Julie Ashley Thomas v. Steve Erin Crawford, D.C.

Judgment rendered May 10, 2023.
Application for rehearing may be filed
within the delay allowed by Art. 2166,
La. C.C.P.

No. 55,085-CA

COURT OF APPEAL
SECOND CIRCUIT
STATE OF LOUISIANA

*****

JULIE ASHLEY THOMAS Plaintiff-Appellant

versus

STEVE ERIN CRAWFORD, D.C. Defendant-Appellee

*****

Appealed from the
Fifth Judicial District Court for the
Parish of Franklin, Louisiana
Trial Court No. 45,765B

Honorable Will R. Barham, Judge

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KENNETH ST. PÉ, APLC Counsel for Appellants,
By: Kenneth St. Pé Patrick Thomas,
Julie Ashley Thomas,
Ashley O’Mera Thomas,
Raylee Walker Thomas,
and Rylan Coy Thomas

COWAN LAW FIRM, LLP Counsel for Appellee
By: Thomas Clifton Cowan
Leah T. Therio

*****

Before COX, THOMPSON, and HUNTER, JJ.

THOMPSON, J.

Julie Thomas visited her chiropractor for treatment of a “crick” in her

neck, which was treated with a C-1 Toggle maneuver, a chiropractic

maneuver she had never before received. Immediately after the maneuver,

she suffered the onset of symptoms of a stroke, which included vomiting,

loss of vision, dizziness, and weakness in part of her body. The seriousness

of her symptoms required that she be transported from the chiropractic office

by ambulance to the emergency room at the closest hospital, and ultimately

by helicopter to University Health in Shreveport, where she was diagnosed

with a vertebral artery dissection and stroke. She filed a medical malpractice

claim, and the medical review panel found her chiropractor did not breach

the standard of care. The case proceeded to trial in district court, and

following the presentation of her evidence, the trial judge granted a motion

for directed verdict in favor of the chiropractor, which she now appeals.

Finding that reasonable jurors could have arrived at a contrary conclusion,

we reverse the trial court’s grant of a directed verdict, and remand this

matter for further proceedings.

FACTS AND PROCEDURAL HISTORY

Julie Thomas (“Thomas”) occasionally experienced back or neck pain

over the past several years and would see a Winnsboro, Louisiana

chiropractor, Steve Erin Crawford, D.C. (“Dr. Crawford”), as needed on

those occasions. Thomas was experiencing pain associated with what she

described as a “crick” in her neck and consulted Dr. Crawford on May 4 and

May 5, 2016, for treatment. Those treatments provided limited relief, and

Thomas again returned to Dr. Crawford’s office on May 11, 2016, for

treatment. At the time of this visit, Thomas was a 36-year-old mother of

four, who was in good health and worked as an elementary school teacher.

During this visit, Dr. Crawford explained that he was going to try

something different from the adjustments he had performed on her in the

past. Dr. Crawford performed a chiropractic technique called the C-1

Toggle maneuver. The C-1 Toggle maneuver involved Thomas lying on her

side on a special table equipped with a headrest that could be set to an

appropriate height. As part of the maneuver, the headrest would then drop

down, in conjunction with some force applied very quickly to her neck by

Dr. Crawford, resulting in the adjustment of her C-1 vertebra.

Immediately following Dr. Crawford’s performance of the C-1 Toggle

maneuver, Thomas began experiencing serious symptoms, including

vomiting, dizziness, vision loss, and the inability to control her body,

particularly the right side. As a result of Thomas’ sudden onset of

symptoms, Dr. Crawford contacted Thomas’ mother, who immediately

drove to his office. The record indicates that after Thomas’ mother arrived

and observed her daughter’s condition, she insisted that Thomas required

immediate medical attention. Dr. Crawford’s assistant contacted EMS.

Thomas was transported from Dr. Crawford’s office via ambulance to

Richardson Medical Center in Rayville, Louisiana. From there, Thomas was

airlifted to University Health in Shreveport, where it was determined that

she had suffered a stroke caused by a vertebral artery dissection at the

C-1/C-2 vertebrae level of her neck.

There is a factual dispute between the parties as to the way the C-1

Toggle maneuver was performed. Thomas claims that Dr. Crawford jerked

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her chin toward the ceiling during the maneuver, which caused the

immediate onset of her symptoms. Dr. Crawford claims that he did not jerk

her chin toward the ceiling, and any contact with her chin would have been

confined to positioning her head prior to performing the maneuver.

On February 7, 2018, a medical review panel convened and issued its

opinion, finding that Dr. Crawford did not breach the standard of care. On

March 15, 2018, Thomas filed a medical malpractice action in the district

court, seeking to recover from him for the resulting medical expenses and

damages that resulted from his chiropractic treatment.

On September 3, 2019, Thomas filed a motion to strike the medical

review panel opinion and panel testimony at trial. Thomas’ argument in

favor of striking the panel opinion was that panelist Jason Abshire, D.C.

(“Dr. Abshire”) testified during his January 15, 2019 deposition that he

found no breach of the standard of care by concluding that Dr. Crawford’s

version of events was correct. However, when questioned further regarding

the panel’s final conclusion that Dr. Crawford did not breach the standard of

care, Dr. Abshire admitted that if Thomas’ description of the maneuver was

to be believed, then Dr. Crawford would have in fact breached the standard

of care. Therefore, Thomas contended that the panel made a credibility

determination by choosing to believe Dr. Crawford’s version of events.

Thomas argued that the contradictory accounts of the incident presented a

credibility issue for the jury and asserted that the resolution of the credibility

issue was not appropriate for the medical review panel. As such, the panel

opinion should be struck.

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On October 21, 2019, a hearing was held on Thomas’ motion to strike

the panel opinion and testimony at trial. Ultimately, the parties agreed to

strike the medical review panel opinion, and that it would not be admitted

into evidence at trial. However, the parties agreed that the medical review

panelists would be allowed to testify at trial if they were subpoenaed and

called as witnesses. A stipulation outlining this agreement was entered into

the record.

On June 20, 2022, the jury trial began. Thomas testified at trial

regarding her experience on May 11, 2016, at Dr. Crawford’s office. She

explained that she lay on her left side on the table with a headrest and that

Dr. Crawford stood behind her and placed one hand on her head and one

hand on her chin. She described the force applied by Dr. Crawford and the

movement as “a quick jerk” and that her “chin went toward the ceiling.”

Immediately after the maneuver, Thomas testified that her right arm flopped,

she became so dizzy that she could not see anything, she also immediately

began vomiting, and that the room was spinning. Thomas asked Dr.

Crawford if she was okay; he responded that she was okay, stating that “this

happens sometimes,” and you “just need to go home and sleep it off.”

Thomas testified that Dr. Crawford used a light to check her eyes, and

specifically told her, “you’re not having a stroke.” Thomas described her

body “flopping over,” and she required a chair to be placed against a wall so

she could sit down, propped against the wall, so she would not fall over.

Thomas testified that she believed Dr. Crawford’s assistant called

EMS after her mother arrived at his office and insisted she needed medical

attention. When EMS arrived at his office, Thomas was placed on a stretcher

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because she could not walk. Thomas testified that she has vague memories

of her ambulance ride to Rayville, followed by her helicopter ride to

Shreveport. The record reflects that she spent approximately four days in

the ICU at University Health, and then was moved to a different floor in the

hospital to undergo physical therapy and occupational therapy. Thomas

testified that initially in the hospital, she could not walk and required a

walker and a belt to assist her because she could not lift her right leg. After

seven days at University Health, she was released to go home. She

continued to use a walker and receive assistance from her husband. She

received home health care and had follow-up visits with Dr. Bharat

Guthikonda, her treating neurosurgeon, for several weeks. Thomas testified

that her life drastically changed following the stroke due to the loss of her

independence. Thomas also testified regarding the emotional toll of the

stroke on herself and her family, as well as the physical and cognitive

limitations she still experiences, which she attributes to the stroke.

Dr. Crawford also testified at trial. During his testimony, he admitted

that vertebral artery dissection is one possible result of chiropractic care.

When describing the C-1 Toggle maneuver, Dr. Crawford testified that the

chiropractor applies a quick thrust to the patient’s neck to affect the

adjustment. He testified it “can be a bit of a shock the very first time it’s

done.” He confirmed that use of excessive force in chiropractic

manipulation is a breach of the standard of care, and that lifting the chin is

not proper chiropractic technique and is a breach of the standard of care.

However, Dr. Crawford denied jerking Thomas’ chin toward the ceiling, and

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testified that the only contact he would have made with her chin would be to

position her prior to the maneuver.

Medical review panelist Dr. Jason Abshire’s January 15, 2019

deposition was read into the record at trial. As noted above, Dr. Abshire

testified that he disagreed with Thomas’ account of how Dr. Crawford

performed the C-1 Toggle maneuver. Specifically, Dr. Abshire did not

believe that Dr. Crawford had jerked her chin toward the ceiling. Dr.

Abshire testified that he does not perform the C-1 Toggle maneuver on his

patients, due to personal preference. Dr. Abshire testified that if Thomas’

version of the incident was true – that Dr. Crawford took her chin and jerked

it toward the ceiling – that would constitute a breach of the standard of care.

Dr. Bharat Guthikonda (“Dr. Guthikonda”), a board-certified

neurosurgeon at University Health and professor of neurosurgery at the LSU

School of Medicine in Shreveport, Louisiana was Thomas’ treating

physician at University Health following her stroke. His July 9, 2019

videotaped deposition was presented to the jury at trial, in lieu of his live

testimony. He acknowledged that Thomas’ symptoms began immediately

following her chiropractic treatment with Dr. Crawford: “[…] when she

went to the chiropractor I don’t think she had these symptoms. And then

when she had the chiropractic treatment, I think that’s what started these

symptoms.”

Dr. Guthikonda testified regarding Thomas’ diagnosis of vertebral

artery dissection: “[W]hen we are taught in neurosurgery residency this is

kind of, this exact scenario is kind of a classic example of how someone

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might develop a vertebral artery dissection specifically, is through

chiropractic manipulation.” Additionally, Dr. Guthikonda provided:

I think this is an inherent risk to chiropractic manipulation that I
think, you know, any chiropractor would agree that this would
be a possible risk with their treatment, and I think it’s a rare
occurrence in terms of what we see for this to actually happen.
But I think it’s kind of a known risk for that type of treatment.

Dr. Guthikonda further testified: “I’m not a chiropractor, so their exact

manipulations and things like that, I’m not familiar with. But I think that the

concept of any sort of neck trauma or neck manipulation could cause a

vertebral artery dissection.” Dr. Guthikonda testified that a vertebral artery

dissection is more typically caused by trauma, rather than some underlying

blood vessel issue. In response to a direct question on whether a quick jerk

to the ceiling could cause Thomas’ vertebral artery dissection, Dr.

Guthikonda stated:

I mean, I just am not a chiropractor so it’s kind of hard for me.
I think it could be. I also think it’s probably a maneuver you
could do, you know, without that happening, you know 999 out
of 1,000 times and not have it happen. So I think, again, mild
trauma, big trauma, I think any of those things could probably
cause some arterial injury in you know, an unfortunate
circumstance.

At the conclusion of the presentation of Thomas’ case and her

witnesses, Dr. Crawford moved for a directed verdict. During the arguments

related to the motion for directed verdict, counsel for Dr. Crawford argued

that the testimony presented during Thomas’ case that was related to

causation did not answer the question of whether “there’s medical certainty

that the actions of Dr. Crawford caused these injuries.” Counsel for Dr.

Crawford further argued that Dr. Guthikonda never stated that the

chiropractic treatment caused Thomas’ injuries, more probably than not.

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Prior to issuing his oral ruling on the motion for directed verdict, the

trial judge appeared to be fixated on Dr. Guthikonda’s testimony that in “999

out of 1000 cases,” no injury resulted from a chiropractic manipulation. The

trial judge stated: “[…] the 999 out of a thousand, that’s – please tell me

how I in good conscious [sic] send that to a jury and – and be fair to this

man as well.” When Thomas’ counsel implored the trial judge to send the

case to the jury, the trial judge concluded: “I don’t feel that that would serve

the interest of justice.” The trial judge issued his oral ruling, granting the

directed verdict in favor of Dr. Crawford. This appeal followed.

DISCUSSION

Thomas asserts two assignments of error:

Assignment of Error Number 1: The trial court erred in granting
Defendant’s directed verdict because the testimony of Thomas’ witnesses,
including her treating neurosurgeon, Dr. Guthikonda, established the causal
link between Dr. Crawford’s chiropractic manipulation and her vertebral
artery dissection, and the trial court improperly ignored uncontradicted fact
and expert testimony, and/or alternatively made factual determinations
belonging to the jury.

Assignment of Error Number 2: The trial court erred in reading the medical
review panel opinion to the jury when the parties had stipulated and the
court had ordered that the opinion would not be admissible.

In her first assignment of error, Thomas argues the trial court erred in

granting Dr. Crawford’s directed verdict because the testimony of her

witnesses, including her treating neurosurgeon, established a causal link

between the chiropractic manipulation and her vertebral artery dissection.

Thomas argues that the trial court improperly ignored witness testimony, and

made credibility determinations that belonged to the jury. Thomas asserts

that the issue presented on the trial court’s grant of the motion for directed

verdict is not whether she has proven her case against Dr. Crawford by a

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preponderance of the evidence, but whether, upon reviewing the evidence

submitted, the reviewing court concludes that reasonable people could not

have reached a verdict in favor of Thomas against Dr. Crawford.

A motion for directed verdict is a procedural device available in jury

trials to promote judicial efficiency. La. C.C.P. art. 1810; Gray v. State

Farm Ins. Co., 53,554 (La. App. 2 Cir. 1/13/21), 310 So. 3d 768, writ

denied, 21-00242 (La. 4/7/21), 313 So. 3d 978. The motion is appropriately

made at the close of the evidence offered by the opposing party and should

be granted when, after considering all evidentiary inferences in the light

most favorable to the movant’s opponent, it is clear that the facts and

inferences so overwhelmingly favor a verdict for the movant, that reasonable

jurors could not have arrived at a contrary conclusion. Id. See also, Clifton

v. Coleman, 32,612 (La. App. 2 Cir. 12/23/99), 748 So. 2d 1263, writ

denied, 00-0201 (La. 3/24/00), 758 So. 2d 151. If there is substantial

evidence opposed to the motion, i.e., evidence of such quality and weight

that reasonable and fair-minded jurors in the exercise of impartial judgment

might reach different conclusions, the motion should be denied and the case

submitted to the jury. Gray, supra.

The trial judge is prohibited from making any credibility

determination, but otherwise, he has much discretion in deciding a motion

for directed verdict. Barnes v. Thames, 578 So. 2d 1155 (La. App. 1 Cir.

1991); Vallery v. All American Life Ins. Co., 429 So. 2d 513 (La. App. 3 Cir.

1983). The standards are liberally construed in favor of the nonmoving

party. Gray, supra.

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The standard of review of a trial judge’s granting of a directed verdict

is whether, viewing the evidence submitted, reasonable men could not reach

a contrary verdict. Watson v. Willis-Knighton Med. Ctr., 47,295 (La. App. 2

Cir. 6/20/12), 93 So. 3d 855; Dowles v. Conagra, Inc., 43,074 (La. App. 2

Cir. 3/26/08), 980 So. 2d 180. The appellate court must evaluate the

propriety of a directed verdict in light of the substantive law related to the

claims. Id. Appellate courts review the district court’s granting of a directed

verdict under the de novo standard of review. Hall v. Folger Coffee Co., 03-

1734, p.10 (La. 4/14/04), 874 So. 2d 90, 99.

In a medical malpractice case, the plaintiff bears the burden of

proving a causal relationship between the injury and the accident which

caused the injury. Maranto v. Goodyear Tire & Rubber Co., 94-2603 (La.

2/20/95), 650 So. 2d 757. The burden of proof is by a preponderance of the

evidence. Id. The test for determining the causal relationship is whether the

plaintiff proved through medical testimony that it is more probable than not

that the subsequent injuries were caused by the accident. Id.

After reviewing this record, we find that Dr. Crawford failed to prove

that the facts and inferences so overwhelmingly favor a verdict in his favor,

such that reasonable jurors could not have arrived at a contrary conclusion.

During the trial, Dr. Guthikonda testified that a trauma to the neck can cause

a vertebral artery dissection. The trial judge based his decision to grant a

directed verdict by focusing on Dr. Guthikonda’s testimony that the majority

of chiropractic treatments do not result in any injury to a patient. However,

the additional evidence presented by Thomas’ other witnesses should also be

considered by the factfinder. Thomas herself provided testimony that was

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pertinent to the causation issue. Her testimony contradicted the version of

events provided by Dr. Crawford, creating a genuine factual dispute that

should be resolved by the jury. Additionally, Dr. Abshire provided medical

testimony, admitting that if Thomas’ version of events was to be believed,

then Dr. Crawford’s performance of the C-1 Toggle maneuver did in fact

constitute a breach of the standard of care. Based on the record before us, it

appears the trial court made credibility determinations that are reserved for

the ultimate factfinder. Such credibility determinations are inappropriate

when ruling on a motion for directed verdict.

After considering all evidentiary inferences in the light most favorable

to Thomas, it is not clear from the record that the facts and inferences so

overwhelmingly favor a verdict for Dr. Crawford that reasonable jurors

could not have arrived at a contrary conclusion. We find that the evidence

submitted by Thomas demonstrated that reasonable jurors could have

concluded that Dr. Crawford’s chiropractic treatment was the cause of her

injuries. Accordingly, we reverse the trial court’s judgment granting the

motion for a directed verdict. Because the case should be submitted to the

jury, we remand the case for further proceedings.

Our finding on Thomas’ first assignment of error above pretermits

consideration of her remaining assignment of error.

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CONCLUSION

Considering the foregoing, the trial court’s grant of directed verdict in

favor of Steve Erin Crawford, D.C., is hereby reversed. The case is

remanded for further proceedings. Costs of this appeal are assessed to Steve

Erin Crawford, D.C..

REVERSED; REMANDED.

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