# Dobbs v. United States

> District Court, E.D. Arkansas · December 5, 2023

URL: https://www.frixlaw.com/law-library/cases/10008345

## Case

- **Court:** District Court, E.D. Arkansas
- **Decided:** December 5, 2023
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/10008345

## How later opinions describe it (automated extraction)

- describing a loss of consortium claim as “derivative” to the claim of the injured party
- explaining that the Arkansas Medical Malpractice Act “implements the traditional tort standard of requiring proof that but for the tortfeasor’s negligence, the plaintiff’s injury or death would not have occurred[]” (internal quotation marks omitted)

## Opinion text

Case 4:20-cv-01192-LPR Document 50 Filed 12/05/23 Page 1 of 107

IN THE UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF ARKANSAS
CENTRAL DIVISION

CRAIG DOBBS and PLAINTIFFS
EILEEN DOBBS

v. Case No.: 4:20-cv-01192-LPR

UNITED STATES OF AMERICA DEFENDANT

MEMORANDUM OF DECISION

On October 7, 2020, Plaintiffs Craig and Eileen Dobbs filed a Complaint against the United

States of America under the Federal Tort Claims Act, alleging that Mr. Dobbs suffered a brain

hemorrhage as a result of negligent medical care by Dr. Diaa Bahgat.1 More specifically, the

Complaint alleges that: (1) during the laminectomy surgery performed by Dr. Bahgat, Mr. Dobbs

suffered a dural tear; and (2) Dr. Bahgat’s subsequent medical treatment of Mr. Dobbs—

particularly the placement of a drain near the dural tear site—was below the standard of care in

Arkansas and caused Mr. Dobbs to suffer a brain hemorrhage.2

The Court held a bench trial from November 29, 2022, through December 2, 2022.3 At

this trial, Plaintiffs pressed their right to monetary relief for the following categories of damages:

(1) Mr. Dobbs’s past and future physical pain and suffering; (2) his past and future mental pain

and anguish; (3) his past and future permanent physical impairment; (4) his past and future mental

impairment; (5) his past and future physical disfigurement; (6) his past and future medical, health

care, and attendant care expenses; (7) his out-of-pocket expenses; (8) his past and future loss of

1
See Compl. (Doc. 1) ¶¶ 6.1–7.2.
2
See id. At trial, the witnesses used the terms “dural tear” and “durotomy” interchangeably. For consistency, the
Court will refer to the tear as a “dural tear.”
3
See Clerk’s Minutes (Docs. 37–39, 41).
Case 4:20-cv-01192-LPR Document 50 Filed 12/05/23 Page 2 of 107

enjoyment of life; (9) the loss of consortium with his wife; and (10) Mrs. Dobbs’s loss of

consortium with her husband.4

After the Plaintiffs rested, the Government made a Motion for Judgment on Partial

Findings under Federal Rule of Civil Procedure 52(c).5 Parts of that Motion were easy to address.

For example, the Government argued that the Plaintiffs had failed to introduce any evidence that

Dr. Bahgat (1) negligently caused the dural tear, and (2) negligently repaired the dural tear.6

Plaintiffs’ counsel effectively conceded the points. She explained that Plaintiffs were not making

a claim that Dr. Bahgat was negligent in making the dural tear.7 She also explained that they were

not alleging that the dural-tear repair itself was negligent, except to the extent that Dr. Bahgat

“negligently left a drain in place in the absence of a complete repair.”8 Accordingly, and without

objection, the Court granted the Government’s Motion for Judgment on Partial Findings on the

two very specific issues raised by the Government.9

Other parts of the Government’s Motion for Judgment on Partial Findings were not so easy.

For example, with respect to Plaintiffs’ claims concerning the placement of a drain, the

Government argued that there had been no evidence to suggest that the use of a drain in the

circumstances of this case fell below the standard of care in Arkansas.10 The Government also

4
See Compl. (Doc. 1) ¶¶ 8.1, 8.2. At the start of the trial, Mr. Dobbs withdrew his claim for loss of earning capacity.
See Tr. of Bench Trial (Doc. 45) at 20:15–20. And Mrs. Dobbs withdrew her claims for negligent infliction of
emotional distress and for loss of household services. See id. at 20:21–21:7.
5
See Tr. of Bench Trial (Doc. 47) at 652:20–22.
6
See id. at 658:7–659:19. The Government made a Motion for Judgment on Partial Findings with respect to a third
issue as well: that there was no evidence Dr. Bahgat had improperly delayed taking Mr. Dobbs for a re-exploration
surgery. See id. But the Government withdrew this part of its Motion when Plaintiffs’ counsel explained that Plaintiffs
were not making any claim for relief related to the delay in the re-exploration surgery. See id. at 662:11–22, 663:6–
15. Instead, this was merely a fact pled, not an independent allegation of wrongdoing. See id.
7
See Tr. of Bench Trial (Doc. 47) at 659:23–24.
8
Compl. (Doc. 1) ¶ 6.12. See also Tr. of Bench Trial (Doc. 47) at 660:3–8.
9
See Tr. of Bench Trial (Doc. 47) at 662:9–10.
10
See Tr. of Bench Trial (Doc. 47) at 654:8–657:7.

2
Case 4:20-cv-01192-LPR Document 50 Filed 12/05/23 Page 3 of 107

argued that there was not enough evidence to prove that the use of the drain was a “but-for” and

proximate cause of the brain hemorrhage.11 The Court denied those parts of the Motion because

the Court had heard evidence that could ultimately lead to the conclusion that Plaintiffs had proved

Dr. Bahgat’s decision to place the drain fell below the standard of care in Arkansas and caused the

injury at issue.12 At the conclusion of the trial, the Government again moved for Judgment on the

Findings on these issues.13 And the Court again denied the Government’s Motion.14

On December 19, 2022, the parties submitted post-trial proposed findings of fact and

conclusions of law. In accordance with Federal Rule of Civil Procedure 52(a), and after reviewing

the entire trial record, the Court makes the following findings of fact and conclusions of law as set

out below. As a threshold matter, however, the Court wishes to note several global points. First,

the Court makes all findings of fact in this case subject to the preponderance-of-the-evidence

standard.15 And Plaintiffs bear the burden of proof with respect to all findings. Second, the Court

notes that sometimes—but not always—it expressly discusses the evidence in the trial record that

is contrary to the Court’s ultimate finding. Whether or not the Court expressly discusses

conflicting or contrary evidence, the Court’s findings should be taken to imply that any such

conflicting evidence was overcome by the evidence supporting the particular fact found. Third, to

the extent the Court has erroneously designated any findings of fact as conclusions of law, they

11
See id.
12
See id. at 657:8–10.
13
See Tr. of Bench Trial (Doc. 48) at 885:6–11.
14
See id. at 885:17–18.
15
Although the Court may not always expressly state it, all medical opinions were given to a reasonable degree of
medical certainty. The terms “certainty” and “probability” were used interchangeably at trial, but either term is
appropriate and sufficient under Arkansas law. See Williamson v. Elrod, 348 Ark. 307, 311, 72 S.W.3d 489, 492
(2002).

3
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should be deemed findings of fact.16 And any conclusions of law erroneously designated by the

Court as findings of fact shall be likewise deemed conclusions of law.17 Fourth, and finally, some

of the findings of fact (and maybe conclusions of law) in the liability section are relevant to the

issue of damages as well. The particular section of this Memorandum of Decision in which a

finding is made, or conclusion is drawn, does not affect the substance of this Memorandum of

Decision.

FINDINGS OF FACT – LIABILITY

1. During the bench trial, 11 witnesses provided testimony. Plaintiffs called

Dr. Christopher Taylor,18 Dr. Diaa Bahgat,19 Dr. Paul Moore,20 Dr. Arthur Joyce,21 Dr. Carl

16
See Ridings v. Maurice, 444 F. Supp. 3d 973, 981 n.5 (W.D. Mo. 2020).
17
See id.
18
Dr. Taylor is the Vice Chairman of Clinical Outreach for UT Southwestern Medical Center’s Department of
Neurosurgery. See Pls.’ Trial Ex. 28 at 1. He was called by the Plaintiffs to provide expert testimony about the
neurosurgical standard of care and the cause of Mr. Dobbs’s brain injury. See generally Tr. of Bench Trial (Doc. 45)
at 47:25–134:22.
19
Dr. Bahgat was a staff neurosurgeon for the Central Arkansas Veterans Healthcare System from December 2015
until October 2019. See Def.’s Trial Ex. 4 at 2. Dr. Bahgat was the surgeon who performed Mr. Dobbs’s October 9,
2018 laminectomy and his re-exploration repair surgery on October 15, 2018. See Tr. of Bench Trial (Doc. 45) at
164:3–12. Plaintiffs’ counsel treated Dr. Bahgat as an adverse party, and the Government did its direct examination
of Dr. Bahgat as cross-examination. See id. at 162:21–163:2. Under the Arkansas Medical Malpractice Act, “[n]o
medical care provider shall be required to give expert opinion testimony against himself or herself as to any” standard
of care or proximate cause opinions “at a trial.” Ark. Code Ann. § 16-114-207(3).
20
Dr. Moore is the Medical Director for Somnologix, Limited and specializes in neurology and sleep medicine. See
Pls.’ Trial Ex. 26 at 1; Tr. of Bench Trial (Doc. 46) at 366:1–6. Dr. Moore was called by the Plaintiffs to provide
expert testimony about Mr. Dobbs’s injury and how the injury affected Mr. Dobbs. See Tr. of Bench Trial (Doc. 46)
at 330:1–364:4. Dr. Moore is not a neurosurgeon, and he testified that he is not qualified to render neurosurgical
standard-of-care opinions. See id. at 365:12–16.
21
Dr. Joyce is a neuropsychologist in private practice. See Pls.’ Trial Ex. 25 at 2. Dr. Joyce was called by the Plaintiffs
to give expert testimony about a neuropsychological evaluation he gave to Mr. Dobbs and the type of care Mr. Dobbs
would need throughout his life as a result of the brain hemorrhage. See generally Tr. of Bench Trial (Doc. 46) at
386:14–419:15.

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Hubbard,22 Victoria Powell,23 Dave Hussey,24 and Eileen Dobbs.25 The Government called

Dr. John Day26 and Dr. Margaret Tremwel.27

2. For purposes of liability, our story begins on October 9, 2018. That is when

Mr. Dobbs (a 61-year-old, retired United States Marine28) arrived at the Central Arkansas Veterans

Healthcare System for a scheduled laminectomy with Dr. Bahgat.29 Mr. Dobbs’s laminectomy

was “an L2 to S1 fusion and decompression.”30 In layman’s terms, Mr. Dobbs was getting spinal

surgery.

3. Once Mr. Dobbs was admitted to the hospital, Dr. Bahgat met with Mr. Dobbs to

examine and evaluate him.31 In what looks and reads like a boilerplate paragraph, Dr. Bahgat’s

22
Dr. Hubbard is an economist and retired business professor. See Pls.’ Trial Ex. 24 at 1. Dr. Hubbard was called by
the Plaintiffs to provide expert testimony about the cost of a life care plan for Mr. Dobbs. See generally Tr. of Bench
Trial (Doc. 46) at 432:5–438:19.
23
Ms. Powell is a nurse and certified life care planner. Pls.’ Trial Ex. 27 at 1. Ms. Powell was called by the Plaintiffs
to provide expert testimony about a proposed life care plan she created for Mr. Dobbs. See generally Tr. of Bench
Trial (Doc. 47) at 485:1–535:21.
24
Mr. Hussey lives next door to Mr. and Mrs. Dobbs in Cotter, Arkansas. See Tr. of Bench Trial (Doc. 47) at 561:11–
12. Mr. Hussey has known Mr. and Mrs. Dobbs since they moved next door to him in 2015. See id. at 561:14–15.
25
Mrs. Dobbs is the wife of Mr. Dobbs and is a Plaintiff in this case. See Tr. of Bench Trial (Doc. 47) at 574:20;
Compl. (Doc. 1) ¶ 8.2.
26
Dr. Day is a professor and Chairman of the Department of Neurosurgery at the University of Arkansas for Medical
Sciences. See Def.’s Trial Ex. 2 at 1. Dr. Day was called by the Government to offer expert testimony about the
neurological standard of care and cause of Mr. Dobbs’s brain hemorrhage. See generally Tr. of Bench Trial (Doc. 47)
at 668:24–718:17.
27
Dr. Tremwel is a neurologist and Medical Director of the Comprehensive Stroke Center at Washington Regional
Medical Center in Fayetteville, Arkansas. See Def.’s Trial Ex. 3 at 1; Tr. of Bench Trial (Doc. 48) at 821:14–19.
Dr. Tremwel was called by the Government to provide expert testimony about Mr. Dobbs’s physical and neurological
state post-hemorrhage. See generally Tr. of Bench Trial (Doc. 48) at 822:17–859:4. She also examined Mr. Dobbs
and provided expert testimony about the results of that examination. See generally id.
28
See Tr. of Bench Trial (Doc. 45) at 54:11–12; Tr. of Bench Trial (Doc. 47) at 576:22.
29
See Pls.’ Trial Ex. 1 at 1578–79. Although the medical records typically refer to the surgery as some variation of
an “L2-S1 decompression and fusion” surgery, multiple witnesses at trial referred to the procedure as a “laminectomy”
or “laminectomy and fusion.” See, e.g., Tr. of Bench Trial (Doc. 45) at 164:9–12. Thus, the Court will simply refer
to Mr. Dobbs’s procedure as either a laminectomy or a surgery throughout this Memorandum of Decision.
30
See Tr. of Bench Trial (Doc. 45) at 138:19–22.
31
See Pls.’ Trial Ex. 1 at 1575–79.

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pre-surgery notes reflect that “[t]he patient and/or family representative have been presented with

the risks, benefits, potential complications and alternatives to planned surgery and agree with the

planned procedure.”32 In these same notes, Dr. Bahgat also recorded that a history and physical

exam of Mr. Dobbs was performed on September 27, 2018, and, having “reviewed and assessed

the patient[,]” Dr. Bahgat determined “[t]here [had] been NO CHANGES since that exam.”33 The

Court finds Dr. Bahgat’s notes to be an accurate representation of his post-admission encounter

with Mr. Dobbs.

4. Dr. Bahgat testified at trial that he remembered having another “case to do” before

Mr. Dobbs’s laminectomy on October 9, 2018.34 Dr. Bahgat admitted that his memory of finishing

the earlier case and of seeing Mr. Dobbs before his laminectomy was “very vague.”35 Dr. Bahgat

could not remember what the earlier case was about.36 He could not remember what he had for

breakfast that morning.37 He could not remember the specifics of his drive to work.38 He could

not remember giving the consent forms to Mr. Dobbs or getting them back from him.39 As a

32
Id. at 1579. This was not the first time Mr. Dobbs had been presented with such information. At a July 2018
appointment, Dr. Bahgat discussed with Mr. Dobbs the potential risks of the surgery, as well as the potential success.
See id. at 1614; Tr. of Bench Trial (Doc. 45) at 176:12–179:7. According to Dr. Bahgat’s July 2018 notes, he informed
Mr. Dobbs that “[r]isks include but [are] not limited to weakness, paralysis, infection, hemorrhage, pulmonary
embolism, increased pain, bowel and bladder problems[,] . . . injury to surrounding neurovascular structures, durotomy
with [cerebrospinal fluid] leak . . . .” Pls.’ Trial Ex. 1 at 1614. But Dr. Bahgat testified at trial that he did not remember
whether he specifically informed Mr. Dobbs about the risk of a brain hemorrhage. See Tr. of Bench Trial (Doc. 45)
at 178:19–179:7. At first, Dr. Bahgat testified that he only told Mr. Dobbs about the risk of “stroke and bleeding in
general.” Id. Dr. Bahgat later clarified at trial that he did not actually remember the specific conversation with Mr.
Dobbs about the risks of the surgery. See Tr. of Bench Trial (Doc. 46) at 259:9–260:3. Instead, his recollection was
“based on what [he] normally would do . . . .” Id. at 259:18.
33
Pls.’ Trial Ex. 1 at 1575.
34
Tr. of Bench Trial (Doc. 46) at 270:23.
35
Id. at 270:25.
36
See id. at 271:3–7.
37
See id. at 271:8–10.
38
See id. at 271:11–14.
39
See id. at 271:15–17. This was the second set of consent forms obtained from Mr. Dobbs. Because the original
consent forms—which Mr. Dobbs had signed on an earlier date—were only valid for 30 days, Dr. Bahgat had to again

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general matter, the Court finds that Dr. Bahgat did not remember that day—which was more than

four years prior to trial—very well.

I. The Surgery and the Dural Tear

5. Mr. Dobbs’s laminectomy began at 11:42 on October 9, 2018, and finished at 16:19

the same day.40 Other people were in the room with Dr. Bahgat during the surgery (or portions of

the surgery), including an anesthesiologist (or anesthetist).41 However, none of these people were

called to testify by either party. Accordingly, the only three sources of direct evidence concerning

what occurred during the surgery are: (1) Dr. Bahgat’s post-operative report, (2) Dr. Bahgat’s trial

testimony, and (3) the anesthesiologist’s (or anesthetist’s) notes. And, as the Court will explain

below, the Court discounts a great deal of Dr. Bahgat’s trial testimony—when it is in tension with

Dr. Bahgat’s medical notes—because the Court finds that Dr. Bahgat’s memory of the day in

question is, at best, hazy.

6. Dr. Bahgat authored his post-operative report very shortly after he finished

Mr. Dobbs’s surgery.42 The post-operative report has several sections, including sections titled

Indication, Operative Findings, Adverse Events, and Procedure.43

7. In the Indication section, Dr. Bahgat recounted Mr. Dobbs’s medical history and

the reasons for surgery.44 Then, in the Operative Findings section, Dr. Bahgat explained that:

obtain Mr. Dobbs’s consent to proceed with the laminectomy on the morning of the procedure. See id. at 269:22–
270:4.
40
See Pls.’ Trial Ex. 1 at 1563. The records also show Mr. Dobbs’s anesthesia care began shortly before his surgery
at 10:51 and ended at 16:38. See id.
41
See id. at 1987.
42
See id. at 1984–86. The record reflects that the post-operative report was entered at 16:33 on October 9, 2018, and
signed by Dr. Bahgat at 18:17 the same day. See id. See also Tr. of Bench Trial (Doc. 45) at 188:20–22.
43
See Pls.’ Trial Ex. 1 at 1984–86.
44
See id. at 1984–85. The report incorrectly states that Mr. Dobbs was 55 years old at the time of the surgery. See
id. at 1984. As the Court explained above, Mr. Dobbs was 61 years old at the time of the surgery. See, e.g., Tr. of
Bench Trial (Doc. 45) at 54:11–12.

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Intraoperative navigation with the use of the O arm was used for placement of L2,
L3[,] L4, L5, S1 pedicle screws as well as interbody cage[]at L2-3. Pre and
postplacement spin was used to confirm adequate positioning of the implants. That
was significant lateral recess stenosis and facet arthropathy and foraminal stenosis
at L4-L5.45

8. In the Adverse Events section of Dr. Bahgat’s post-operative report, Dr. Bahgat

provided the following details about Mr. Dobbs’s dural tear:

Dural tear at right L2-3 t closed with onlay muscle and Duraseal
EBL: 500 mL
Counts: Complete at the end of the procedure
Anesthesia: Gen. prone position
Implants: Medtronic Solera system (L2 : Right side 5.5 x 45, left side splint 5 x 45,
L3 bilateral 6.5 x 45, L4 6.5 x 45 mm screws, L5 6.5 x 45 right side 6.5 x 50 mm
screws, S1 4.5x40mm screws
-7 mm elevate cage at L2-3 and 10 mL of MAP3 putty.46

This is the entirety of Dr. Bahgat’s notes in the Adverse Events section of the post-operative

report.47

9. In the Procedure section of the post-operative report, Dr. Bahgat detailed how he

performed Mr. Dobbs’s laminectomy.48 These details included everything from identifying

Mr. Dobbs as the correct patient and marking the site for the incision, to “hand[ing]” Mr. Dobbs

“to anesthesia for extubation and recovery.”49 This section also included further reflections by Dr.

Bahgat about Mr. Dobbs’s dural tear.50 Dr. Bahgat’s notes recounted that:

45
See Pls.’ Trial Ex. 1 at 1985.
46
See id.
47
See id.
48
See id. at 1985–86.
49
Id.
50
See id. at 1986.

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[During] the cage placements [a] dural tear at the axilla was identified. This tear
was not amenable to primary [repair] so a muscle graft was placed on top of which
a thin piece of Gelfoam was placed.51
Along with the discussion in the Adverse Events section, this description is the extent of

Dr. Bahgat’s notes about Mr. Dobbs’s dural tear and the efforts taken to repair it.52

10. A dural tear is a tear in the dura mater, which is a “covering that encases the brain

and the spinal cord and contains spinal fluid[,]” specifically cerebrospinal fluid (CSF).53 A dural

tear is a known complication of spine surgery.54 As even the Plaintiffs’ expert witness (Dr. Taylor)

admits, the fact that a dural tear occurs during surgery does not mean the surgeon did something

wrong.55 Approximately five to seven percent of patients who undergo lumbar surgeries

experience dural tears.56 But only 1 in 10,000 spinal surgeries (or about 0.03 percent) result in the

patient experiencing an intracranial hemorrhage.57

11. The Court finds that Mr. Dobbs’s intraoperative dural tear occurred when

Dr. Bahgat “took out the disc material and then put the cage in.”58 The cage, which was “thick

and metal[,]” had to be hammered in.59 Mr. Dobbs suffered a dural tear when Dr. Bahgat was

hammering the cage in.60

51
Id. At trial, Dr. Bahgat testified that he cannot pronounce the letter “R” correctly when dictating his notes, “[s]o
during is often put in [as] doing.” Tr. of Bench Trial (Doc. 45) at 189:13–16. The Court finds this is one of those
instances where “doing” should read “during.”
52
See Pls.’ Trial Ex. 1 at 1984–86.
53
See Tr. of Bench Trial (Doc. 45) at 55:8–9.
54
See id. at 141:6–8.
55
See id. at 141:12–14.
56
See id. at 129:1–5.
57
See id. at 53:25–54:4; Tr. of Bench Trial (Doc. 47) at 712:21–713:2. The testimonial evidence is conflicting as to
whether the 1 in 10,000 figure means one brain hemorrhage in 10,000 surgeries or one brain hemorrhage in 10,000
dural tears. This is not a conflict that requires resolution. In either scenario, the agreed consensus is that the vast
majority of dural tears do not lead to a brain hemorrhage.
58
Tr. of Bench Trial (Doc. 46) at 276:18.
59
Id. at 276:19.
60
See id. at 276:22–23.

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12. When a patient loses CSF, the loss can cause his brain to “sag.”61 That’s because

one role of CSF is to help the brain float.62 The sag can cause veins in the brain to stretch and

occlude, which in turn can cause a brain hemorrhage.63

13. But not all losses of CSF cause brain sag. For brain sag to occur, a patient has to

lose enough CSF to cross some unknown threshold. As a rough and general matter, and holding

all things equal, the larger and more sudden the loss of CSF, the more likely it is to cause brain

sag (and, consequently, a brain hemorrhage).64 Conversely, a smaller and less sudden loss of CSF

is less likely to cause brain sag.

14. In this case, the Government contends that there was a large and immediate loss of

CSF associated with the intraoperative dural tear.65 The Government’s point is that this large loss

of CSF caused the brain to sag (and the consequent brain hemorrhage) on its own. If this is true,

then any loss of CSF associated with the placement of subfascial drains would not be a but-for or

proximate cause of Mr. Dobbs’s brain sag (and consequent brain hemorrhage). So, it is important

to determine whether the evidence shows a large and immediate loss of CSF associated with the

intraoperative dural tear.

61
See Tr. of Bench Trial (Doc. 45) at 93:11–12.
62
See Tr. of Bench Trial (Doc. 46) at 331:20–22.
63
See, e.g., Tr. of Bench Trial (Doc. 45) at 93:8–14.
64
See, e.g., id. at 209:11–18; Tr. of Bench Trial (Doc. 47) at 697:1–3. Dr. Day testified that, “[b]ecause of the initial
gush of spinal fluid . . . [t]hat’s when the large, immediate loss occurs, sagging of the cerebellum, compromise of the
veins bridging there and then also happened up above in this gentleman’s case, unfortunately.” Id. at 709:18–22. To
the Court, this testimony suggests that an average loss of CSF at the time of an intraoperative dural tear (i.e., not a
large gush) would likely not cause brain sag. Furthermore, the trial record reveals that the body contains
approximately 300 milliliters of CSF and reproduces CSF at a rate of about 20 milliliters per hour. See Tr. of Bench
Trial (Doc. 45) at 55:24–56:6, 56:23–57:2. Considering both of these things, the Court finds that an average loss of
CSF from an intraoperative dural tear is unlikely to be enough to cause the brain to sag. That is consistent with the
fact that only 1 in 10,000 spinal surgeries result in a brain hemorrhage even though far more result in dural tears. See,
e.g., id. at 129:5–8.
65
See, e.g., Tr. of Bench Trial (Doc. 45) at 41:1–2. Throughout trial, the “gush” was variously qualified as “big,”
“large,” or “sudden.” See, e.g., id. at 128:18–19, 191:6–7, 192:8.

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15. The evidence in favor of a large gush of CSF during the surgery comes principally

from Dr. Bahgat’s testimony. Dr. Bahgat testified that “the cut would have produced a lot of fluid,

a sudden gush.”66 He also testified that “there was definitely a gush.”67 And he testified that he

“vividly remember[ed] the tear” and the fact that “it gushed.”68

16. But Dr. Bahgat didn’t know how much CSF leaked from the dural tear.69 Indeed,

Dr. Bahgat testified that there was no way to specifically measure the CSF that leaks when there’s

a dural tear.70 And there was no way for him to reasonably guess how much came out.71

17. Dr. Bahgat also conceded at trial that he did not note the quantity of CSF in the

post-operative report.72 And he concedes that he never mentioned in his post-operative report (or

to Mrs. Dobbs after surgery) that there was a big, large, or otherwise abnormal amount of CSF that

leaked from the intraoperative dural tear.73 Concerning the absence of any reference to a gush of

CSF in the post-operative report, Dr. Bahgat testified that his notes were “not to describe, you

know, an event as a movie and give, you know, the surrounding atmosphere about what

happened[,]” and “it wouldn’t occur to [him] to describe like how much fluid there was or the

intensity at the time T [sic] didn’t seem like a big deal, because it happens all the time.”74

66
Id. at 192:7–8.
67
Id. at 192:24–25.
68
Tr. of Bench Trial (Doc. 46) at 284:9–12.
69
See Tr. of Bench Trial (Doc. 45) at 192:7–25.
70
See Tr. of Bench Trial (Doc. 46) at 290:24–25.
71
See id. at 291:1–6.
72
See Tr. of Bench Trial (Doc. 45) at 193:20–194:8.
73
See id. at 193:20–194:1; Tr. of Bench Trial (Doc. 47) at 588:18–20. Based on this testimony, the Court finds that
the “EBL: 500 mL” notation in the post-operative report is not about this supposed “gush” of CSF. Pls.’ Trial Ex. 1
at 1985.
74
See Tr. of Bench Trial (Doc. 45) at 191:9–17.

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18. When asked by Plaintiffs’ counsel (in the context of Dr. Bahgat’s prior evaluations

of Mr. Dobbs and the corresponding medical records) whether, “if there were anything unusual,

you would note it in the medical record[,]” Dr. Bahgat responded, “If it was something that was,

you know, clearly, you know, a problem, yeah, we would have [sic] at least have to address it.” 75

19. One of the Plaintiffs’ expert witnesses, Dr. Taylor, testified that, if there was a large

CSF leak at the time of the dural tear, he (Dr. Taylor) would have documented it.76 One of the

Government’s expert witnesses, Dr. Day, testified that, despite no record of a “large gush” of CSF

in Dr. Bahgat’s post-operative report, Dr. Day believed there was a “large gush” at the time of the

dural tear because he has “seen it in surgery.”77 Dr. Day did not attempt quantify or otherwise

explain the possible volume of the gush.78

20. Considering paragraphs 12–19 above, the Court finds it more likely than not that

only an average amount of CSF immediately leaked from Mr. Dobbs’s intraoperative dural tear.

Dr. Bahgat couldn’t quantify the amount. Moreover, given his hazy recollections of other specifics

on that day, the Court does not believe Dr. Bahgat could accurately remember whether the

immediate leak was small, average, or large.79 And the mere fact that Dr. Day has seen large

gushes occur in other operations is not a basis to speculate that one occurred here. On the other

side of the ledger is the omission of any reference to a “gush” or an otherwise large amount of CSF

75
See id. at 171:1–5.
76
See id. at 128:18–24.
77
Tr. of Bench Trial (Doc. 47) at 725:20–726:4.
78
See id.
79
See supra ¶ 4.

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leakage in the post-operative report.80 And there is also the fact that Mrs. Dobbs was told right

after the surgery that everything went well; she was not told anything about a serious CSF leak.81

21. The Court understands Dr. Bahgat’s testimony that the post-operative report is not

a movie script. But if the dural tear resulted in an abnormally big or large gush of CSF, the Court

finds that Dr. Bahgat would have made note of that in the post-operative report that he authored

very shortly after Mr. Dobbs’s surgery concluded. This finding is consistent with Dr. Bahgat’s

comment that, if there was anything unusual or problematic, it would be documented in the medical

records.82 It is also consistent with Dr. Taylor’s expert testimony that, if there was a large CSF

leak at the time of the dural tear, Dr. Taylor would have documented such an occurrence.83 Taking

all the foregoing into account, Plaintiffs have proved that it is more likely than not that the

intraoperative CSF leak that immediately followed the dural tear was not large, but rather no more

than an average leak of CSF that would occur from the average dural tear.84

II. The Secondary Repair

22. When there is a dural tear, there are two methods by which a surgeon can repair

it.85 The first method is a primary repair.86 As Dr. Taylor explained, a primary repair entails using

a “suture” and “sewing the opening closed so that it is watertight.”87 When the dural tear is not

80
See Pls.’ Trial Ex. 1 at 1984–86.
81
See Tr. of Bench Trial (Doc. 47) at 588:18–20.
82
See Tr. of Bench Trial (Doc. 45) at 171:1–5.
83
See id. at 128:18–24.
84
The Court understands that the implication of its finding is that Dr. Bahgat’s testimony on the stand was inaccurate.
But the Court wishes to emphasize two points. First, this does not mean that Dr. Bahgat was lying. It only means that
there is a greater than 50 percent likelihood that he was remembering things incorrectly. Second, because the Court
is only finding facts on a more-likely-than-not standard, there is a fair (but less than 50 percent) chance that Dr. Bahgat
was actually testifying accurately.
85
See Tr. of Bench Trial (Doc. 45) at 62:24–63:2, 64:13–65:1.
86
Id. at 63:3–5.
87
See id. at 62:24–63:2.

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amenable to a primary repair, the surgeon must attempt a secondary repair.88 As Dr. Taylor

explained, a secondary repair generally consists of using muscle, fascia, Gelfoam, or dural sealants

to “cover the hole . . . long enough for the dura to heal.”89 A secondary repair is weaker than a

primary repair.90 This is because, among other reasons, the tear is not sutured closed.91 As

Dr. Taylor and Dr. Day agree, there can be a CSF leak after either type of repair.92 Logic, of

course, suggests that there is greater risk of a CSF leak with the secondary repair as opposed to the

primary repair. And there was credible testimony to support this finding.93 Nonetheless, a

secondary repair can be considered watertight if the seal passes one of the tests described below.94

23. Because of the location of Mr. Dobbs’s dural tear, Dr. Bahgat was unable to do a

primary repair.95 As a result, Dr. Bahgat attempted a secondary repair “with onlay muscle and

Duraseal”—more specifically, “a muscle graft was placed on top of which a thin piece of Gelfoam

was placed.”96

88
See id. at 62:24–63:2, 64:13–65:14.
89
See id. at 64:13–65:1.
90
See id. at 65:12–14.
91
See id. at 62:22–65:20.
92
See id. at 144:20–22; Tr. of Bench Trial (Doc. 47) at 684:2–21.
93
See Tr. of Bench Trial (Doc. 45) at 74:22–75:13, 196:14–23.
94
See Tr. of Bench Trial (Doc. 47) at 683:24–684:1.
95
See Pls.’ Trial Ex. 1 at 1986; Tr. of Bench Trial (Doc. 46) at 278:25–279:19.
96
Pls.’ Trial Ex. 1 at 1985, 1986.

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24. After a surgeon has repaired a dural tear—whether by a primary or secondary

repair—the surgeon must confirm the seal is closed.97 The standard of care in Arkansas requires

such confirmation.98 And such confirmation can be accomplished in two ways.99

25. First, a surgeon can use the Valsalva maneuver.100 The Valsalva maneuver is done

by having the anesthesiologist (or anesthetist) “stop respiration and increase intrathoracic

pressure.”101 This “increase[s] the spinal fluid pressure, which is continuous, with the lumbar

spinal pressure.”102 When the pressure increases, CSF will come out of the tear if the seal is not

closed.103

26. The other way to determine whether a seal is closed is to elevate the patient’s head,

which also “increase[s] the pressure of the fluid in the lumbar spine . . . .”104 This is known as a

reverse Trendelenburg position.105

97
See Tr. of Bench Trial (Doc. 45) at 62:22–63:2, 63:25–64:2, 66:3–20; Tr. of Bench Trial (Doc. 47) at 764:7–17.
98
See Tr. of Bench Trial (Doc. 45) at 144:2–19. The standard of care for laminectomies does not vary from one
locality to another. See id. at 50:9–12. The literature is the same throughout the United States, and none of the
literature is unique to Arkansas or another region. See id. at 50:3–12. As Dr. Taylor testified, following the repair of
an intraoperative dural tear, it is within the standard of care to perform a Valsalva maneuver to check and see if there
is a persistent leak. See id. at 144:2–15. And if Dr. Bahgat had performed the Valsalva maneuver (or otherwise
checked the sufficiency of the secondary repair’s seal), that would have been within the standard of care. See id. at
144:12–19. As Dr. Day similarly testified, if Dr. Bahgat had checked the sufficiency of the secondary repair’s seal,
Dr. Bahgat’s surgical actions would have been within the standard of care. See Tr. of Bench Trial (Doc. 47) at 687:2–
8.
99
See Tr. of Bench Trial (Doc. 45) at 66:5.
100
See id. at 66:5–6.
101
Id. at 66:6–7.
102
Id. at 66:8–9.
103
See id. at 66:10–11.
104
See id. at 66:12–17.
105
See id. at 66:15.

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27. The post-operative report does not show that Dr. Bahgat used either method to

check whether the secondary repair was sufficiently sealed.106 The Government does not contend

that Dr. Bahgat used the reverse Trendelenburg position to determine whether the secondary repair

was sealed. Thus, a principal fact question in dispute is whether Dr. Bahgat performed the

Valsalva maneuver to test the sufficiency of the secondary repair’s seal.

28. At trial, Dr. Bahgat testified multiple times that he performed the Valsalva

maneuver after completing the secondary repair.107 In one instance, Dr. Bahgat and the Plaintiffs’

counsel engaged in the following colloquy:

Q: In the October 9th surgery, you do not document at all confirming that that
tear was sealed, right?

A: Yes. But, again, this is—I’m describing one part of a big procedure. If and
when I say, “this tear was not amiable to primary tear, so a muscle graft was
placed on top, of which a thin piece of Gelfoam was placed,” it’s not like I just
dumped it on there and went, oh, no. I actually did do at least the first part of
the second procedure, because I have to tuck it around and make sure it’s
secured in place, and then I have to put the Gelfoam on it in that location, make
sure it’s tight, and I have to do a Valsalva to make sure it’s not leaking, because
I’m not there to cheat on myself. I have no reason to cut corners and not do that
stuff. And then at the end—

Q: Dr. Bahgat, let me stop you there. All I’m asking is whether in the first
surgery operative note, you note that you looked for a leak. And you don’t note
that, do you?

A: I don’t note it, but it happened.

Q: And you also—you mentioned the Valsalva maneuver. You say, you
testified in deposition that you did a Valsalva maneuver. You remember that?

A: I did.

106
See Pls.’ Trial Ex. 1 at 1984–86. Nor do the anesthesiologist’s (or anesthetist’s) post-operative or intraoperative
reports document that the Valsalva maneuver was performed. See id. at 44–65; Tr. of Bench Trial (Doc. 45) at 203:11–
204:2.
107
See Tr. of Bench Trial (Doc. 45) at 202:9–204:2; Tr. of Bench Trial (Doc. 46) at 279:23–280:3.

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Q: But in the operative note on October 9th, 2018, nowhere in there does the
word “Valsalva maneuver” or phrase “Valsalva maneuver” appear, right?

A: Correct.

Q: And we talked about earlier in this trial how a Valsalva maneuver is done
with the help of an anesthesiologist, right?

A: Yes.

Q: And that’s because the patient is unconscious. He can’t bear up/down, right?

A: Correct.

Q: And we have the anesthesiology notes in this case, right?

A: I assume so.

Q: And you didn’t find any note from your anesthesiologist that he helped you
perform a Valsalva maneuver, right?

A: I don’t know if they ever document that. This is a 15-, 20-second thing that
we just ask them, okay, hold his breath, do a Valsalva maneuver. When the
pressure reach 30, let me know. They control the bag, elevate the patient’s
pressure in his lung, we count to 10, I keep looking, there is no CSF, we release
it, okay, let him breathe again.

Q: Well, Doctor—

A: I don’t know if they ever have documented it.

Q: What we can agree on is neither you, in your operative note, nor the
anesthesiologist, in the anesthesiology notes, document a Valsalva maneuver,
right?

A: I haven’t reviewed the anesthesiology notes, but if you say so.108

At another point in his testimony, Dr. Bahgat testified that “we . . . did the Valsalva, even though

I didn’t document it, because I have to make sure that he’s not leaking. . . . So at that point I was

satisfied that it wasn’t leaking . . . .”109

108
Tr. of Bench Trial (Doc. 45) at 202:3–204:2.
109
Tr. of Bench Trial (Doc. 46) at 279:23–280:3.

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29. When asked about his memory of performing the Valsalva maneuver, Dr. Bahgat

testified that:

I remember [asking] anesthesia to perform a Valsalva and make sure that it wasn’t
leaking. It’s just a reflex thing we ask for. Like, let’s say when I do brain surgery.
After I finish, I tell them do Valsalva to make sure that it doesn’t bleed at the
surgical bed. When I do, like, neck surgeries, after I put the retractors, I ask them
to deflate and inflate the cuff. I’ve never thought about dictating it, but it’s just a
routine thing. I mean, I have no reason to, again—[.]110

30. Dr. Bahgat also testified that:

I remember doing it. I remember. Again, I only remember the vivid time of the
tear, the repair and how tedious I tried to do it, and then was glad that when I put
the muscle and the Gelfoam and did the Valsalva, that it wasn’t leaking. Because
if it was leaking, it’s just more time, and then at some point you run out of options.
You keep packing stuff, and then you don’t know what to do. . . . So I remember
looking at it, asking if he do Valsalva, are you up to 30, or whatever number I said,
10 seconds. The dura started to pulsate, but I didn’t see spinal fluid coming out for
the most part. . . . I mean, I don’t remember what number they said, if it was for 10
seconds or 15 seconds. But I remember looking at it. You know, you have this,
like, snapshot memory of something pulsating, the muscle patch, the white Gelfoam
on it and nothing coming out of it.111

31. The Court again discredits Dr. Bahgat’s testimony based on his hazy memories of

other parts of that day.112 There is no support in the evidence for why the performance of the

Valsalva maneuver would stand out in Dr. Bahgat’s memory. And the absence of it from his

post-operative report is significant evidence that it did not occur.

32. The Government’s standard-of-care expert, Dr. Day, testified that it was standard

practice for a surgeon to record the use of the Valsalva maneuver in his notes in the post-operative

report.113 The Court credits this testimony. Dr. Day qualified his testimony about this standard

110
Id. at 288:4–12.
111
Id. at 288:15–21, 289:1–10.
112
See id. at 259:24–260:3, 270:10–271:17. See also supra ¶ 4.
113
See Tr. of Bench Trial (Doc. 47) at 685:2–20.

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practice by explaining that “[k]ind of in every day [sic] reality have I seen where people didn’t do

it? Sure. Is it possible that I’ve forgotten to do that myself a time or two in my orientation? Yeah,

I’m not infallible with that. . . . [But] I think most of the time it should—it should be in there,

yeah.”114 When asked by Plaintiffs’ counsel: “if Dr. Bahgat had done a Valsalva maneuver, you’d

expect it to be documented,” Dr. Day responded, “I would hope so.”115 But Dr. Day also testified

that, while surgeons are expected to document relevant procedures undertaken in the operation,

“unfortunately there’s a difference between expectations and reality sometimes.”116

33. Dr. Day’s qualifications to his testimony do not help Dr. Bahgat much at all, given

the applicable preponderance-of-the-evidence standard. While it is possible that Dr. Bahgat

performed the Valsalva maneuver without documenting it, the Court finds that it is more likely

than not that Dr. Bahgat would have documented such a procedure had he performed it.

34. At trial, it came to light that Dr. Bahgat was once one of Dr. Day’s residents at the

University of Arkansas for Medical Sciences.117 Plaintiffs’ counsel elicited testimony from

Dr. Day about whether he teaches his residents to document performing a Valsalva maneuver.118

Dr. Day testified that he teaches his residents to document when they do a Valsalva maneuver, but

he could not specifically remember whether he had ever told Dr. Bahgat to do so.119 Based on this

testimony, the Court finds that it is more likely than not that Dr. Day did teach Dr. Bahgat to

114
Id. at 685:9–13, 19–20.
115
Id. at 731:22–24.
116
See id. at 733:23–734:1.
117
See id. at 721:15–20. Dr. Day testified that he “hardly see[s]” Dr. Bahgat since Dr. Bahgat left residency. Id. at
721:24–25. The Court does not find that Dr. Day’s past relationship with Dr. Bahgat undermines Dr. Day’s credibility
in any way.
118
See id. at 729:19–21.
119
See id. at 729:19–24.

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document the use of the Valsalva maneuver. And this strengthens the Court’s foregoing finding

that Dr. Bahgat would have documented the maneuver if he had done it.

35. For the reasons explained in Paragraphs 27–34 above, the Court finds that Plaintiffs

have proved that it is more likely than not that Dr. Bahgat did not perform the Valsalva maneuver

or otherwise test the sufficiency of the secondary repair’s seal.120

III. The Use of a Drain

36. The post-operative report and Dr. Bahgat’s testimony reveal that Dr. Bahgat

installed a subfascial drain in Mr. Dobbs near the end of Mr. Dobbs’s laminectomy.121 There

appears, however, to be some confusion in the medical records about the precise type of drain

used.122 For example, in the post-operative report, Dr. Bahgat documents that he installed a

Jackson-Pratt (JP) drain.123 The use of a JP drain is also reflected in the nurse’s Progress Notes

from the day after surgery.124 But the Post Anesthesia Care Unit (“PACU”) records reflect, in part,

that the drain was a “Hemovac” drain.125 The PACU records also refer to the drain as a “[b]ulb

drain” in one instance.126

37. Testimony at trial went some way to clearing up the seemingly conflicting

documentary descriptions of the drain. At trial, Dr. Bahgat referred to the drain as a JP drain

120
The Court’s two observations made in note 84, supra, apply here as well.
121
See Pls.’ Trial Ex. 1 at 1986; Tr. of Bench Trial (Doc. 45) at 195:20–196:1. The Progress Notes refer to multiple
drains. See, e.g., Pls.’ Trial Ex. 1 at 1560. However, the testimony suggests that only one drain was installed. See,
e.g., Tr. of Bench Trial (Doc. 46) at 282:17, 287:7–8. The Court understands the medical records and testimony to
mean that there was one drain, but there were two compartments into which the drain emptied. See, e.g., Pls.’ Trial
Ex. 1 at 49. Ultimately, the number of drains doesn’t matter. As discussed below, placing any drain without ensuring
a watertight seal of the dural tear falls below the standard of care in Arkansas.
122
Compare Pls.’ Trial Ex. 1 at 1545, 1986, with Pls.’ Trial Ex. 1 at 48, 49.
123
See id. at 1986.
124
See id. at 1545.
125
Id. at 48, 49.
126
Id. at 47.

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multiple times.127 He also described Mr. Dobbs’s drain as “a hand bulb . . . .”128 When asked if

“[t]here was a JP lumbar drain that was a Hemovac drain installed in the lumbar region of

Mr. Dobbs,” Dr. Taylor testified that:

JP and Hemovac are both—are two different types of drains that are used in surgery,
and I think both of those words are used in the medical record. So it was one or the
other. It’s irrelevant in terms of the function and in terms of the issues of this case,
I think.129

Later in his examination, Dr. Taylor again testified that a JP drain and Hemovac drain are

essentially the same thing.130 Like Dr. Bahgat, Dr. Taylor refers to Mr. Dobbs’s drain as a bulb.131

Dr. Day similarly testified that “I don’t use the ones that are called Hemovacs, which a lot of

people—you know, people will use that word even for a bulb. They’re just using it like a general

term, but it’s not accurate.”132 He further explained that:

[U]nfortunately in the hospital, there are other examples of this where a—like a
trade name of something is used kinda broadly, but it’s not—it’s not correct. So
they could have written Hemovac, but it was the little bulb suction. So that doesn’t
mean it was a Hemovac on suction. It means that somebody’s using that as a
general term for the drain, wrongly unfortunately, but then they put that in the chart.
Then it creates confusion.133

Considering all this testimony and the evidence admitted at trial, the Court finds that the drain

installed in Mr. Dobbs at the end of his surgery was, more likely than not, a JP drain with a bulb

suction function—not a high suction Hemovac drain. The one stray reference to the Hemovac

drain in the PACU records was, more likely than not, made in error.

127
See Tr. of Bench Trial (Doc. 45) at 212:6; Tr. of Bench Trial (Doc. 46) at 282:22.
128
Tr. of Bench Trial (Doc. 46) at 293:6.
129
Tr. of Bench Trial (Doc. 45) at 58:23–59:4.
130
Id. at 110:9–15.
131
See, e.g., id. at 69:23–70:4.
132
Tr. of Bench Trial (Doc. 47) at 692:4–7.
133
Id. at 765:19–766:1.

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38. It is still unclear from the trial record, however, whether the drain used was only

gravity-based, or also had a negative suction feature that could either be turned on or manually

employed. The Court need not resolve this factual dispute because the Court finds that it is below

the standard of care in Arkansas to use either type of drain when the sufficiency of the seal of the

dural tear has not been confirmed by way of the Valsalva maneuver of reverse Trendelenburg

position.134 The use of any drain near a dural-tear site without confirmation of a watertight seal of

the dural tear is below the standard of care because it allows, encourages, or promotes additional

leakage of CSF if the repaired dural tear is not sufficiently sealed.135

39. Dr. Bahgat testified that, near the end of surgery, he installed a JP drain in

Mr. Dobbs to remove excess blood and tissue fluid from the cavity around Mr. Dobbs’s spine.136

Dr. Bahgat testified that the build-up of excess blood and tissue fluid in this cavity could lead to

increased pressure in the cavity, which could cause pain, paralysis, blood clots, or numerous other

problems.137 The Court accepts this portion of Dr. Bahgat’s testimony as fact.

40. Dr. Bahgat testified that, when deciding to install the drain, he “put into

consideration” the fact that Mr. Dobbs had suffered a dural tear.138 Dr. Bahgat also testified that

he was “fully aware” that the dural tear “could leak again.”139 At one point, Dr. Bahgat suggested

that he weighed the risk of a rare complication, e.g., a remote cerebral brain hemorrhage, with

134
See, e.g., id. at 729:25–730:11, 764:7–13.
135
See, e.g., id. See also Tr. of Bench Trial (Doc. 45) at 160:23–24 (“The drain makes its [sic] more likely that the
patch is going to fail.”); id. at 97:18–20 (“It is not safe [to use a drain] when there has been a durotomy, and the
durotomy has not been closed in a watertight fashion.”).
136
See Tr. of Bench Trial (Doc. 45) at 195:23–196:1; Tr. of Bench Trial (Doc. 46) at 280:20–283:24.
137
See Tr. of Bench Trial (Doc. 46) at 282:11–23, 283:8–23.
138
Id. at 282:24–25.
139
Id. at 283:2–3.

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other more common complications.140 But after being questioned about his memory of the

decision-making process, Dr. Bahgat testified that, while he “vividly remember[ed] the tear,” he

“[wouldn’t] lie and say [he] was focusing on the cerebral hemorrhage. . . . [He] didn’t think about

it.”141 When asked whether he was “really thinking about at that moment, should I put this drain

in or should I not[,]” Dr. Bahgat testified, “One hundred percent, yes.”142

41. Although there is some internal conflict in Dr. Bahgat’s testimony in the preceding

paragraph, the Court need not resolve the conflict. Whatever Dr. Bahgat’s reasoning for placing

the drain, it is clear that doing so without confirming a watertight seal of the dural tear was below

the standard of care in Arkansas.

IV. Post-Laminectomy Events

42. The Court finds that Plaintiffs have proved that it is more likely than not that, after

Dr. Bahgat performed the secondary repair and finished the surgery, CSF continued to leak out of

the dural-tear site. The reasons for this finding are set out below, but generally consist of evidence

that (1) a significant amount of fluid was collected over many hours by the drain, and (2) CSF

leakage from the dural-tear site was found during a second surgery six days later.

43. After surgery, Mr. Dobbs was taken to the PACU to recover from his anesthesia.143

The PACU records show that at 17:29—an hour and ten minutes after Mr. Dobbs’s surgery

ended—the right side of the drain had collected a total of 25 milliliters of fluid, and the left side

140
See id. at 283:17–23 (“The remote cerebral hemorrhage is one in 10,000, you know, again, give or take the
literature. So this is where being rare puts into the consideration. I can either not put the drain and avoid potentially
causing that, or not put it and then get a clot, and then he can have bowel and bladder problems where he has to
catheterize himself, or he has more pain or more weakness.”).
141
Id. at 284:11, 22–24.
142
Id. at 285:6–9.
143
See Pls.’ Trial Ex. 1 at 1986.

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of the drain had collected 75 milliliters of “all serous sanguinous [sic]” fluid.144 Dr. Taylor testified

that serosanguineous means “blood-tinged fluid[,]” and Dr. Day testified that it means “that there

is blood in fluid.”145 The 17:29 notes also show that Mr. Dobbs was alert, awake, and following

commands, but he was moaning.146

44. At 18:35, the PACU record shows that Mr. Dobbs’s right side of the drain now

contained an additional 150 milliliters of fluid, and the left side of the drain had an additional 100

milliliters of fluid.147 A 19:04 check-up shows that Mr. Dobbs was still alert, awake, and following

commands.148 At 19:08, the fluid collected in the drains still measured 150 milliliters in the right

side of the drain and 100 milliliters in the left side of the drain.149 The fluid was again described

as serosanguinous.150

45. Mr. Dobbs’s next check-up was at 20:30.151 In a record labeled “Progress Notes[,]”

Mr. Dobbs’s neurological assessment revealed that he was alert, oriented to person, place, and

time, and able to respond to verbal commands and answer questions appropriately.152 He did not

exhibit any signs of weakness, numbness, tingling, inattention, disorganized thinking, or visual or

hearing impairments.153 At this time, he spoke clearly and could move all extremities.154 Another

144
Id. at 48.
145
Tr. of Bench Trial (Doc. 45) at 106:23; Tr. of Bench Trial (Doc. 47) at 755:2–3.
146
See Pls.’ Trial Ex. 1 at 48.
147
See id. at 49.
148
See id. There was no longer any indication that Mr. Dobbs was moaning.
149
See id.
150
See id.
151
See id. at 1549.
152
See id. at 1550.
153
See id.
154
See id.

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check-up at 00:30 on October 10th revealed that Mr. Dobbs’s neurological assessment was

essentially unchanged.155

46. Mr. Dobbs’s next check-up was four-and-a-half hours later at 05:00.156 This time,

the nurse noted that Mr. Dobbs had “poor verbal expression[.]”157 Dr. Taylor testified that this

was a “nonspecific comment that the person doing the evaluation thought that [Mr. Dobbs’s]

speech was not normal for him.”158 But otherwise, the nurse’s observations were unchanged from

the 20:30 and 00:30 check-ups.159

47. At 05:06, the records show that an additional 200 milliliters of fluid had collected

in Mr. Dobbs’s drain.160 At 07:06, there was an additional 225 milliliters collected in the drain.161

48. By this point, Mr. Dobbs had lost approximately 775 milliliters of fluid since

Dr. Bahgat installed the drain fourteen hours earlier.162

49. Drs. Taylor, Bahgat, and Day all testified that there was no way to know exactly

how much of the drained fluid was CSF.163 Dr. Taylor testified that the average person has

155
See id. at 1551–52.
156
See id. at 1552. There is no record of any check-ups between 00:30 and 05:00 on October 10th. However, Mrs.
Dobbs testified that on the night of October 9th and in the early morning of October 10th, Mr. Dobbs was repeatedly
vomiting and “would roll back and forth in his bed, back and forth, back and forth, because he said his head was
hurting so badly.” Tr. of Bench Trial (Doc. 47) at 590:21–591:3. Mrs. Dobbs also testified that she “felt like [Mr.
Dobbs’s talking] was normal, you know, but, I mean, obviously he wasn’t talking too much because all that other stuff
was kinda going on. So, I mean, but I didn’t think to myself, wow, he’s not responding normally or looking at me
normally. It seemed all fine to me.” Id. at 594:7–12. Moreover, Mrs. Dobbs testified that Mr. Dobbs continued to
vomit at least until he was taken for his MRI, but it is unclear which trip to the MRI she is referring to. See id. at
594:19–595:3. Of course, Mrs. Dobbs is likely not a particularly reliable witness here. That night, she passed out and
hit her head. See id. at 591:4–15. As Mrs. Dobbs testified, she “was knocked out cold.” Id. at 591:14–15. The Court
accepts the general tenor of her testimony but cannot accept the specifics because of the head injury.
157
Pls.’ Trial Ex. 1 at 1552.
158
Tr. of Bench Trial (Doc. 45) at 110:2–5.
159
See Pls.’ Trial Ex. 1 at 1552–53.
160
See id. at 1545.
161
See id.
162
See Tr. of Bench Trial (Doc. 45) at 113:13–17.
163
See id. at 112:7–9; Tr. of Bench Trial (Doc. 46) at 306:4–11; Tr. of Bench Trial (Doc. 47) at 715:2–6.

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approximately 300 milliliters of CSF in his body at one time.164 Dr. Taylor also testified that the

average person produces about 20 milliliters of CSF per hour.165

50. By 07:20, Mr. Dobbs had begun to exhibit signs of expressive aphasia, which is the

inability to speak.166 Dr. Bahgat was informed of this development, and an urgent brain MRI was

ordered.167 Mr. Dobbs, however, did not have an MRI until later that afternoon.168 In the

intervening hours, nurses performed two neurological checks at 08:00 and 13:00.169 At both

checks, Mr. Dobbs was alert and able to follow commands, but he was still unable to speak.170

51. Mr. Dobbs’s MRI revealed that he had three brain bleeds.171 The neuroradiologist’s

notes explain that:

The cerebral venous sinuses appear widely patent on 3D postcontrast imaging.
Diffuse mildly thickened dural enhancement consistent with the given history of
recent dural tear. Favor transient intracranial hypotension that resulted in brain
sagging and mechanical obstruction of cingulate and superior cerebellar veins. This
likely resulted in venous ischemia/infarction with subsequent hemorrhage.172

When asked about the neuroradiologist’s findings at trial, Dr. Bahgat said it would be fair to

conclude that the most likely cause of the brain bleeds was CSF draining through the dural tear,

164
See Tr. of Bench Trial (Doc. 45) at 56:23–57:2. Specifically, Dr. Taylor said the average person could have
anywhere from 150 to 400 milliliters of CSF in his body, with an average of 300 milliliters. See id.
165
See id. at 55:24–56:6. Under normal circumstances (i.e., when there is no dural tear), CSF is recycled into the
bloodstream. See id. at 56:8–20. Dr. Day agreed with Dr. Taylor’s estimate. See Tr. of Bench Trial (Doc. 47) at
708:1–6.
166
See Pls.’ Trial Ex. 1 at 1540; Tr. of Bench Trial (Doc. 45) at 114:1–2.
167
See Pls.’ Trial Ex. 1 at 1540; Tr. of Bench Trial (Doc. 45) at 206:1–4.
168
See Pls.’ Trial Ex. 1 at 1530. Mr. Dobbs’s MRI was delayed because he had a metal Foley catheter with a
temperature probe, which needed to be removed before he could have an MRI. See id. at 1529, 1539.
169
See id. at 1524, 1527.
170
See id.
171
See id. at 644–45, 1521; Tr. of Bench Trial (Doc. 45) at 206:10–15.
172
Pls.’ Trial Ex. 1 at 645.

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which would have resulted in the brain sagging.173 In turn, the brain sag would have stretched and

torn veins in Mr. Dobbs’s brain.174

52. At 15:55, Mr. Dobbs was transferred to the Surgical Intensive Care Unit

(“SICU”).175 Dr. Bahgat’s post-MRI notes show that he ordered the drains to stay in Mr. Dobbs.176

At 17:00, Mr. Dobbs was able to follow some commands, such as squeezing a nurse’s hands, but

he could not hold up two fingers when asked.177 By 19:00, Mr. Dobbs was “becoming increasingly

more apneic and less responsive to following commands.”178

53. A CT scan of Mr. Dobbs’s head was performed at 20:12.179 The CT scan revealed

that Mr. Dobbs’s “ventricles were bigger. They looked enlarged.”180 Based on the CT results,

Dr. Bahgat’s concern was, “maybe the blood or the shift in the brain had blocked any of these

outflows, and it was building enough that these cavities were now expanding[,]” which could “just

squeeze the brain tissue against the walls of the skull, and then it can cause more damage.”181 As

173
See Tr. of Bench Trial (Doc. 45) at 211:19–23.
174
See id.
175
See Pls.’ Trial Ex. 1 at 1516, 1521. When asked at trial whether he considered taking the drain out after the MRI,
Dr. Bahgat testified:
Probably. I mean, I don’t remember vividly, but definitely I think logic would dictate I would have
thought about taking it out. But I believe it was solid, looked at the drainage, and then again assessed
whether was [sic] coming out of it was blood more or exudate more or spinal fluid, and decided that
to keep it to prevent other issues with not—with taking it out, like you get a clot or a hematoma.
That would be my guess of why I kept it. I don’t remember vividly, but that would be—definitely
had to consider it, because I remember looking at it, remember reviewing the output of it.
Tr. of Bench Trial (Doc. 46) at 300:14–24.
176
See Pls.’ Trial Ex. 1 at 1457, 1521; Tr. of Bench Trial (Doc. 45) at 206:16–207:4.
177
See Pls.’ Trial Ex. 1 at 1493.
178
See id.
179
See id.
180
Tr. of Bench Trial (Doc. 46) at 302:8–9.
181
Id. at 302:9–15. See also Pls.’ Trial Ex. 1 at 1492 (“CT shows enlarging ventricle with loss of CSF space and
sylvian [fissure] tightness”).

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a result, an external ventricular drain (“EVD”) was placed at 22:20.182 Dr. Bahgat testified that an

EVD was necessary to measure the pressure of the brain and drain fluid to reduce the pressure, if

necessary.183

54. Mr. Dobbs had another CT scan the next morning (October 11th), which showed

that the “stability of the bleed . . . was the same.”184 At this point, Mr. Dobbs’s drain output over

the previous twenty-four hours was 300 milliliters, which, according to Dr. Bahgat, was “within

what you would expect.”185 The Progress Notes from 08:00 on October 11th reflect that Mr. Dobbs

“does not follow commands but will withdraw to painful stimuli. Occasional blinking of eyes

noted but [Mr. Dobbs] does not open eyes to command or track around room.”186 At 10:34, a

check-up of Mr. Dobbs showed the “EVD working well with very low pressure. CSF is clear. . . .

Continue surgical drains which have thin output serosanginous [sic].”187

55. On the morning of October 12th, Mr. Dobbs underwent an electroencephalography

(“EEG”) to determine whether he was having seizures.188 The impressions of the EEG showed

that the EEG was “[a]bnormal . . . because of generalized slowing of teh [sic] EEG activity and

frequent bifrontal epileptiform discharges. This [is] indicative of moderate-severe generalized

cerebral [dysfunction] with bifrontal potential epileptogenicity.”189

182
See Pls.’ Trial Ex. 1 at 1493.
183
See Tr. of Bench Trial (Doc. 46) at 302:19–21.
184
Id. at 303:8–11.
185
Id. at 303:18–20. See also Pls.’ Trial Ex. 1 at 1458.
186
Pls.’ Trial Ex. 1 at 1461.
187
Id. at 1456–57.
188
See id. at 1401; Tr. of Bench Trial (Doc. 46) at 307:3–8.
189
Pls.’ Trial Ex. 1 at 1401–02.

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56. Because of “worsening mentation since yesterday[,]” Mr. Dobbs had another CT

scan on October 12th.190 This scan revealed “[t]hat everything [was] stable.”191 (Dr. Bahgat

testified that, when the bleeds are stable, it simply means they have not worsened.192) However,

Mr. Dobbs’s “EVD and lumbar JP drains” were “pulled” at this time.193 Dr. Bahgat testified that

he decided to remove the drains at this time because:

[T]he EVD was, the pressure was not high, the ICPs were controlled. We didn’t
need to drain anything out of it. We got a repeat CT scan. The ventricles weren’t
enlarged, were appropriate size, so they had no function. We had closed them that
morning and then got a scan later in the day, make sure that it doesn’t expand. So
we took them out, the JP drain. That time the flow coming out of it had gone down.
The odds of having a hemorrhage or anything concerning that I needed to drain was
not needed, so I pulled them out. They did the function that I wanted them to do.194

57. On October 13th, Mr. Dobbs’s consciousness level was not improving, so another

MRI was done.195 Dr. Bahgat testified that “[f]or the most part [the findings of the MRI were]

stable. . . . [T]he ventricles were a little bit larger, but there was air in them probably from taking

out the EVD . . . .”196 When Dr. Bahgat checked on Mr. Dobbs after his most recent MRI,

Dr. Bahgat observed that Mr. Dobbs had a “[s]table neuroexam, slight improved flexation on left

[upper extremity], flex both [lower extremity] to minimal stimulation, [o]pen eye to stimuli once

. . . .”197 Dr. Bahgat testified that these observations indicated that Mr. Dobbs “was stable” and

“[n]othing had changed.”198

190
Id. at 1399.
191
See Tr. of Bench Trial (Doc. 46) at 307:13.
192
See id. at 317:8–12.
193
Pls.’ Trial Ex. 1 at 1426.
194
Tr. of Bench Trial (Doc. 46) at 308:7–18.
195
See id. at 309:4–17; Pls.’ Trial Ex. 1 at 1329–30.
196
Tr. of Bench Trial (Doc. 46) at 309:14–16. See also Pls.’ Trial Ex. 1 at 1328.
197
Pls.’ Trial Ex. 1 at 1328.
198
Tr. of Bench Trial (Doc. 46) at 309:25.

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58. Dr. Bahgat’s next interaction with Mr. Dobbs was the following day (October 14th)

around noon. Dr. Bahgat’s notes and testimony reveal that nothing happened to Mr. Dobbs

overnight, and that Mr. Dobbs was “showing subtle improvement in neurological function.”199

59. Despite subtle improvement, Dr. Bahgat decided on October 15th that Mr. Dobbs

would need a second surgery.200 In deciding that a second surgery was necessary to determine

whether there was a CSF leak, Dr. Bahgat testified:

So the thought process was that he hadn’t gotten any better. There’s no significant
change. We got repeat scans that for the most part were stable. Other than keep
watching, there’s nothing active we can do. The only thing surgical I could offer
is to say, okay, maybe he does have a leak in his back, maybe it was still leaking
some. There was nothing leaking out of the incision. The incision wasn’t puffed,
wasn’t leaking to the outside, wasn’t soft, wasn’t . . . no clear clinical indication
that would say he definitely had a leak. It was just an assumption that, okay, if he
was having a leak, why not to go in. The risk of going in again is low; and look at
it. If there is a leak we can fix it, give him a better chance. And I explained to the
family as best as I could this is what we’re thinking. It may end up being a helpful
surgery, maybe not, but the risk is low, and the potential benefit could be worth
it.201

Because Mr. Dobbs was unable to give consent, Dr. Bahgat “believe[s]” he obtained consent from

Mrs. Dobbs to perform the re-exploration surgery.202 Again, while there were other people in the

operating room with Dr. Bahgat for the re-exploration surgery, including an anesthesiologist (or

anesthetist), neither party called any of those other people to testify at trial.203

60. The October 15th re-exploration surgery revealed that, after “the paraspinal

muscles were separated with a cerebellar retractor[,]” Dr. Bahgat “could see fluid within the

199
Pls.’ Trial Ex. 1 at 1290. See also Tr. of Bench Trial (Doc. 46) at 310:11–14 (“So seems to be he’s opening his
eyes, had more consistent responses. So maybe somewhat better, but really nothing major worse or better, just some
very subtle improvement I would say.”).
200
See Pls.’ Trial Ex. 1 at 1238–41.
201
Tr. of Bench Trial (Doc. 46) at 311:3–19 (ellipsis in original).
202
Id. at 311:20–23.
203
See Pls.’ Trial Ex. 1 at 1981.

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epidural space.”204 “The fluid was suctioned out . . . to inspect the site of the dural tear[,]” and

“[t]he prior muscle graft and Gelfoam was removed and the tear was identified.”205 The Operative

Findings in the post-operative report state that “[t]he site of the prior dural tear was explored[,]

[and] CSF could be seen coming from the tear but was not aggressive.”206

61. At one point, Dr. Bahgat testified that, “[t]heoretically, [Mr. Dobbs] could have

been not leaking at the time . . . [a]nd once [Dr. Bahgat] opened it the pressure is less and it could

start to leak.”207 He also testified that he saw “some fluid coming out of the edges of the repair[,]”

but doesn’t “remember if it was when [he] manipulated it or before [he] even touched it . . . .”208

Dr. Bahgat testified that the leak was “nothing that was like a gush of fluid.”209 Instead, according

to Dr. Bahgat, it was “[j]ust like a small trickle.”210 Dr. Bahgat testified that it could have been “a

combination of blood, normal tissue fluid, and in this case it could be CSF.”211 Dr. Bahgat could

not remember “exactly how much [fluid] it was.”212

62. At this point, “a large muscle graft was obtained and gently tucked and wrapped

around the tear.”213 Dr. Bahgat then “placed another piece of muscle graft to hold it in place after

which an onlay Gelfoam was placed soaked in blood.”214 Dr. Bahgat “sprayed DuraSeal after

204
Id. at 1980.
205
Id.
206
Id. at 1979.
207
Tr. of Bench Trial (Doc. 46) at 312:25–313:4.
208
Id. at 313:5–7.
209
Id. at 313:7–8.
210
Id. at 313:8. Dr. Bahgat testified that it was possible that the re-exploration surgery could have caused the leak.
See id. at 315:24–316:4. But he also testified that Mr. Dobbs could have had an active leak on October 15th. See Tr.
of Bench Trial (Doc. 45) at 199:16–18.
211
Tr. of Bench Trial (Doc. 45) at 199:6–8.
212
Tr. of Bench Trial (Doc. 46) at 313:8–9.
213
Pls.’ Trial Ex. 1 at 1980.
214
Id.

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which another muscle layer was placed and a Gelfoam.”215 “These were secured and held in place

with a crossing stitch after which we inspected the rest of the surgical cavity for sites of other leaks

or tears.”216 No other leaks or tears were identified.217

63. After Mr. Dobbs’s “skin was closed with a stapler[,]” he “was flipped to a supine

position . . . and an EVD catheter was placed advanced to about 6-7 cm.”218 Dr. Bahgat’s

post-operative report for the re-exploration surgery explains that on “[t]he first pass we could not

obtain any CSF so a second pass was attempted this point we could see CSF coming back but at a

very low pressure.”219 This time, Dr. Bahgat did not install a JP drain.220 A post-surgery CT scan

revealed that Mr. Dobbs’s brain bleeds were “stable, but there was more air just from putting the

catheter in, that air just got in, filled up the ventricles.”221

64. The Court finds that the re-exploration surgery revealed a CSF leak from the

original dural-tear site. It is sheer speculation to suggest that this leak only began at the time the

re-exploration surgery was conducted. Based on the chain of events and testimony discussed

above, it is far more likely that the CSF discovered during the re-exploration surgery on October

15th was from an ongoing CSF leak from Mr. Dobbs’s original dural tear during the October 9th

laminectomy. Given Dr. Bahgat’s failure to confirm the sufficiency of the seal of the dural tear in

the first surgery, the subsequent placement of a drain, and the significant amount of drainage noted

between the first surgery and the second surgery, it is more likely that CSF began to leak shortly

215
Id.
216
Id.
217
See id.
218
Id.
219
Id.
220
See Tr. of Bench Trial (Doc. 45) at 133:4–6.
221
See Tr. of Bench Trial (Doc. 46) at 316:13–23.

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after the first surgery was completed.222 While no one can know how much of the fluid collected

in the drains was CSF compared to other fluids, it is very likely that some portion of it was CSF.

The Court finds that Plaintiffs have proved this by a preponderance of the evidence.

65. The Court also finds that Plaintiffs have proved that it is more likely than not that

the drain promoted the CSF leak after the end of the October 9th surgery. Dr. Taylor explained

that a “negative pressure drain draws fluid out of the space and would promote CSF leakage from

the dura.”223 He also testified that “[t]he drain makes its [sic] more likely that the [secondary

repair] is going to fail.”224 For his part, Dr. Bahgat agreed with the Plaintiffs’ counsel’s assertion

that “a subfascial drain in that secondary closure setting promotes the movement of fluid from

inside the body to out . . . .”225 Even gravity drains encourage such leakage by creating an easy

path for the CSF to take.226 That is consistent with Dr. Day’s fervor about not placing a drain

without confirming a watertight seal. When asked whether he had ever placed a drain in such

circumstances, Dr. Day testified, “if I couldn’t fix it with suture or with a graft and then prove that

nothing’s coming with a Valsalva maneuver, then, no, that’s not something that anybody would

222
The Court cannot determine with any accuracy how much of the drainage between the two surgeries was CSF.
However, the Court can and does find that some significant portion of the drainage was CSF. See Tr. of Bench Trial
(Doc. 45) at 129:20–22 (“I think that his injury occurred following surgery, as there was CSF drained out, and a large
volume of CSF drained out the morning after surgery.”). That finding follows—at least given the preponderance-of-
the-evidence-standard—from the fact that the seal of the dural tear in the first surgery was not confirmed and that CSF
was found leaking from the same place during the re-exploration surgery. In sum, the overarching story told by the
Plaintiffs—a dural tear not confirmed to be sealed, followed by post-operative leakage of CSF into the drain, eventual
brain hemorrhage from the continuous post-operative loss of CSF, and discovery of the leakage during a second
surgery—is far more persuasive than the one told by the Government—a dural tear properly closed, no CSF in the
drains at all, CSF only found in the second surgery because that surgery somehow opened the original dural-tear site,
and a delayed brain hemorrhage arising many hours after the initial intraoperative dural tear. The Court cannot
definitively say the Government’s version of events is wrong. But the Court can definitively say that the Government’s
version of events is less likely than Plaintiffs’ version of events. Plaintiffs’ version of the events is more likely than
not what happened.
223
Id. at 100:4–6.
224
Id. at 160:23–24.
225
Id. at 209:1–4.
226
See id. See also id. at 160:23–24.

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do.”227 According to Dr. Day, no neurosurgeon in his right mind would place a drain in that

situation.228 The reasonable inference from this is that a drain—whether a gravity, negative

pressure, or suction drain—would promote or exacerbate a CSF leak.

V. The Cause of the Brain Sag and Hemorrhage

66. The Court finds that Plaintiffs have proved that it is more likely than not that the

immediate, intraoperative CSF leak from the dural tear did not—on its own—cause Mr. Dobbs’s

brain sag. Correspondingly, the Court finds that the Plaintiffs have proved that it is more likely

than not that the continuous CSF leak caused by the placement of the drain was a but-for cause

and proximate cause of the brain sag. That is, whether or not the immediate loss of CSF during

the October 9th surgery contributed to the brain sag, it is more likely than not that the brain sag

would not have occurred without the post-operative CSF leak caused by the placement of the drain.

The Court finds that Plaintiffs have proved this by a preponderance of the evidence for the

following reasons.

67. Dr. Taylor testified that he believed, within a reasonable degree of medical

certainty, that the drain caused Mr. Dobbs’s brain bleeds.229 He opined that Mr. Dobbs’s “injury

occurred following surgery, as there was CSF drained out, and a large volume of CSF drained out

the morning after surgery.”230 Dr. Taylor based this opinion “on the understanding of the

mechanism of injury, that symptoms of brain injury from intracranial hypotension and brain shift

and compressed veins and ischemia, those are all things that occur fairly quickly.”231 Quoting an

227
Tr. of Bench Trial (Doc. 47) at 764:7–13.
228
See id. at 764:14–17.
229
See Tr. of Bench Trial (Doc. 45) at 130:9–12.
230
Id. at 129:20–22.
231
Id. at 129:24–130:2.

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article titled Symptomatic Intracranial Hemorrhage After Dural Tear in Spinal Surgery—A Series

of 10 Cases and Review of the Literature (“the Allouch Article”), Dr. Taylor testified that when a

patient loses CSF, “‘brain sagging may take place and possibly promote intra cerebral

hemorrhaging as a result of stretching of cortical bridging veins.’”232 According to Dr. Taylor, the

symptoms of the insult to the brain that Mr. Dobbs suffered “occur immediately or within minutes

or an hour or two[]” of the brain sag, “not a half a day later or 16 hours later.”233 The point being,

if the symptoms occur fairly quickly after the brain sag, then the timeline is far more consistent

with a brain sag occurring hours after the surgery as opposed to a brain sag occurring during or

right after surgery.

68. Dr. Day’s testimony generally supports Dr. Taylor’s testimony that the loss of CSF

can lead to a brain hemorrhage.234 Dr. Day testified that:

[W]hen you get a loss, a sudden loss of spinal fluid, and you get this so-called
cerebellar sag, then it stretches those veins and pulls on them. These veins are
fragile. The same thing can happen up top along the cerebrum, especially near the
midline. That’s where most of our big bridging veins are, above the tentorium.
Those veins are very fragile. When they stretch, they close down. So, you know,
if it’s loose, then it’s, you know, it has the volume like that. But as it stretches, it
goes like this. And some of them will tear. So whether they’re stretched and
flattened and not flowing or they actually tear, the result is the same. You’ve
interrupted the normal outflow of venous blood from that brain tissue.235

The stretching of the veins, Dr. Day concluded, could lead to a brain hemorrhage.236

232
Id. at 86:14–17, 93:11–14.
233
Id. at 129:24–130:4.
234
See Tr. of Bench Trial (Doc. 47) at 723:19–724:9.
235
Id. at 697:1–13.
236
See id. at 700:5–7, 12–13. (“And it’s because it’s the loss at the time of the big drainage of CSF is when the sag
occurs and you have the problem . . . You get the sag, the veins break, stretch, occlude, and then things go from
there.”).

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69. But Dr. Day testified that the cause of Mr. Dobbs’s brain sag—and, therefore, the

cause of the brain hemorrhage—was the loss of a large amount of CSF at the time of the dural

tear.237 In support of this theory, the Dr. Day testified that Mr. Dobbs brain sagged sometime

before 16:30 on October 9th.238 That is, the brain sagged during surgery or immediately

thereafter.239

70. Dr. Day acknowledged that Mr. Dobbs had normal neurological checks in the 15

hours following his first surgery.240 But Dr. Day suggested this was not inconsistent with his

timeline of when the brain sag occurred. According to Dr. Day:

[When y]ou occlude a vein, patient’s doing pretty well, and then usually about
12-ish hours later things start to change. And things get worse and worse, and then
you end up getting a scan somewhere between 12 and 38 hours, and there’s the
hemorrhage, it’s in the tissue. So, you know, when a vein busts initially from that
sag, you could have some hemorrhage then, but that hemorrhage is outside the brain
tissue. It’s not in the tissue like you see on Mr. Dobbs’[s] scan. That’s hemorrhage
in the tissue.241

As the Court best understands Dr. Day’s testimony, it is his opinion that the initial dural tear

resulted in a “big gush” of CSF, which caused the brain to immediately sag. But the sag did not

immediately cause the brain hemorrhage. Instead, it caused some veins to “break, stretch, occlude,

and then things go from there.”242 Dr. Day described the things going from there as a “cascade of

events[,]” with the manifestation of the insult taking place “somewhere between 12 and 38 hours”

later.243 According to Dr. Day, the ultimate manifestation is a bleed in the brain tissue (i.e., the

237
See, e.g., id. at 700:11–12, 725:20–22, 726:5–7.
238
See id. at 726:24–727:2.
239
See id.
240
See id. at 727:3–6.
241
Id. at 699:6–14. See also id. at 728:4–6 (“We know that it occurs somewhere between 12 and up to 48 hours later,
when the scans are done, when we see the hemorrhage.”).
242
Id. at 700:12–13.
243
Id. at 698:14–699:15.

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hemorrhage) no sooner than 12 hours after the sag, which immediately followed the significant

loss of CSF.244

71. Based on this theory, Dr. Day testified that, because of the significant loss of CSF

at the time of the dural tear, Mr. Dobbs’s brain hemorrhage would have occurred regardless of

Dr. Bahgat’s decision to install a drain.245 And the hemorrhage would’ve been just as severe.246

72. The Court finds that Dr. Taylor’s theory of the injury here is more likely than

Dr. Day’s theory. First, Dr. Day’s theory is premised on a fact that the Court has already concluded

did not occur—namely, an unusually large and immediate loss of CSF at the time of the

intraoperative dural tear. Dr. Day does not suggest an average release of CSF from an

intraoperative dural tear would cause the brain to immediately sag. And, given the statistics the

Court has already credited concerning the frequency of intraoperative dural tears and the

infrequency of resulting brain hemorrhages, something more than an average loss of CSF during

the surgery would be necessary to support Dr. Day’s theory.

73. Second, Dr. Taylor testified that “symptoms of brain injury from intracranial

hypotension and brain shift and compressed veins and ischemia, those are all things that occur

fairly quickly. They occur immediately or within minutes or an hour or two, not a half a day later

or 16 hours later.”247 So this really is a true battle of the experts on the timeline from CSF loss to

brain sag to brain hemorrhage. After listening to the dueling expert testimony, the Court finds

Dr. Taylor’s testimony about the usual timeline of the brain bleed more credible than Dr. Day’s

244
See id. at 699:11–25.
245
See id. at 710:8–17.
246
See id. at 710:12–17.
247
Tr. of Bench Trial (Doc. 45) at 129:25–130:4.

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testimony.248 It is not that Dr. Day’s scenario is impossible. Rather, the Court believes the

Dr. Day’s scenario is more of an outlier than Dr. Taylor’s scenario.249

74. The facts in this case line up better with the more compressed timeline testified to

by Dr. Taylor. Put another way, Dr. Taylor’s testimony concerning the likely chain of events

seems to be consistent with, and accounts for, all the facts found by the Court so far in this case—

especially the absence of a large and immediate “gush” of CSF during the October 9th surgery.

And given the compressed timeline between the CSF loss, brain sag, and hemorrhage, it is far less

likely that the brain sag occurred during or immediately after the surgery than several hours later.

This, in turn, means that the brain sag must have occurred because of the post-operative CSF leak

into the drain (either alone or in combination with the original CSF leak during surgery), which

eventually caused the loss of so much CSF that the remaining CSF could no longer keep that part

of the brain afloat.

CONCLUSIONS OF LAW – LIABILITY

The Dobbses brought their claim against the United States under the Federal Tort Claims

Act.250 When analyzing a claim brought under the Federal Tort Claims Act, courts apply the

substantive law of the state where the events giving rise to the complaint occurred.251 Because the

alleged medical malpractice occurred in Arkansas, Arkansas law applies.252 The Arkansas

Medical Malpractice Act governs claims of medical negligence.253

248
See Kaplan v. Mayo Clinic, 847 F.3d 988, 991 (8th Cir. 2017) (the Court of Appeals “‘give[s] due regard to the
opportunity of the district court to judge the credibility of the witnesses’” (quoting Tadlock v. Powell, 291 F.3d 541,
546 (8th Cir. 2002)).
249
See supra note 222.
250
See Compl. (Doc. 1) ¶ 1.4.
251
See Day v. United States, 865 F.3d 1082, 1086 (8th Cir. 2017).
252
See id.
253
See Ark. Code Ann. § 16-114-201 et seq.

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“[W]hen the asserted negligence does not lie within the jury’s comprehension as a matter

of common knowledge,” Arkansas statute provides that a plaintiff has the burden of proving:

(1) By means of expert testimony provided only by a medical care provider of
the same specialty as the defendant, the degree of skill and learning ordinarily
possessed and used by members of the profession of the medical care provider in
good standing, engaged in the same type of practice or specialty in the locality in
which he or she practices or in a similar locality;

(2) By means of expert testimony provided only by a medical care provider of
the same specialty as the defendant that the medical care provider failed to act in
accordance with that standard; and

(3) By means of expert testimony provided only by a qualified medical expert
that as a proximate result thereof the injured person suffered injuries that would not
otherwise have occurred.254

But there is an important tweak to this standard. In Broussard v. St. Edward Mercy Health System,

Inc., the Supreme Court of Arkansas held unconstitutional the requirement that standard-of-care

opinions must be given by a doctor of the same specialty as the defendant.255 In short, given this

gloss on the statute, Plaintiffs must prove by competent medical expert testimony: (1) the

applicable standard of care, (2) that Dr. Bahgat failed to act in accordance with that standard, and

(3) that this failure was a proximate cause of Mr. Dobbs’s injuries.256 Plaintiffs must only prove

these by a preponderance of the evidence.257

254
Ark. Code Ann. § 16-114-206(a)(1)–(3).
255
2012 Ark. 14, at 6, 386 S.W.3d 385, 389. Even though the Court is not required to make the “same specialty”
finding, the Court finds that Dr. Taylor and Dr. Day were of the same specialty as Dr. Bahgat—neurosurgery.
256
See e.g., Webb v. Bouton, 350 Ark. 254, 264, 85 S.W.3d 885, 891 (2002).
257
See id., at 261–62, 85 S.W.3d at 889.

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I. Standard of Care

Plaintiffs called Dr. Taylor as their standard-of-care expert.258 Dr. Taylor testified that he

was familiar with the standard of care for neurosurgeons.259 At the time of trial, Dr. Taylor had

performed laminectomies at least hundreds of times.260 He testified that the standard of care for

laminectomies and dural tears does not change from one locality to another; for example, it is the

same in Dallas, Texas, as it is in Little Rock, Arkansas.261

Dr. Taylor did not criticize Dr. Bahgat for causing a dural tear, and Dr. Taylor agreed that

the fact a dural tear occurred does not alone mean that Dr. Bahgat was negligent.262 Moreover, it

was Dr. Taylor’s opinion that, to a reasonable degree of medical certainty, Dr. Bahgat’s secondary

repair of Mr. Dobbs’s dural tear (as well as Dr. Bahgat’s inability to do a primary repair) was

within the standard of care.263

The meat of Dr. Taylor’s standard-of-care testimony centered on Dr. Bahgat’s failure to

perform a Valsalva maneuver and his use of a JP drain. Quoting Treatment of Dural Tears

Associated with Spinal Surgeries (“the Eismont Article”), Dr. Taylor testified that when repairing

a dural tear, “‘[a]ll repairs should be tested by using the reverse Trendelenburg position and

Valsalva maneuvers to increase intrathecal pressure. Any persistent leaks should be repaired.’”264

Still quoting the Eismont Article, Dr. Taylor testified that “‘[t]here is no evidence that simply

placing Gelfoam or muscle over a dural leak is effective. This use of Gelfoam and muscle has

258
Supra note 18. Dr. Taylor was accepted as an expert witness without objection. See Tr. of Bench Trial (Doc. 45)
at 51:7–15.
259
See Tr. of Bench Trial (Doc. 45) at 47:25–48:2.
260
See id. at 48:3–7.
261
See id. at 49:6–13, 50:4–23.
262
See id. at 141:12–21.
263
See id. at 143:12–144:1.
264
Id. at 76:11–17, 79:15–18.

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been associated with failure of closure of the dura in other series.’”265 Furthermore, Dr. Taylor

testified that the Eismont Article clearly stood for the proposition that, “in closing around the dura

when there’s been a spinal fluid leak, no drain should be used.”266

Another article Dr. Taylor relied on was Incidental Durotomy in Spine Surgery (“the

Cammisa Article”).267 This article reviewed a study of 2,144 patients, 74 of whom had dural

tears.268 None of these 74 patients with dural tears suffered brain hemorrhages.269 And all 74 dural

tears “‘were deemed watertight to Valsalva maneuver before closure of the facie and skin.’”270

Quoting the Cammisa Article (which in turn cited the Eismont Article), Dr. Taylor testified that

the “‘Valsalva maneuver was recommended to check for the completeness of repair. Finally, they

advised against placement of subfascial drains in deference to the possibility of formation of duro-

cutaneous fistula.’”271

According to Dr. Taylor, the Cammisa Article also referenced another study: the Wang

Study.272 In the Wang Study, 87 of the 88 patients had primary repairs, while only one patient had

a secondary repair.273 There, “‘[a] substantial closed suction drain was used for all patients and

remained in place for an average of 2.1 days.’”274 Considering this study, the Cammisa Article

concluded that “‘[c]losed suction wound drainage does not seem to aggravate the leak and can be

265
Id. at 80:12–15.
266
Id. at 81:19–20.
267
See id. at 82:22–25.
268
See id. at 83:8–11.
269
See id. at 83:12–16.
270
Id. at 84:13–15.
271
Id. at 85:7–11.
272
See id. at 85:15–17.
273
See id. at 85:22–25, 151:22–152:10.
274
Id. at 152:11–15.

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used safely in the presence of a dural repair.’”275 Dr. Taylor testified that the Cammisa Article and

the studies cited within the article instruct doctors “[t]hat in general, drains should be avoided, but

they can be used safely if there’s been a suture watertight closure.’”276

Dr. Taylor testified that it was not his position that a neurosurgeon should never use a

drain.277 Instead, according to Dr. Taylor, a neurosurgeon should not use a drain when there has

been a dural tear, and the dural tear was not “closed in a watertight fashion.”278 He based this

testimony on an article titled Intracranial Hemorrhage After Spine Surgery (“the Kaloostian

Article”), which, provided, in part, that “‘drain placement and continued suction at the site of dural

repair have also been proposed as a mechanism for sustained cerebral hypotension.’”279 The

Kaloostian Article further explained that “‘[r]ecent reports reflect a growing concern over the

placement of drains at the surgical site, which has emerged as one of the most consistently

confirmed variables in patients with intracranial hemorrhage after spine surgery.’”280 As

Dr. Taylor explained, the Kaloostian Article concluded that based on the eight patients studied,

“‘the presence of interoperative CSF leak and the use of drains postoperatively, with

aforementioned moderate outputs, were all common factors shared among [the] patients. This

does not indicate a causal relationship because of the lack of statistical validation, but merely that

these are factors that show an association.’”281

275
Id. at 152:20–22.
276
Id. at 86:2–6.
277
See id. at 97:15–17.
278
Id. at 97:18–20.
279
Id. at 94:21–95:1, 96:3–5.
280
Id. at 96:18–21.
281
Id. at 97:1–7.

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Dr. Taylor also testified about the Allouch Article, which the Court introduced earlier.282

The Allouch Article found that, in a survey of 12,185 patients who underwent spinal surgery, eight

of them suffered intracranial hemorrhages.283 Quoting the Allouch Article, Dr. Taylor testified

that the risk of post-operative CSF loss following an intraoperative dural tear “‘is especially

increased by suction drains[,] [which] seem to be risk factors for intracranial hemorrhage,

complicating the spinal surgery.’”284 According to the Allouch Article, “‘[i]n every case in our

series, CSF loss was enhanced through use of drains in the subfascial space. In cases of observed

durotomy, we used gravity-driven drains, whereas in the four patients with occult dural tears,

drains with negative pressure were used, according to our usual practice in our department.’”285

Importantly, the Allouch Article explained that:

In cases of intra operative durotomy and [sic] intra operative repair in a watertight
fashion should be attempted. Intraoperative assessment of sealing the dural tear
may be controlled by visual inspection under the Valsalva maneuver for 10 seconds
or longer. In complex defects, lumbar drainage should be considered.
Minimization of CSF loss during spinal surgery through the immediate closure of
a dural tear and head-down positioning of the patient is suggested.
***
In cases of intracranial hemorrhage after spinal surgery, drains should be removed,
and patients should be advised to stay in bed rest. Some investigators advocate
resting in the Trendelenburg position. We perform MRI of the spinal index region
to exclude persistent CSF leakage. In these patients, we consider revision surgery
with dural repair to reduce CSF loss if the general condition of the patient allows
it.
***

282
See generally id. at 86:14–94:3.
283
See id. at 88:3–6.
284
Id. at 88:14–17.
285
Id. at 89:10–15. Dr. Taylor explained that an occult dural tear is one where the doctors are unaware of it at the
time of the surgery. Id. at 89:17–19.

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An intentional or inadvertent opening of the dura during spinal surgery should be
managed by a watertight closure. Whenever possible, drains should be avoided or,
if necessary, placed without negative pressure.286

Finally, Dr. Taylor considered Remote Cerebellar Hemorrhage as a Complication of Lumbar

Spine Surgery (“the Lim Article”).287 In doing so, Dr. Taylor testified that drains are an associated

risk for brain hemorrhages.288

Considering the medical records, the relevant medical literature, and his own experience,

Dr. Taylor concluded, to a reasonable degree of medical certainty, that Dr. Bahgat failed to act in

accordance with the standard of care in Arkansas by installing a drain after a secondary repair.289

Dr. Taylor testified that this was a failure to act in accordance with the standard of care, even if

the Valsalva maneuver was done or the seal of the secondary repair was otherwise confirmed to

be sufficient.290

The Government called Dr. Day as its standard-of-care expert.291 To establish the standard

of care, Dr. Day testified about some of the same articles Dr. Taylor relied on, while also

considering a few additional articles.292 Like Dr. Taylor, Dr. Day testified that it was within the

286
Id. at 91:7–14, 92:19–93:1, 93:19–22.
287
See generally id. at 97:21–100:18.
288
See id. at 97:23–25. The Lim Article explained that “‘[t]he presence of a subfascial drain was observed in 42
percent, suggesting that a prolonged postoperative CSF leak may be riskier than an intraoperative leak, which would
have been promptly repaired.’” Id. at 98:18–21.
289
Id. at 51:4–6, 102:8–14, 134:20–22.
290
Id. at 102:8–19.
291
See generally Tr. of Bench Trial (Doc. 47) at 668:24–718:17. Dr. Day was accepted as an expert witness without
objection. See id. at 668:17–22.
292
One of the additional articles Dr. Day testified about was titled Cerebellar Hemorrhage After Spinal Surgery: Case
Report and Review of Literature (“the Konya Article”). See generally Tr. of Bench Trial (Doc. 47) at 710:23–712:8.
But in this article, the patient had a dural tear that was closed with a primary repair, and the doctor didn’t see any more
leakage of CSF. See id. at 711:16–712:8. This is quite distinguishable from Dr. Bahgat’s repair of Mr. Dobbs’s dural
tear. The other article was Cerebellar Hemorrhage After Spinal Surgery, Report Two of Cases and Literature Review
(“the Friedman Article”). See id. at 757:10–12. The Friedman Article discussed two patients who suffered dural tears.
See id. at 757:13–17. One patient had a drain, and the other didn’t. See id. at 757:16–17. The article does not discuss
how each patient’s dural tear was repaired, but the patient who had a drain suffered a brain hemorrhage. See id. at

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standard of care for Dr. Bahgat to attempt a secondary repair of the dural tear when he was unable

to do a primary repair.293 Dr. Day also testified that the simple failure to document the Valsalva

maneuver in the post-operative report was within the standard of care, so long as Dr. Bahgat did,

in fact, perform the Valsalva maneuver.294

When asked about the use of a drain after a spinal surgery, Dr. Day testified that “if you

didn’t use a drain you’d be criticized . . . .”295 Dr. Day explained that this is because excess tissue

fluid and blood from the surgery could collect and cause inflammation and swelling.296

Furthermore, Dr. Day testified that “when you look at the bulk of people that have been reported

[to] have had [a brain hemorrhage], the presence of a drain is not a common factor. A CSF leak

is a common factor.”297 According to Dr. Day’s testimony, there are “just as many people that had

a spinal fluid leak and had no drain placed that ended up with a delayed hemorrhage in those cases,

as those who had a leak and then there was a drain. So what that tells me is the drains don’t make

a difference.”298

But during cross-examination, Dr. Day agreed that it is important for a doctor to do the

Valsalva maneuver so he can know whether the dural tear is sufficiently sealed.299 Dr. Day went

757:13–15, 22–24. Dr. Day’s testimony about the Friedman Article seems to support the Plaintiffs’ theory that a drain
can increase the risk of a brain hemorrhage.
293
See id. at 680:13–681:15.
294
See id. at 687:2–8.
295
Id. at 687:13–14. Despite this assertion, Dr. Day later testified that he did not criticize Dr. Bahgat’s decision to not
install a drain after the re-exploration surgery. See id. at 751:5–11. Dr. Day maintained this assertion, even though
the repair of the dural tear in the re-exploration surgery consisted of many more layers than the first repair (as well as
a suture). See id. at 751:12–14. Dr. Day later agreed with the Government’s assertion that one reason Dr. Bahgat
would not have used a drain in the second surgery is “because the fluids had gone down and the drains had done their
job . . . .” Id. at 766:5–11.
296
See id. at 688:2–689:10.
297
Id. at 716:15–17.
298
Id. at 716:20–24.
299
Id. at 729:25–730:4.

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on to testify that, “[i]f you have an active leak, you’re not going to use a drain . . . you’re not going

to put a drain in and continue to suck out spinal fluid.”300 Furthermore, when asked whether he

had ever placed a drain in a situation where he did not achieve a sufficient closure of the dural tear,

Dr. Day testified: “No. If there’s—if I couldn’t fix—if I couldn’t fix it with suture or with a graft

and then prove that nothing’s coming with a Valsalva maneuver, then, no, that’s not something

that anybody would do.”301 Again, according to Dr. Day, no neurosurgeon in his right mind would

place a drain in that situation.302 This opinion was clearly given to a reasonable degree of medical

certainty.

Considering Dr. Taylor’s and Dr. Day’s expert testimony (to a reasonable degree of

medical certainty) about the use of the Valsalva maneuver and the placement of a drain after a

dural tear, Plaintiffs have proved by a preponderance of the evidence that the standard of care

requires a doctor to (1) check—either by way of the Valsalva maneuver or reverse Trendelenburg

position—that the repair of a dural tear is sufficiently sealed, and (2) not place a drain—whether

gravity, negative pressure, or high suction—if the doctor cannot determine that the repair of the

dural tear is sufficiently sealed.

II. Deviation From the Standard of Care

Plaintiffs must also prove by a preponderance of the evidence that Dr. Bahgat “failed to act

in accordance with” the applicable standard of care—i.e., that Dr. Bahgat did not test the

sufficiency of the secondary repair’s seal, but he nevertheless installed a drain.303 Because the

Court has found that Dr. Bahgat did not perform the Valsalva maneuver or otherwise test the

300
Id. at 730:4–5, 10–11.
301
Id. at 764:7–13.
302
See id. at 764:14–17.
303
Ark. Code Ann. § 16-114-206(a)(2).

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sufficiency of the secondary repair’s seal, Plaintiffs have proved by a preponderance of the

evidence that Dr. Bahgat failed to act in accordance with the applicable standard of care by placing

a JP drain.304

Both Dr. Taylor and Dr. Day testified that, to a reasonable degree of medical certainty, the

installation of a drain after a secondary repair falls below the standard of care when the seal of the

secondary repair has not been tested to see whether the seal was sufficient. These opinions were

clearly made to a reasonable degree of medical certainty. And even though Dr. Day testified that

physician judgment is a part of neurosurgery—particularly in the context of weighing the risks of

surgery and the likelihood of more common complications versus less common complications—

he did not testify that physician judgment allows a surgeon to place a drain in the absence of a

confirmed watertight seal of a dural tear.305 Considering this, Plaintiffs have proved by a

preponderance of the evidence that Dr. Bahgat failed to meet the standard of care by installing a

drain (whether a gravity drain or other type of drain) without first performing the Valsalva

maneuver to confirm a watertight seal of the dural tear.

III. Proximate Cause

Finally, Plaintiffs must prove (by a preponderance of the evidence) that, “as a proximate

result” of Dr. Bahgat’s failure to act in accordance with the applicable standard of care, Mr. Dobbs

“suffered injuries that would not otherwise have occurred.”306 “[I]t is not enough for an expert to

304
The Government all but conceded during closing arguments that, if the Court finds that Dr. Bahgat did not perform
the Valsalva maneuver or otherwise check the sufficiency of the secondary repair’s seal, the Government loses on the
standard-of-care and breach issues. See Tr. of Bench Trial (Doc. 48) at 968:1–970:14.
305
See Tr. of Bench Trial (Doc. 47) at 713:12–22. Again, a watertight seal is possible even with a secondary repair.
See, e.g., Tr. of Bench Trial (Doc. 45) at 196:9–23. When the Valsalva maneuver is used, and no CSF leaks, a
watertight seal is confirmed. See id. at 66:3–11.
306
Ark. Code Ann. § 16-114-206(a)(3).

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opine that there was negligence that was the proximate cause of the alleged damages.”307 “The

opinion must be stated within a reasonable degree of medical certainty or probability.”308 That

standard has been satisfied here.

Under Arkansas law, for a cause to be considered a proximate cause of injury, the cause

must be a but-for cause of the injury.309 However, while that is necessary, it is not sufficient.310

In addition, there must be a sufficiently tight, legally cognizable nexus between the cause and the

injury.311 In short, a “[p]roximate cause is ‘that which in a natural and continuous sequence,

unbroken by any efficient intervening cause, produces the injury, and without which the result

would not have occurred.’”312 That is, Plaintiffs must prove “causation in fact and legal

causation.”313

The Court has already found above—based on the expert medical testimony given to a

reasonable degree of medical certainty—that Mr. Dobbs’s brain hemorrhage was a direct result of

the continuous, post-operative CSF leak, which occurred because of the use of a drain without

confirmation of a watertight seal of the intraoperative dural tear. The Court’s findings above

already satisfy but-for (factual) causation. Without the continuous post-operative CSF leak, there

would have been no brain sag and no brain hemorrhage. Legal causation is also satisfied by the

Court’s previous factual findings. The line from using a drain in the absence of a confirmed

307
Williamson, 348 Ark. at 311, 72 S.W.3d at 492.
308
Id.
309
See Ford v. St. Paul Fire & Marine Ins. Co., 339 Ark. 434, 437, 5 S.W.3d 460, 462–63 (1999) (explaining that the
Arkansas Medical Malpractice Act “implements the traditional tort standard of requiring proof that but for the
tortfeasor’s negligence, the plaintiff’s injury or death would not have occurred[]” (internal quotation marks omitted)).
310
See Ark. Code Ann. § 16-114-206(a)(3).
311
See id.
312
Dodson v. Charter Behav. Health Sys. of Nw. Ark., Inc., 335 Ark. 96, 105, 983 S.W.2d 98, 103 (1998) (quoting
Union Pac. R.R. Co. v. Sharp, 330 Ark. 174, 181, 952 S.W.2d 658, 662 (1997)).
313
Id.

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watertight seal of the dural tear, to the continuous post-operative CSF leak, to the brain sag, to the

brain hemorrhage, is short, direct, and unbroken by any intervening cause. The trial testimony

shows this to a reasonable degree of medical certainty. The Court now turns to damages.

FINDINGS OF FACT – DAMAGES

1. When Mr. Dobbs suffered the brain hemorrhage, he was 61 years old.314

2. Mr. Dobbs is a retired United States Marine.315 He served in the Marines for 32

years.316

3. While in the Marines, Mr. Dobbs completed multiple combat tours.317 He also

served as a drill instructor and aircraft structures mechanic.318

4. Mr. Dobbs is married to Eileen Dobbs, and they have been married since June

2015.319

5. Mr. Dobbs first saw Dr. Bahgat about neck and arm pain in June of 2017.320

Dr. Bahgat ordered physical therapy and a regimen of steroid injections.321 Mr. Dobbs returned

for a follow-up appointment with Dr. Bahgat in September of 2017 and reported that his neck pain

had improved.322 But Mr. Dobbs now complained about lower back pain, so Dr. Bahgat ordered

imaging and more physical therapy.323

314
See Tr. of Bench Trial (Doc. 45) at 54:11–12.
315
See, e.g., Tr. of Bench Trial (Doc. 47) at 576:22.
316
See id.
317
See id. at 577:6–13.
318
See Tr. of Bench Trial (Doc. 48) at 880:19–24.
319
See Tr. of Bench Trial (Doc. 47) at 574:19–24.
320
See Pls.’ Trial Ex. 1 at 1709; Tr. of Bench Trial (Doc. 46) at 248:17–24.
321
See Pls.’ Trial Ex. 1 at 1709 (“[W]ill order PT and and [sic] ESI and will FU in 3 months . . . .”).
322
See Tr. of Bench Trial (Doc. 46) at 250:14–20.
323
See id. at 250:20–25; Pls.’ Trial Ex. 1 at 1671.

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6. As reflected in Dr. Bahgat’s September 2017 notes, Mr. Dobbs “ha[d] noweakness

[sic], no bowel or bladder problems[.]”324 Dr. Bahgat’s physical exam of Mr. Dobbs showed that

Mr. Dobbs was “[a]lert and oriented to person, place” and had “[f]luent comprehensive speech.”325

Mr. Dobbs had “[n]o dysarthria, no dysphasia[,] CN II-XII grossly intact.”326 Dr. Bahgat also

observed that Mr. Dobbs’s “[f]ace [was] symmetric with no mouth droop.”327 Concerning

Mr. Dobbs’s motor power and strength, Dr. Bahgat noted that “Right UE 5/5, LE 5/5[,] [l]eft UE

5/5, LE 5/5[,] [n]ormal tone and bulk bilaterally[,] [c]erebellar function with finger-to-nose testing

normal[,] [s]ensation to light touch and pin prick is normal[,] [r]eflex are normal, [n]egative

Babinski sign[,] [g]ait normal, [and] kyphotic posture.”328 Dr. Bahgat also noted that Mr. Dobbs

had an earlier “lumbar decompression” surgery in August 2016.329 Dr. Bahgat’s assessment of

Mr. Dobbs in September 2017 provided:

X-ray shows L3-4 laminectomy[,] patient has kyphotic posture, will order [a] long
spine x-ray to assess his sagital [sic] balance[,] will start PT to help with his muscle
stifness [sic] and range of motion since with effort he is able to stnad [sic] up stright
[sic] and if needed will order an ESI. If these maesures [sic] fail will need an MRI
to better assess his spinal condition but will wait for now.330

The Court finds all these notes to be an accurate reflection of the facts.

7. Mr. Dobbs returned to Dr. Bahgat in February 2018 for another follow-up

appointment.331 At that visit, Mr. Dobbs “complain[ed] of constant aching lower lumbar pain in

324
Pls.’ Trial Ex. 1 at 1669.
325
Id. at 1670.
326
Id.
327
Id.
328
Id. at 1670–71.
329
Id. at 1669.
330
Id. at 1671.
331
See id. at 1628.

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the midline that increases with sitting and relieved partially with standing.”332 Mr. Dobbs also

complained to Dr. Bahgat that the pain sometimes radiated to his inner thigh and groin.333 Despite

chiropractic adjustments and steroid injections, Mr. Dobbs complained that “[h]is pain ha[d]

become increasingly intense[,]” which “affected his day-to-day living and ability to bend[,] sits

[sic] and even sleep comfortably.”334

8. Based on this, Dr. Bahgat’s assessment of, and plan for, Mr. Dobbs was as follows:

Patient’s MRI shows multilevel degenerative disc disease with spondylosis and a
right L2-3 disc collapse with root compression. His standing MRI shows a positive
sagittal balance of 4-5 cm.

Patient has back pain with significant spondylosis Modic changes at multiple levels.
I explained to the patient if his main problem is his leg pain and an L2-3
decompression would help with his radicular pain. The patient states that his main
problem is his back in this case he would require a multilevel fusion. The patient
has not had any recent physical therapy and and [sic] would like to try that prior to
having an extensive procedure.

Will plan for physical therapy if that fails then the patient may require an L2-S1
fusion either from a combined anterior and posterior approach O just posterior
approach. Patient will follow up according to his progression with physical
therapy.335

Mr. Dobbs followed Dr. Bahgat’s direction and went to physical therapy.336

9. Mr. Dobbs again saw Dr. Bahgat in July 2018.337 By this point, Mr. Dobbs had

“tried physical therapy and injections but his pain ha[d] continued to progress.”338 As the July

332
Id.
333
Id.
334
Id. Dr. Bahgat’s observations of Mr. Dobbs’s neurological and motor strength characteristics were unchanged
from the September 2017 examination, except that Dr. Bahgat now characterized Mr. Dobbs’s kyphotic posture as
“slight[.]” Compare id., with id. at 1670–71.
335
Id. at 1628.
336
See Tr. of Bench Trial (Doc. 45) at 174:7–17; Pls.’ Trial Ex. 1 at 1614.
337
See Pls.’ Trial Ex. 1 at 1614.
338
Id.

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2018 medical records reflect, Mr. Dobbs’s “pain [was] a constant aching pain in his low lumbar

region” that radiated into his legs and “affect[ed] his walking standing up all all [sic] activity.”339

But Mr. Dobbs “ha[d] no weakness and no focal deficits.”340

10. Mr. Dobbs’s pre-surgery “MRI showed multilevel degenerative disc disease with

spondylosis and Modic changes at the L2-3 and also extensive changes at L3-4 L4-5 and L5-

S1.”341

11. Based on the foregoing, before the brain hemorrhage, Mr. Dobbs suffered from

some chronic back pain, but otherwise had normal cognitive and neurological functions. The back

pain made some daily activities more difficult and painful, but it did not appear to prevent him

from doing the normal activities of daily life.

12. After the brain hemorrhage, Mr. Dobbs’s physical and cognitive abilities were

severely diminished. For example, he had expressive aphasia—i.e., the inability to speak—on the

morning after the surgery.342 A little over a week later, on October 18th, Mr. Dobbs had

spontaneous, non-purposeful movement.343 Mr. Dobbs was able to “[f]urrow[] [his] brow to

noxious stimuli.”344 But he did not obey commands.345 Mr. Dobbs could not grip with either

339
Id.
340
Id.
341
See id. at 1985.
342
See id. at 1540; Tr. of Bench Trial (Doc. 45) at 113:25–114:2.
343
See Pls.’ Trial Ex. 1 at 1065, 1076, 1082.
344
See id.
345
See id.

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hand.346 His right hand was curled tight, and his left hand was flaccid.347 As the medical notes

say, Mr. Dobbs had a “[n]eurologial impairment due to CVA[.]”348

13. On October 19th, Mr. Dobbs had “some neurological improvement although it

[was] fluctuating[.]”349 Mr. Dobbs was able to wiggle his toes on command and, in one instance,

was able to give a thumbs-up.350

14. On October 20th, Mr. Dobbs was transferred via helicopter to Houston Methodist

Hospital, where he was admitted to the neuro-intensive care unit (“NICU”).351

15. Upon admission to Houston Methodist Hospital, it was determined that Mr. Dobbs

had suffered a frontal intracranial hemorrhage and a bilateral cerebellar intracranial hemorrhage

and had acute respiratory failure.352 He was in a coma and had to be put on a ventilator.353 On

October 22nd, doctors at Houston Methodist determined it was necessary to place a feeding tube

and perform a tracheotomy.354 Although the Court cannot determine from the Houston Methodist

medical records when Mr. Dobbs awoke from his coma, the reasonable inference from the

evidence is that he awoke well before November 20th.

16. In any event, Mr. Dobbs underwent a month of treatment at Houston Methodist’s

NICU before doctors concluded that “admission to inpatient rehabilitation [was] medically

346
See id. at 1055, 1065, 1076, 1082.
347
See id.
348
Id. at 1065, 1076, 1082. “CVA” is a cerebrovascular accident.
349
Id. at 1017.
350
See id.
351
See id. at 953; Pls.’ Trial Ex. 6 at 1, 495.
352
See Pls.’ Trial Ex. 6 at 4, 16, 24, 26.
353
See id. at 16; Pls.’ Trial Ex. 1 at 971, 1054. While at Houston Methodist, Mr. Dobbs developed several additional
complications, including a urinary tract infection, a pulmonary embolism, and deep vein thrombosis. See Pls.’ Trial
Ex. 6 at 474.
354
See Pls.’ Trial Ex. 6 at 15.

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necessary.”355 On November 20th, Mr. Dobbs was discharged from the NICU and entered

inpatient rehabilitation.356 His discharge notes showed that Mr. Dobbs had “gradually

improved . . . .”357

17. Among the goals of Mr. Dobbs’s admission to the in-patient rehabilitation program

were to “improve functional independence and decrease caregiver burden[.]”358 To accomplish

these goals, Mr. Dobbs would need:

24 hour rehabilitation nursing for management of bowel, bladder, skin integrity,
medication management, safety measures and preventing risk factors and
complications . . . [and] will require a minimum of 15 hours every 7 days throughout
the hospitalization, including at least the following: 1-2 hours Physical Therapy,
1-2 hours Occupational Therapy and 1 hour Speech-Language pathology,
Neuropsychology. These disciplines will be needed in order to improve [Mr.
Dobbs’s] impairments in mobility, transfers, activities of daily living, swallowing
and cognition and evaluation of durable medical equipment if needed at
discharge.359

18. On December 12, 2018, Mr. Dobbs was discharged from Houston Methodist’s in-

patient rehabilitation and returned to his home in Cotter, Arkansas.360 As the discharge notes

showed, Mr. Dobbs was “referred to [r]ehab for extensive therapy services and for further medical

management & close monitoring of his medical condition.”361

355
Id. at 474.
356
See id.
357
Id. at 149.
358
Id. at 487.
359
Id. at 488.
360
Id. at 519.
361
Id. at 513.

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I. Personal Observations of Mr. Dobbs’s Post-Hemorrhage Changes

19. Mrs. Dobbs testified that, before the brain hemorrhage, Mr. Dobbs was “very

strong” and “very physically fit.”362 Now he is “weaker and very unstable.”363 The Court credits

this testimony and finds it as fact.

20. However, that is not the whole picture. Despite Mrs. Dobbs’s description of her

husband’s diminished physical abilities, he still suffered from some physical deficits before his

brain hemorrhage. Mr. Dobbs had chronic back pain (the underlying reason for the

laminectomy).364 He also suffered from lumbar spondylosis, osteoarthritis, degenerative joint

disorder, cervical disc disorder, hypertension, and gastroesophageal reflux disease (“GERD”), and

he had problems with neck pain that radiated to his shoulder.365 Mrs. Dobbs testified that

Mr. Dobbs “had trouble with his hands” before the brain hemorrhage.366 He also had problems

with his gait, and he was diagnosed with neuropathy before the brain hemorrhage.367 As a result,

he had some balance issues and problems with falling before he suffered the brain hemorrhage.368

He also (at least in 2016) had difficulty walking barefoot and experienced dizziness and light-

362
Tr. of Bench Trial (Doc. 47) at 635:9–13.
363
Id. at 635:14–16.
364
See, e.g., Tr. of Bench Trial (Doc. 46) at 367:8–10; Tr. of Bench Trial (Doc. 47) at 639:5–17, 670:18–21; Tr. of
Bench Trial (Doc. 48) at 824:24–825:1.
365
See, e.g., Tr. of Bench Trial (Doc. 45) at 249:20–24; Tr. of Bench Trial (Doc. 46) at 367:11–24; Tr. of Bench Trial
(Doc. 48) at 825:2–10.
366
Tr. of Bench Trial (Doc. 47) at 568:13–14.
367
See, e.g., Tr. of Bench Trial (Doc. 46) at 368:3–4; Tr. of Bench Trial (Doc. 47) at 568:12; Tr. of Bench Trial (Doc.
48) at 825:11–12.
368
See, e.g., Tr. of Bench Trial (Doc. 46) at 368:5–7; Tr. of Bench Trial (Doc. 48) at 825:13–15; Pls.’ Trial Ex. 1 at
1805.

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headedness when standing.369 And on top of all that, he suffered from general high levels of

pain.370 Again, all of this was before the brain hemorrhage.

21. As Mrs. Dobbs testified, Mr. Dobbs likes to fish, and the two of them used to go

out on their boat together every week.371 They would also hike through the woods on their property

and ride four-wheelers around the neighboring properties.372

22. After the brain hemorrhage, Mr. Dobbs can no longer fish or go out on his boat.373

The one instance when Mr. Dobbs tried to take his boat out after his brain hemorrhage “turned into

a disaster[,]” and Mr. Dobbs’s daughter’s boyfriend had to “jump into the driver’s seat . . . .”374

Mr. Dobbs has not attempted to drive the boat since this incident because Mrs. Dobbs “won’t let

him.”375

23. Nor can Mr. and Mrs. Dobbs go on walks or hikes around their property anymore.376

Mrs. Dobbs credibly testified that, after the brain hemorrhage, Mr. Dobbs “can’t do it anymore

[because] [h]e doesn’t have the balance . . . [and] [their] land is not flat . . . .”377 Mrs. Dobbs

credibly explained that “even if there’s a rock on the road, [Mr. Dobbs] can trip over that.”378

369
See Pls.’ Trial Ex. 1 at 1821–22.
370
See, e.g., Tr. of Bench Trial (Doc. 46) at 368:8–10; Tr. of Bench Trial (Doc. 48) at 825:16–17. Mr. Dobbs also
had an earlier back surgery and knee replacement in 2016, and an arthroscopy of his right shoulder in 2017. Tr. of
Bench Trial (Doc. 47) at 586:14–22; Tr. of Bench Trial (Doc. 48) at 826:19–827:2.
371
See Tr. of Bench Trial (Doc. 47) at 580:15–581:5.
372
See id. at 584:22–585:5, 635:17–25.
373
See id. at 581:17–582:1.
374
Id. at 582:4–10.
375
Id. at 582:18–22.
376
Id. at 636:7–9.
377
Id. at 636:11–13.
378
Id. at 636:14–15.

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24. Mr. Dobbs has stopped driving his tractor around his nine-acre property since his

brain hemorrhage.379 While he has been able to drive his four-wheeler “down to get the mail and

drive it back up[,]” he does not drive the four-wheeler around their property (or any of the

neighboring property) like he used to do.380 He has, however, visited his neighbor “once in a while

on his four-wheeler . . . .”381

25. A neurologist signed of

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10008345. Public record. Not legal advice.