Latarsha Creekmore v. MARYVIEW HOSPITAL, No. 10-1183 Defendant-Appellant, and UNITED STATES OF AMERICA

PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
 LATARSHA CREEKMORE,
Plaintiff-Appellee,
v.
MARYVIEW HOSPITAL, No. 10-1183 Defendant-Appellant,
and
UNITED STATES OF AMERICA,
Defendant. 
Appeal from the United States District Court
for the Eastern District of Virginia, at Norfolk.
Henry Coke Morgan, Jr., Senior District Judge.
(2:08-cv-00235-HCM-JEB; 2:09-cv-00057-HCM-FBS)
Argued: September 22, 2011
Decided: December 8, 2011
Before WILKINSON, WYNN, and FLOYD, Circuit Judges.
Affirmed by published opinion. Judge Wynn wrote the opin-
ion, in which Judge Wilkinson and Judge Floyd joined.

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COUNSEL
Brewster Stone Rawls, RAWLS & MCNELIS, PC, Rich-
mond, Virginia, for Appellant. Kim Michelle Crump, Norfolk,
Virginia, for Appellee.
OPINION
WYNN, Circuit Judge:
Plaintiff Latarsha Creekmore sued Defendant Maryview
Hospital ("Maryview"),1 alleging that its negligent care fol-
lowing the Caesarean section delivery of her baby injured her.
After a three-day bench trial, the district court found Mary-
view liable for medical malpractice and entered a judgment
awarding Creekmore nine hundred thousand dollars
($900,000.00) in damages.
Maryview appeals, arguing that the district court abused its
discretion by allowing an obstetrician-gynecologist ("OB-
GYN") to testify as an expert regarding the standard of care
for a nurse’s postpartum monitoring of a high-risk patient
with preeclampsia. Maryview maintains that Creekmore
failed to make her prima facie case for negligence because the
testimony of the OB-GYN did not meet the expert testimony
requirements of Virginia Code § 8.01-581.20. Because neither
the statute nor Virginia case law precludes the expert testi-
mony in question, we find no abuse of discretion and affirm.
1Because Dr. Sidath Jayanetti, the defendant doctor in this case, was a
federal employee "acting within the scope of his office or employment at
the time of the incident out of which the claim arose," the United States
was substituted as the named party defendant. 28 U.S.C. § 2679(d)(1); see
also 42 U.S.C. § 233(c) (providing for the removal of such actions to fed-
eral district court). Although Creekmore settled with the United States
before trial, the district court retained subject matter jurisdiction over the
case on the basis of the supplemental jurisdiction statute, 28 U.S.C.
§ 1367. The appeal before us involves only defendant Maryview.
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I.
On February 25, 2005, Creekmore was admitted to Mary-
view’s Labor and Delivery Unit for the delivery of her fourth
child. She had a history of pregnancy-induced high blood
pressure, known as severe preeclampsia. Around 7:00 p.m.,
Creekmore gave birth to a baby boy via a Caesarean section
("C-section") performed by Dr. Sidath Jayanetti, an OB-GYN.
She was then taken to a recovery room and attached to a
machine that automatically monitored and recorded her blood
pressure and heart rate every ten minutes.
Sandra Sutliff, an obstetrics nurse, was assigned to attend
to Creekmore, who was the only patient in Sutliff’s care for
the night. Dr. Jayanetti gave Sutliff orders to check Creek-
more’s incision site and uterus for bleeding initially every
half-hour and then every hour. Hospital records and testimony
from Creekmore’s partner, Whitt Johnson, indicate that over
the next several hours, Creekmore’s blood pressure and heart
rate were erratic, and that her urine output and general physi-
cal condition declined. According to Dr. Richard Stokes,
Creekmore’s expert OB-GYN, these three symptoms—falling
blood pressure, rising pulse rate, and lack of urine out-
put—are "classic signs of blood loss shock," which can be a
result of excessive bleeding, a significant and well-known risk
to patients with preeclampsia such as Creekmore.
Around midnight, Johnson noticed that Creekmore had
begun to have hot flashes and to sweat; he paged the nurse
twice but got no response. Sutliff checked on Creekmore at
1:00 a.m. and recorded only that she was resting comfortably,
despite readings from the monitors showing low blood pres-
sure and a high heart rate. Over the next hour and a half,
Creekmore’s blood pressure continued to drop, and her heart
rate increased gradually. Johnson paged the nurse again, still
with no answer.
At 2:26 a.m., in response to a significant difference
between Creekmore’s systolic and diastolic arterial blood
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pressures, or pulse pressure, nurse Christine Weber directed
Sutliff to administer a large quantity of intravenous fluid, or
bolus, to raise Creekmore’s low diastolic pressure. However,
less than twenty minutes later, at 2:45 a.m., an alarm on
Creekmore’s monitor sounded when her blood pressure
descended precipitously. Sutliff responded to the alarm and
recorded that Creekmore was clammy and unresponsive,
sweating profusely, and had gone into hypovolemic shock
from low blood volume. Sutliff also noted that Creekmore’s
urine output had dropped dramatically. She administered
another bolus.
Three minutes later, at 2:48 a.m., Weber called Dr. Jaya-
netti to inform him of Creekmore’s blood pressure and urine
output. Another nurse called Dr. Jayanetti again at 3:07 a.m.,
and Sutliff called him at 3:08 a.m. and told him that Creek-
more was unresponsive. On Dr. Jayanetti’s instructions,
Sutliff summoned the house resident, who arrived in Creek-
more’s room at 3:10 a.m. At that point, Johnson recalled
being awoken and asked to move out of the way, as he
watched several people come into the room, move Creekmore
into another bed, and wheel her out. He noticed a significant
amount of blood on Creekmore’s sheets and gown.
Creekmore was transferred to the surgical intensive care
unit at 3:28 a.m. Upon evaluation, it was determined that she
had lost approximately half of her blood volume, causing oxy-
gen deprivation to the brain and a massive stroke. Dr. Stokes
testified that he believed Creekmore had suffered from hemo-
lyses low platelets (HELLP) syndrome, a severe form of pree-
clampsia that can result in a loss of the ability to clot one’s
blood, or disseminated intravascular coagulopathy (DIC).
Creekmore underwent additional surgery as well as transfu-
sions of clotting factors and blood.
As a result of her stroke, Creekmore suffered severe and
painful physical and cognitive impairments that continue to
impact her life today. On February 5, 2009, Creekmore filed
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a complaint against, among others, Maryview, seeking three
million five hundred thousand dollars ($3,500,000). Follow-
ing dismissal of the United States as a party, Creekmore filed
a motion to remand the remaining claims against Maryview
to state court in Virginia. On November 16, 2009, the district
court denied that motion and retained jurisdiction pursuant to
its discretionary authority under 28 U.S.C. § 1367(c), identi-
fying convenience and fairness to the parties and consider-
ations of judicial economy as the key factors in its decision.
The matter proceeded to a bench trial on December 9, 10, and
11, 2009, and the district court entered judgment in favor of
Creekmore on January 10, 2010. Maryview appealed.
II.
On appeal, Maryview contends that the district court should
have barred Dr. Stokes, an OB-GYN, from testifying as an
expert with respect to the standard of care for a nurse’s post-
partum monitoring of a high-risk patient with preeclampsia.
We review the trial court’s determination of this issue for
abuse of discretion. See United States v. Grimmond, 137 F.3d
823, 831 (4th Cir. 1998) ("A district court’s evidentiary rul-
ings are reviewed under the narrow abuse of discretion stan-
dard."); Hinkley v. Koehler, 269 Va. 82, 91, 606 S.E.2d 803,
808 (2005) ("[A]scertaining whether a proffered witness is
qualified to testify as an expert is a determination lying within
the sound discretion of the trial court" that will not be
reversed "‘unless it appears clearly that [the expert] was not
qualified in the field in which he gives evidence.’" (quoting
Swersky v. Higgins, 194 Va. 983, 985, 76 S.E.2d 200, 202
(1953))).
It is worthwhile to point out that because this case was
heard by a federal district court, the Federal Rules of Evi-
dence would generally control the admissibility of expert wit-
ness testimony. See, e.g., Bryte ex rel. Bryte v. Am.
Household, Inc., 429 F.3d 469, 475-76 (4th Cir. 2005) (noting
that in diversity cases, federal evidentiary law governs the
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procedural question of the admissibility of expert testimony,
while state law controls substantive matters concerning the
sufficiency of evidence).
Nevertheless, because the testimony at issue here was
required for a medical malpractice claim under Virginia law,
the sufficiency of its substance to meet plaintiff’s prima facie
case is governed by state law. See Hottle v. Beech Aircraft
Corp., 47 F.3d 106, 110 (4th Cir. 1995) ("[T]here are circum-
stances in which a question of admissibility of evidence is so
intertwined with a state substantive rule that the state rule . . .
will be followed in order to give full effect to the state’s sub-
stantive policy." (internal quotation marks omitted) (quoting
DiAntonio v. Northampton-Accomack Mem’l Hosp., 628 F.2d
287, 291 (4th Cir. 1980))).
Under either the Federal Rules of Evidence or the Virginia
Rules of Evidence, the district court’s decision to allow Dr.
Stokes to testify as an expert was discretionary and is
reviewed as such. Thus, our analysis and conclusion remain
the same regardless of which evidentiary rules control.
In an action for medical malpractice under Virginia law,
the standard of care by which the acts or omissions
are to be judged shall be that degree of skill and dili-
gence practiced by a reasonably prudent practitioner
in the field of practice or specialty in this Common-
wealth, and the testimony of an expert witness, oth-
erwise qualified, as to such standard of care, shall be
admitted.
Va. Code § 8.01-581.20(A) (2010) (emphasis added). A wit-
ness shall be qualified as an expert in the applicable standard
of care
if he demonstrates expert knowledge of the standards
of the defendant’s specialty and of what conduct
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conforms or fails to conform to those standards and
if he has had active clinical practice in either the
defendant’s specialty or a related field of medicine
within one year of the date of the alleged act or
omission forming the basis of the action.
Id. Both requirements—the so-called "knowledge require-
ment" and the "active clinical practice requirement"—must be
satisfied before an expert may testify regarding the standard
of care. Hinkley, 269 Va. at 88, 606 S.E.2d at 806.
The knowledge requirement does not demand an identical
level of education or degree of specialization; rather, it can be
shown by "evidence that the standard of care, as it relates to
the alleged negligent act or treatment, is the same for the prof-
fered expert’s specialty as it is for the defendant doctor’s spe-
cialty." Jackson v. Qureshi, 277 Va. 114, 122, 671 S.E.2d
163, 167 (2009) (citation omitted). Thus, the inquiry focuses
on the expert’s knowledge of, and experience with, the spe-
cific procedure at issue, not on the expert’s professional quali-
fications relative to those of the defendant practitioner.
The active clinical practice requirement likewise concerns
the "‘relevant medical procedure’ at issue in a case" or, more
specifically, the "‘actual performance of the procedures at
issue,’" which "must be read in the context of the actions by
which the defendant is alleged to have deviated from the stan-
dard of care." Hinkley, 269 Va. at 89, 606 S.E.2d at 807
(quoting Wright v. Kaye, 267 Va. 510, 522-23, 593 S.E.2d
307, 313-14 (2004)). The Virginia Supreme Court has stated
that "[o]ne of the purposes of that [active clinical practice]
requirement is to prevent testimony by individuals who do not
provide healthcare services in the same context in which it is
alleged that a defendant deviated from the standard of care."
Hinkley, 269 Va. at 91, 606 S.E.2d at 808.
Taken together, these cases indicate that the Virginia
Supreme Court elevates the substance of an expert’s back-
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ground, knowledge, and practice over a particular title or
form. See, e.g., Jackson, 277 Va. at 126, 671 S.E.2d at 169
(permitting a pediatrician specializing in pediatric infectious
diseases to testify on the standard of care for a pediatrician
specializing in emergency medicine, where the standards for
both pediatricians overlapped as to the relevant procedure);
Hinkley, 269 Va. at 91, 606 S.E.2d at 808 (finding an abuse
of discretion in the admission of expert testimony from a doc-
tor in the same specialty as the defendant doctor because the
purported expert’s teaching and consultation work did not
qualify him to testify concerning the direct care and manage-
ment of a pregnancy); Lloyd v. Kime, 275 Va. 98, 112-13, 654
S.E.2d 563, 571 (2008) (finding a neurologist qualified as an
expert on the standard of care for post-operative evaluation
and treatment because the standard of care is the same in that
setting for neurologists, neurosurgeons, and orthopedists);
Wright, 267 Va. at 522, 593 S.E.2d at 313-14 (rejecting the
defendant doctor’s argument that a witness must have per-
formed the same procedure with the exact same pathology to
be qualified as an expert); Perdieu v. Blackstone Family Prac-
tice Ctr., Inc., 264 Va. 408, 419-20, 568 S.E.2d 703, 709-10
(2002) (focusing on whether the proffered experts had "re-
cently engaged in the actual performance of the procedures at
issue," rather than their titles or prior experience (internal
quotation marks and citation omitted)); Griffett v. Ryan, 247
Va. 465, 472-73, 443 S.E.2d 149, 153-54 (1994) (holding that
an internist was qualified to testify as an expert because the
evidence demonstrated that the standard of care applicable to
the internist did not vary from the standard of care in the
defendant’s specialty, gastroenterology, a subspecialty of
internal medicine).
In this regard, the Virginia Supreme Court’s opinion in
Sami v. Varn, 260 Va. 280, 535 S.E.2d 172 (2000), is particu-
larly instructive. In that case, the trial court had held that an
OB-GYN was not qualified to testify as an expert regarding
the standard of care applicable to two emergency room physi-
cians who had conducted plaintiff’s pelvic examinations. Id.
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at 283, 535 S.E.2d at 173. The Virginia Supreme Court
reversed, holding that to meet the definition of "related field
of medicine," "it is sufficient if in the expert witness’ clinical
practice the expert performs the procedure at issue and the
standard of care for performing the procedure is the same." Id.
at 285, 535 S.E.2d at 175.
Here, the standard of care at issue concerns the postpartum
monitoring of a high-risk patient with preeclampsia. Accord-
ing to the uncontroverted testimony of Creekmore’s expert
Dr. Stokes, the risks inherent to patients with preeclampsia
are well known to both physicians and nurses working in the
field of obstetrics. Even more importantly, Dr. Stokes offered
the following unrebutted testimony:
[T]here is a great deal of things where [doctors and
nurses] overlap, and I do exactly the same things that
nurses do. So while I don’t have an R.N., we take
blood pressures the same way. We take pulses the
same way. We examine uteruses the same way. We
check for bleeding in the bed the same way. So I
have been employed as a physician to do exactly the
same things nurses do.
(Emphasis added.) Dr. Stokes stated that "one of the things a
nurse is supposed to do is to check the patients for signs of
potential bleeding," including her wound, her womb, and her
urine output, which was not done here for six hours.
Dr. Stokes testified that "[t]he failure to appreciate the dras-
tic fall in blood pressure, combined with a rise in pulse and
no urine, classic for blood loss shock, which [Creekmore]
had, was a gross violation of the standard of care." Moreover,
after Creekmore had gone into shock, Dr. Stokes maintained
that "not hav[ing] a doctor appear from 2:45 to 3:10 [a.m.]
was also a gross violation of the care because medicine would
have to be ordered, blood would have to be ordered, and the
nurse cannot do that." Because of Sutliff’s failure to monitor
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Creekmore or to call a doctor to ensure heightened medical
attention and treatment that could have prevented Creek-
more’s going into shock and ultimately suffering a stroke, Dr.
Stokes opined that she "failed to meet the applicable standard
of care for caring for a postpartum, high risk patient."
Maryview maintains that the district court abused its discre-
tion by permitting Dr. Stokes to testify regarding the standard
of care for obstetrical nurses because Dr. Stokes did not have
an active clinical practice in nursing. We disagree. It is undis-
puted that Dr. Stokes regularly performs the procedure at
issue—the postpartum monitoring of high-risk patients with
preeclampsia—and "the standard of care for performing the
procedure is the same." Sami, 260 Va. at 285, 535 S.E.2d at
175. As such, he "provide[s] healthcare services in the same
context in which it is alleged that [the] defendant deviated
from the standard of care," fulfilling the purpose of the active
clinical practice requirement. Hinkley, 269 Va. at 91, 606
S.E.2d at 808.
Because precedent from the Virginia Supreme Court sup-
ports the district court’s ruling in this case, we are unwilling
to conclude that allowing Dr. Stokes to testify as an expert
regarding the applicable standard of care was an abuse of dis-
cretion. See id. (noting that the determination of whether a
proffered witness is qualified to testify as an expert regarding
the applicable standard of care is a question within the sound
discretion of the trial court). Put another way, this record does
not indicate that Dr. Stokes was not qualified under Virginia
law as an expert in the postpartum monitoring of a high-risk
patient with preeclampsia. See id. (stating that the decision to
allow an expert to testify will not be reversed "unless it
appears clearly that [the expert] was not qualified in the field
in which he gives evidence." (emphasis added) (internal quo-
tation marks and citation omitted)).
This approach is also in keeping with our own Court’s rule
not to set aside or reverse a judgment on the grounds that evi-
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dence was erroneously admitted unless justice so requires or
a party’s substantial rights are affected. Fed. R. Civ. P. 61;
Blum v. Cottrell, 276 F.2d 689, 693-94 (4th Cir. 1960) ("[N]o
error in any ruling is a ground for disturbing a judgment
unless refusal to take such action appears to the court incon-
sistent with substantial justice; and the courts of appeals are
directed . . . to give judgment without regard to harmless
errors which do not affect the substantial rights of the par-
ties.").
Here, even if the admission of Dr. Stokes’s expert testi-
mony was an abuse of discretion, Maryview’s failure to move
either for judgment as a matter of law or to strike the evi-
dence, challenging the sufficiency of Creekmore’s case-in-
chief, results in all subsequently admitted evidence being
allowed to establish Creekmore’s prima facie case. See
Kadala v. Amoco Oil Co., 820 F.2d 1355, 1358 (4th Cir.
1987) ("Once a trial court has before it all the evidence neces-
sary to decide a question, the sequential presentation of evi-
dence does not matter."); Perdieu, 264 Va. at 418, 568 S.E.2d
at 709 (noting that a defendant may challenge the sufficiency
of a plaintiff’s case-in-chief with a motion to strike the evi-
dence, which should be granted "only when it is conclusively
apparent that plaintiff has proven no cause of action against
defendant" (internal quotation marks and citations omitted)).
As noted by the district court, Creekmore had a nurse tes-
tify during rebuttal to "pretty much the same" as what Dr.
Stokes said with respect to the standard of care. Thus, taking
a global view of the evidence, Creekmore made out her prima
facie case of negligence even without Dr. Stokes as an expert
in the applicable standard of care.
III.
In sum, Dr. Stokes performs postpartum monitoring of
high-risk patients with preeclampsia, the same procedure in
the same context in which it is alleged that Maryview and its
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nurses deviated from the standard of care. As such, it does not
appear that Dr. Stokes was not qualified to testify as an expert
in the standard of care under Virginia law. Accordingly, we
find no abuse of discretion and affirm the judgment below.
AFFIRMED
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