Chalfant (Decedent); (2) the record contained conflicting
testimony as to whether Respondents breached the standard of care in providing
post-operative instructions; and (3) expert witness testimony created a question of
fact as to whether the Decedent's tachycardia was a contraindication to performing
surgery on May 12, 2015, without proper cardiac follow-up. We affirm in part,
reverse in part, and remand.

FACTS/PROCEDURAL HISTORY

On March 31, 2015, Dr. Peter J. Stahl, who was Decedent's primary care physician,
referred Decedent to CDG for a consultation regarding skin cancer on his left ear
and forehead. Dr. Stahl indicated that at the time of the visit, Decedent was
seventy-four years old, weighed 103 pounds, and measured five feet, eight inches.
Dr. Stahl also listed Decedent's pulse as 120 beats per minute (bpm) on the referral
form.

On May 12, 2015, Decedent completed a surgery consent form which authorized
Dr. Blaskis to treat the basal cell carcinoma on his left ear and left cheek with
Mohs micrographic surgery. The consent form articulated the risks involved with
surgery, including bleeding, infection, scarring, nerve damage, incomplete
removal, recurrence, and pain. The same day, Dr. Blaskis performed Mohs surgery
on Decedent. Following surgery, the medical report stated: "After a discussion of
the risks of bleeding, scarring, infection, pain, and wound dehiscence, informed
consent was obtained and the defect was referred to Dr. Brett Carlin for repair.
Verbal wound care instructions, with written handout, were given." Dr. Blaskis's
paper discharge instructions instructed a patient to leave the pressure bandage on
for forty-eight hours and to call "(803) 771-7506 ext. 209" with questions.
Unfortunately, Decedent passed away on May 13, 2015. According to Decedent's
death certificate, his primary cause of death was exsanguination and hemorrhage
from his left ear surgical site. The death certificate also listed chronic obstructive
pulmonary disease and coronary artery disease as other significant conditions.

In January 2017, Appellant, individually and as personal representative of
Decedent's estate, filed a complaint against Dr. Blaskis and CDG, alleging medical
malpractice, wrongful death, ordinary negligence, and gross negligence.
At trial in 2019, Appellant testified she remained present with Decedent during the
entirety of his office visit with Dr. Blaskis. She stated Dr. Blaskis never mentioned
the risk of bleeding after surgery and that "[t]he only place [she] saw the word
bleeding at all was on the consent form [Decedent] signed before the surgery."
Appellant denied Dr. Blaskis ever said anything to them about calling 911 or going
to the emergency room (ER) if there was bleeding after surgery. She indicated
they were only told not to remove the pressure bandage on Decedent's ear.

According to Appellant, she and Decedent left Dr. Blaskis's office around 4:00
p.m. She recalled that when they got home from the surgery, Decedent poured
himself a glass of vodka and cranberry juice, which he drank over the course of the
evening. Appellant stated Dr. Blaskis did not advise Decedent to avoid drinking
alcohol or that it would increase the risk of bleeding. She indicated she noticed
"blood oozing from underneath [Decedent's] bandage" around 7:00 p.m. and gave
him some paper towels. Appellant testified she then looked at the post-op
instructions sheet and called the number on the sheet due to her concerns. She
stated she dialed the number and the first prompt said "if this is a true emergency,
hang up, [and] dial 911" but she did not believe the situation was a true emergency.
Appellant explained the next prompt directed her, "if you know your party’s
extension, dial it now," and she entered the extension listed on the instructions
sheet. She testified that because she entered the extension, she did not hear the rest
of the message prompt, as detailed below.
Appellant submitted CDG's after-hours phone message on the date of Decedent's
death as an exhibit. The prompt read:

You have reached Carolinas Dermatology After-Hours.
If this is a true emergency, please hang up now and call
911. If you know your party's extension you may dial it
now. To hear our automated options, press 1. For a
prescription refill or to leave a message to be returned on
the next business day, please press 2. For all other
serious medical concerns, dial 9 now for our answering
service. To hear these options again, press the * key.
Appellant stated she left a message but never received a call back and "assumed
that it must not be an emergency if they didn't immediately call me back."

According to Appellant, as they ate dinner and watched television, Decedent
continued to dab the blood with paper towels. She explained she "suggested that
[they] should go to the [ER] and have it checked out" but Decedent refused to go.
Appellant recalled a conversation with a friend named Bob, and Bob also
suggested they go to the emergency room; however, Decedent refused. Appellant
further indicated that if Dr. Blaskis had said to go to the ER if there was bleeding,
Decedent "would certainly have done what the doctor said."

Appellant testified Decedent changed his shirt before bed because there was blood
on his collar and t-shirt, and she placed a towel over his pillow before they went to
bed. She recalled Decedent awoke at 3:30 a.m., sat on the side of the bed, used his
inhaler, and then laid back down. Appellant stated she heard Decedent get up and
walk to the bathroom around 4:30 a.m., where she found him sitting on the toilet.
According to Appellant, she asked if he was okay, and he requested she bring his
inhaler. She indicated that when she re-entered the bedroom and turned on the
lights, she saw a large amount of coagulated blood on the pillow. Appellant
explained she then heard something fall in the bathroom and returned to find
Decedent slumped against the wall. Appellant testified the paramedics arrived at
5:51 a.m. to transport Decedent to the hospital; unfortunately, medical personnel
were unable to revive him.
On cross-examination, Appellant testified she did not know there were more
prompts on the after-hours message after the prompt to enter a party's extension.
She further acknowledged she never tried to dial the number again.
Dr. Blaskis testified he only provided patients with one page of discharge
instructions after completing surgery because he had been trained to give extensive
verbal post-operative instructions. He maintained, "I've never had a patient in
20,000 patients I've treated, nobody has left my office without . . . having heard
about post[-]op bleeding at least half a dozen times." Dr. Blaskis recalled
Appellant and Decedent "were told extensively to call me if there was bleeding."
He then stated that "the standard of care is . . . verbal instructions are as good as
written."

Dr. Blaskis acknowledged he would have been able to save Decedent if Decedent
had contacted him on the night of surgery. However, Dr. Blaskis further
acknowledged he knew that when patients dialed extension 209, the call would go
to his medical assistant's desk, not an answering service, but if a patient listened to
the entire message prompt, he could reach the answering service. He indicated all
of the doctors and partners of the practice approved the outgoing message and
forms used in this case. Dr. Blaksis further stated another doctor who conducted
Mohs surgery at his practice, Dr. Long Quan, gave patients his cellphone number.
Dr. Blaskis also testified that although Decedent's heartrate was 116 bpm on the
day of surgery, he "felt very comfortable with" Decedent's primary care physician's
assessment and referral for surgery with a heartrate of 120 bpm.
Prior to trial, Respondents completed an interrogatory indicating Debbie Clarke
and Ashley Grant "had the duty or responsibility to establish and implement
polic[]ies, procedures, rules, standing orders and/or protocols which [CDG] had in
place regarding the recognition, management and prevention of post-operative
complications on or about May 12, 2015." However, Clarke later testified she was
not responsible for the forms used with regard to the care given to Decedent.

Dr. Jing Zhang, the president of CDG, also testified at trial that Clarke and Grant—
CDG's practice manager and office manager, respectively—had no medical
training. He explained they were responsible for ensuring "all the policies [were]
fulfilled to the criteria of the law[]" but were not responsible for ensuring the
standard of care. Dr. Zhang indicated that, "For each medical procedure[], it's up
to each individual doctor" and "their training and the medical board
govern[s] . . . what is the standard of care." He further stated CDG's doctors
develop their own forms and materials provided to patients based on different
training and subspecialties.
Dr. Pearon Lang, who was qualified as an expert witness for Respondents, testified
bleeding was a major concern in the first twenty-four hours after surgery, and his
post-op form addressed what to do about bleeding. He indicated that if a surgeon
failed to discuss any unique risks a particular patient presented with based on their
condition, then that failure would fall below the standard of care. According to Dr.
Lang, after reviewing Decedent's complete medical charts and exhibits in the case,
he did not believe Dr. Blaskis breached any standard of care. Dr. Lang indicated
the risks of the procedure were clearly outlined in the consent form Decedent
signed prior to surgery, and it was within the standard of care to give discharge
instructions verbally. He further testified he expected a patient to call 911 or go to
the ER if unable to reach the doctor.

Regarding CDG's after-hours phone message, Dr. Lang acknowledged, "it would
be ideal if [the after-hours phone number] went straight to an answering service,"
but stated if there was "some sort of message system set up so that eventually the
patient will get to the answering service," the message would be acceptable. Dr.
Lang further opined Dr. Blaskis's phone prompt "was a very good
message . . . easy to follow." He recalled the after-hours telephone number at his
office went immediately to an answering service.
Dr. Lang opined Decedent's 116 bpm heartrate on the day of surgery would be
considered tachycardia. When questioned whether tachycardia would be a
contraindication to performing Mohs surgery, Dr. Lang replied, "[Y]ou need to
look at the big picture" and explained Decedent's heartrate at 116 bpm "was
baseline for him." He further opined Decedent was a suitable candidate for Mohs
surgery and it was within the standard of care to proceed when his referral
heartrate showed 120 bpm. Appellant then cross-examined Dr. Lang with his
deposition testimony, in which he stated he would have sent Decedent for an
assessment before performing surgery. Dr. Lang explained he changed his opinion
after reviewing both the referral form and the primary care records from Dr. Stahl,
indicating "the risks [we]re minimal." He explained that although the surgery
could have been postponed for further assessment, it was unnecessary.

Dr. Sean Christensen, who was also qualified as an expert in Mohs surgery and
dermatology, agreed it was within the standard of care to give verbal
post-operative instructions. He further opined that Dr. Blaskis performed
Decedent's Mohs surgery within the standard of care. However, Dr. Christensen
explained that if a doctor failed to discuss with a patient all known risks and
complications of the proposed surgery, then that would fall below the standard of
care. He stated a doctor was also responsible "to tell the patient what to do if they
have any of the potentially expected complications including bleeding . . . ." Dr.
Christensen explained his concern that Dr. Blaskis's discharge instructions did not
adequately educate a patient what to do about bleeding. He stated that although
Dr. Blaskis said he educated Decedent, Dr. Blaskis had not "documented in the
medical record."
Dr. Christensen testified he believed Dr. Blaskis's instructions as to how to get in
touch with his office were inconsistent and confusing. He stated the extension
would not help a patient on the night of surgery "[b]ecause [the message prompt]
clearly says if you know your party's extension, dial it now, and [Dr. Christensen
thought] that most people in that situation would dial it now if they were given an
extension by the surgeon who performed the surgery." He was asked whether
dialing the extension was "common sense," and he replied it was. Dr. Christensen
testified patients were directed immediately to the on-call doctor at his office. He
acknowledged he expected a patient who experienced bleeding like Decedent
would call 911 or go to ER if they could not get in touch with the doctor. Dr.
Christensen opined that stopping Decedent's bleeding would have saved his life.
Dr. Christensen further testified he would have been concerned regarding
Decedent's elevated heartrate and it was unclear whether Dr. Blaskis adequately
assessed the heartrate. However, he acknowledged he may have gone forward
with the Mohs surgery on Decedent after obtaining additional information as to
whether Decedent's heartrate constituted a medically concerning condition.
However, he stated that if a doctor failed to provide his patient with a thorough
examination before surgery, then the doctor's actions would fall below the standard
of care.
Dr. Amy Durso testified she conducted an autopsy on Decedent and explained his
cause of death was blood loss due to hemorrhage from the left ear surgical site with
contributing factors to include "chronic obstructive pulmonary disease, coronary
disease, and adult failure to thrive." Dr. Durso explained Decedent lost enough
blood on the night of his death to fill "two cans of Coke and maybe three."

At the close of Appellant's case, Respondents moved for a directed verdict, arguing
Appellant failed to prove a breach of the standard of care and causation. In
response, Appellant requested to amend her complaint to conform to the evidence
and include the common knowledge exception. Respondents replied the discharge
instructions sheet was prepared and approved by doctors; thus, expert testimony
was necessary to prove a breach of the standard of care.

The trial court denied Appellant's request to amend her complaint and granted
Respondents' motion for a directed verdict, finding there was no evidence upon
which a reasonable jury could conclude the alleged negligent act or omissions from
Dr. Blaskis proximately caused Decedent's death. This appeal followed.
ISSUES ON APPEAL
1. Did the trial court err in granting a directed verdict against Appellant for failure
to establish all elements of medical malpractice claims by expert witness
testimony when the common knowledge exception was applicable because the
evidence introduced at trial established Respondents' failure to provide
Decedent with after-hours contact information and post-surgery instructions?

2. Did the trial court err in granting a directed verdict against Appellant as there
existed conflicting testimony regarding a breach of the standard of care related
to post-surgery instructions?

3. Did the trial court err in granting a directed verdict against Appellant when
conflicting testimony by Respondents' expert witness created a question of fact
regarding a breach as to the standard of care when the Respondents' expert
testified he would not have operated on Decedent because his tachycardia was a
contraindication to performing surgery on May 12, 2015, without proper
cardiac follow-up?

STANDARD OF REVIEW

"A directed verdict should be granted where the evidence raises no issue for the
jury as to the defendant's liability." Guffey v. Columbia/Colleton Reg'l Hosp., Inc.,
364 S.C. 158, 163, 612 S.E.2d 695, 697 (2005). "When reviewing a directed
verdict, [the appellate] court will view the evidence and all reasonable inferences
in the light most favorable to the nonmoving party." Thomas v. Dootson, 377 S.C.
293, 296, 659 S.E.2d 253, 255 (Ct. App. 2008). "This court will reverse the circuit
court's ruling on a directed verdict motion only when there is no evidence to
support the ruling or when the ruling is controlled by an error of law." Turner v.
Med. Univ. of S.C., 430 S.C. 569, 582, 846 S.E.2d 1, 7 (Ct. App. 2020).
LAW/ANALYSIS
I. Common Knowledge Exception

First, we observe Appellant was not required to plead the common knowledge
exception in her complaint because the exception is encompassed as an element of
a medical malpractice claim. See Pederson v. Gould, 288 S.C. 141, 143, 341
S.E.2d 633, 634 (1986) ("In medical malpractice actions, the plaintiff must use
expert testimony to establish both the required standard of care and the defendant's
failure to conform to that standard, unless the subject matter lies within the ambit
of common knowledge and experience, so that no special learning is needed to
evaluate the conduct of the defendant." (emphasis added)).

Second, Appellant argues the trial court erred by granting a directed verdict
because the common knowledge exception was applicable, and the evidence
established Respondents failed to provide Decedent with after-hours contact
information and post-surgery instructions. She asserts that in society today, it is
commonplace to interact with automated telephone prompts and most individuals
will dial the extension when instructed to do so rather than listen to the message in
its entirety. Thus, Appellant contends whether Respondents committed medical
malpractice by providing a discharge form with instructions to dial an extension
lies within the ambit of common knowledge. We disagree.

"[O]ur [s]upreme [c]ourt has held that in any 'area beyond the realm of ordinary lay
knowledge, expert testimony will usually be necessary to establish both the
standard of care and the defendant's departure therefrom.'" Hook v. Rothstein, 281
S.C. 541, 551, 316 S.E.2d 690, 697 (Ct. App. 1984) (quoting Kemmerlin v.
Wingate, 274 S.C. 62, 65, 261 S.E.2d 50, 51 (1979)). "When expert testimony is
not required, the plaintiff must offer evidence that rises above mere speculation or
conjecture." Hickman v. Sexton Dental Clinic, P.A., 295 S.C. 164, 168, 367 S.E.2d
453, 455 (Ct. App. 1988). "The application of the common knowledge exception
in proving negligence in a case involving medical malpractice depends on the
particular facts of the case." Brouwer v. Sisters of Charity Providence Hosps., 409
S.C. 514, 521, 763 S.E.2d 200, 203-04 (2014) (quoting Hickman, 295 S.C. at 168,
367 S.E.2d at 455). "Ultimately, due to the fact-specific nature of the
determination, it is a question that must be left within the discretion of the trial
judge." Babb v. Lee Cty. Landfill SC, LLC, 405 S.C. 129, 154, 747 S.E.2d 468,
481 (2013).

Several courts have addressed the applicability of the common knowledge
exception. Compare Brouwer, 409 S.C. at 522, 763 S.E.2d at 204 (finding that the
"negligent exposure of a patient to latex with a known allergy can result in an
allergic reaction in that patient" was a matter within common knowledge); Green v.
Lilliewood, 272 S.C. 186, 192, 249 S.E.2d 910, 913 (1978) (holding it was a matter
of common knowledge that a tubal ligation renders an intrauterine device or any
other birth control device useless); Dootson, 377 S.C. at 296, 659 S.E.2d at 255
(holding a claim arising from a surgical drill that burns skin on contact falls within
common knowledge or experience of laymen), with Pederson, 288 S.C. at 143, 341
S.E.2d at 634 (finding damage to the ureter during a hysterectomy did not fall in
common knowledge exception); Melton v. Medtronic, Inc., 389 S.C. 641, 665, 698
S.E.2d 886, 899 (Ct. App. 2010) (holding whether something so complex as an
implanted cardioverter defibrillator was operating properly was not common
knowledge); Carver v. Med. Soc’y. of S.C., 286 S.C. 347, 350, 334 S.E.2d 125, 127
(Ct. App. 1985) (explaining that "the use of an electrosurgery machine during
open-heart surgery and the procedures medical personnel should follow when the
machine is in operation are not matters within the ambit of common knowledge or
experience"); Gass v. Haines, 298 S.C. 549, 551, 381 S.E.2d 923, 925 (Ct. App.
1989) (finding the treatment of glass puncture wounds was not in the common
knowledge of a jury).

We hold the trial court properly granted a directed verdict as to the one-page
telephone discharge instructions and the phone prompt because no expert testified
Dr. Blaskis or CDG breached the standard of care. See Babb, 405 S.C. at 154, 747
S.E.2d at 481 ("Ultimately, due to the fact-specific nature of the determination, it is
a question that must be left within the discretion of the trial judge."); Pederson,
288 S.C. at 143, 341 S.E.2d at 634 ("In medical malpractice actions, the plaintiff
must use expert testimony to establish both the required standard of care and the
defendant's failure to conform to that standard, unless the subject matter lies within
the ambit of common knowledge and experience, so that no special learning is
needed to evaluate the conduct of the defendant."). Additionally, we find the
standard of care and breaching the standard of care did not lie within the ambit of
common knowledge. Multiple doctors testified as to their differing uses of
discharge instructions and phone prompt systems, which made the necessity of
expert testimony more likely to aid the jury in determining the standard of care and
a breach of that standard of care. Regarding the discharge instructions, Dr. Zhang
testified CDG's doctors developed their own materials they provided to patients
based on different trainings. As to the phone prompt system, Dr. Quan gave his
patients his cellphone number in case of an emergency, Dr. Lang testified his
office's prompt went directly to an answering service, and Dr. Christensen testified
his after-hour calls were directed immediately to the on-call physician. Thus, we
believe the trial court properly granted a directed verdict on these issues.
II. Breach of Standard of Care and Post-Surgery Instructions
Appellant argues the trial court erred by granting a directed verdict to Respondents
because there existed conflicting testimony regarding the breach of the standard of
care related to post-surgery instructions. She asserts several experts testified that
the standard of care required discussing the risks associated with surgery, including
bleeding, before, during, and after surgery. Appellant contends a question of fact
requiring submission to the jury was created because she testified Dr. Blaskis
failed to provide Decedent with post-operative instructions related to bleeding, in
contradiction to Dr. Blaskis's testimony. She also avers that Dr. Christensen was
not able to testify that Dr. Blaskis breached the standard of care because he could
not definitively state whether Dr. Blaskis gave verbal instructions. Appellant
further argues Dr. Blaskis's actions proximately caused Decedent's death because
experts testified at trial that if Decedent had been able to communicate with Dr.
Blaskis, his bleeding could have been stopped. She contends "circumstantial
evidence that is within the common knowledge of the jury based on the sequence
of events" could also prove proximate cause. We agree.

A plaintiff alleging medical malpractice must provide
evidence showing: (1) the generally recognized and
accepted practices and procedures that would be followed
by the average, competent physician in the defendant's
field of medicine under the same or similar
circumstances, and (2) the defendant departed from the
recognized and generally accepted standards.
Hoard ex rel. Hoard v. Roper Hosp., Inc., 387 S.C. 539, 546, 694 S.E.2d 1, 4
(2010). "Expert testimony is required to establish the duty owed to the patient and
the breach of that duty in medical malpractice claims unless the subject matter of
the claim falls within a layman's common knowledge or experience." Turner, 430
S.C. at 583-84, 846 S.E.2d at 8.
"In a medical malpractice action, the plaintiff must establish proximate cause as
well as the negligence of the physician." Fletcher v. Med. Univ. of S.C., 390 S.C.
458, 462, 702 S.E.2d 372, 374 (Ct. App. 2010) (quoting Guffey, 364 S.C. at 163,
612 S.E.2d at 697). "Generally, expert testimony is required to establish proximate
cause in a medical malpractice case." Bramlette v. Charter-Med.-Columbia, 302
S.C. 68, 72, 393 S.E.2d 914, 916 (1990).

Viewing the facts in the light most favorable to Appellant, we hold the trial court
erred in granting a directed verdict on this issue because it was not within the
court's authority to resolve conflicts in the testimony presented at trial. See
Dootson, 377 S.C. at 296, 659 S.E.2d at 255 ("When reviewing a directed verdict,
[the appellate] court will view the evidence and all reasonable inferences in the
light most favorable to the nonmoving party."); Turner, 430 S.C. at 582, 846
S.E.2d at 7 ("This court will reverse the circuit court's ruling on a directed verdict
motion only when there is no evidence to support the ruling or when the ruling is
controlled by an error of law."). Regarding the standard of care, Dr. Christensen—
a qualified expert—testified a doctor was responsible "to tell the patient what to do
if they have any of the potentially expected complications including bleeding . . . ."
However, as to breaching the duty, Dr. Christensen explained he could not testify
Dr. Blaskis breached his duty because it was unclear whether Dr. Blaskis verbally
explained the possible complications as "[i]t was not documented in the medical
record." Although Dr. Blaskis testified Appellant and Decedent "were told
extensively to call me if there was bleeding," Appellant repeatedly refuted this
testimony. As a result, a conflict in trial testimony existed which required
submission to the jury. See Dootson, 377 S.C. at 297, 659 S.E.2d at 255 ("When
considering directed verdict and JNOV motions, neither the trial court nor the
appellate court has authority to decide credibility issues or to resolve conflicts in
the testimony or evidence." (quoting Welch v. Epstein, 342 S.C. 279, 300, 536
S.E.2d 408, 419 (Ct. App. 2000))).

In Stallings v. Ratliff, 292 S.C. 349, 356 S.E.2d 414 (Ct. App. 1987), Stallings
testified at trial that Dr. Ratliff failed to inform her that there was a risk of a
perforated esophagus prior to obtaining consent to perform an esophagoscopy. Id.
at 353, 356 S.E.2d at 416. However, Dr. Ratliff testified he did inform Stallings
specifically of the risk of sustaining a perforated esophagus. Id. In reversing the
grant of a directed verdict, our court explained, "Based on the expert testimony as
to standard of care, it was assuredly within the competence of the jury to draw the
inference that if [Dr.] Ratliff's testimony was correct there had been no breach of
duty, while if Stallings was correct there had been a breach of duty." Id. at 354,
356 S.E.2d at 417. As such, it presented a simple "question of who was telling the
truth" and "a classic jury issue was presented." Id. Similarly, we hold whether or
not Dr. Blaskis breached the standard of care by failing to educate Decedent
properly was a jury question as to who was telling the truth, Appellant or Dr.
Blaskis. Even though Dr. Christensen could not explicitly testify Dr. Blaskis
breached the standard of care, he did testify it was a doctor's responsibility to give
instructions to the patient regarding bleeding. Moreover, the "breach of duty does
not turn on a ritual incantation of certain magic words by an expert witness." Id. at
353, 356 S.E.2d at 417.

Additionally, there was enough evidence in the record to submit the issue of
proximate cause to the jury. Appellant testified that if Dr. Blaskis had instructed
them to go to the ER if bleeding, Decedent "would certainly have done what the
doctor said." Both Dr. Blaskis and Dr. Christensen testified that if Decedent had
stopped the bleeding, his life would have been saved. Finally, Dr. Durso testified
Decedent's blood loss due to hemorrhage from the left ear surgical site caused his
death. Therefore, a jury could have reasonably inferred a causal connection
between Dr. Blaskis's alleged failure to warn Decedent regarding the risks of
bleeding and his subsequent death by exsanguination. See Lilliewood, 272 S.C. at
191, 249 S.E.2d at 912 ("However, where, as here, [b]oth expert testimony and
circumstantial evidence of a physician's culpability are presented, the inquiry need
only be whether there was sufficient competent evidence from which the jury may
have inferred a causal connection.").

III. Breach of Standard of Care and Tachycardia
Appellant argues the trial court erred by granting a directed verdict because there
was conflicting testimony from Respondents' expert witness resulting in a question
of fact regarding Decedent's tachycardia. She contends that in viewing Dr. Lang's
testimony in the light most favorable to her, she presented sufficient expert
testimony to warrant submission to the jury. We disagree.
We hold the trial court properly granted a directed verdict in favor of Respondents
on this issue because Appellant failed to present expert testimony to establish Dr.
Blaskis breached the duty of care by proceeding with surgery despite Decedent's
tachycardia. See Fletcher, 390 S.C. at 462, 702 S.E.2d at 374 ("On review, an
appellate court will affirm the granting of a directed verdict in favor of the
defendant when there is no evidence on any one element of the alleged cause of
action."); Dawkins v. Union Hosp. Dist., 408 S.C. 171, 176, 758 S.E.2d 501, 504
(2014) (providing expert testimony is required to establish duty and breach of duty
in medical malpractice cases); Brouwer, 409 S.C. at 521, 763 S.E.2d at 203
(finding that to establish an action for medical malpractice, a plaintiff must
establish the "[r]ecognized and generally accepted standards, practices, and
procedures which are exercised by competent physicians in the same branch of
medicine under similar circumstances" (quoting 27 S.C. Jur. Med & Health Prof'ls
§ 10 (2014))).
Here, Dr. Lang testified that after reviewing the complete medical chart from
Decedent's primary care physician, he did not believe Dr. Blaskis breached any
standard of care. He also stated he believed Decedent was a suitable candidate for
Mohs surgery, and it was within the standard of care to proceed when his referral
heart rate was 120 bpm. When cross-examined with his deposition testimony, Dr.
Lang explained he had not previously reviewed Decedent's prior medical records
and, because Decedent's heartrate was normally elevated, the risks of proceeding
with surgery at his baseline heartrate were minimal. Moreover, Dr. Christensen,
Appellant 's own expert witness, failed to testify Dr. Blaskis breached the standard
of care by proceeding with surgery. Thus, there was no conflicting testimony in
the record warranting submission to the jury.

We further find there was no evidence presented Dr. Blaskis proximately caused
Decedent's death by proceeding with surgery despite his tachycardia because all of
the doctors who testified at trial indicated they may have moved forward with
Decedent's surgery with his heartrate at baseline. See Fletcher, 390 S.C. at 463,
702 S.E.2d at 374 (explaining that in a medical malpractice action, "the plaintiff
must present evidence that the defendant's failure to adhere to the standard of care
proximately caused the complained[-]of injury"). Therefore, the trial court did not
err by granting a directed verdict on this issue.

CONCLUSION

Based on the foregoing, we affirm the trial court's granting of a directed verdict on
the issues as to CDG's phone prompt, Dr. Blaksis's one-page discharge
instructions, and proceeding with surgery despite Decedent's tachycardia.
However, we reverse the trial court's grant of a directed verdict on Dr. Blaskis's
post-surgical instructions on bleeding.

AFFIRMED IN PART, REVERSED IN PART, AND REMANDED.
GEATHERS, J., concurs.

HILL, A.J., concurring in a separate opinion:
I concur in the majority opinion but write separately to express my view that the
decedent's inaction in response to his active, extensive bleeding may well have
exceeded the alleged negligence of Dr. Blaskis. But that is a factual issue that we,
except in rare cases, leave to the jury to decide. Bloom v. Ravoira, 339 S.C. 417,
422, 529 S.E.2d 710, 713 (2000). This unfortunate case is almost–but not quite–
such a rarity.