STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

CAROL TRENTALANGE, )

)

)

Petitioner, )

)

vs. ) CASE NO. 91-6305

) DEPARTMENT OF ADMINISTRATION, ) DIVISION OF RETIREMENT, )

)

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, the Division of Administrative Hearings, by its duly designated Hearing Officer, William R. Cave, held a formal hearing in the above- captioned case on April 13, 1992, in Sarasota, Florida.

APPEARANCES

For Petitioner: James A. Sheehan, Esquire

341 Third Street South Sarasota, Florida 33701

For Respondent: Stanley M. Danek, Esquire

Division of Retirement Cedars Executive Center 2639 North Monroe Street Building C

Tallahassee, Florida 32399-1560 STATEMENT OF THE ISSUE

The issue to be decided is whether the Petitioner is entitled to in-line- of-duty death benefits on the retirement account of husband, Donald Trentalange, deceased, under the Florida Retirement System, Chapter 121, Florida Statutes.

PRELIMINARY STATEMENT

Sometime after the death of her husband, on November 2, 1990, Carol Trentalange applied to the Division of Retirement (Division) for in-line-of-duty death benefits on the retirement account of her husband, Donald Trentalange, under the Florida Retirement System (FRS). By letter dated September 6, 1991, the Division notified the Petitioner that her application for in-line-of-duty death benefits was denied. A timely Petition for Formal Agency Action was filed by the Petitioner with the Division. The Division referred the matter to the Division of Administrative Hearings for assignment of a hearing officer, and this proceeding ensued.

At the hearing, the Petitioner testified in her own behalf, but presented no other witnesses. The deposition of T. Z. Coutinho, M.D.; Joseph Krzanowski, Ph.D.; and Herman Weber, M.D.; were received as evidence in lieu of their testimony at the hearing as Petitioner's Exhibits 2, 3 and 4. Petitioner's Exhibits 1, 5 and 6 were also received as evidence in this case. Respondent presented the testimony of James C. Wilson, M. D. ,and Linda Jones. The deposition of Larry D. Fannin, Ph.D.; Diane Adair, R.N.; Phillip Tally, M.D.; John Byrnes, M.D.; and Gary Hansen, M.D.; were received as evidence in lieu of their testimony at the hearing as Exhibits 1, 2, 3, 4 and 5. Respondent's Exhibits 6 through 12 were also received as evidence in this case.

There was no transcript of this case filed with the Division of Administrative Hearings. The parties requested and were allowed until April 28, 1992, to file their proposed findings of fact and conclusions of law. A ruling on each proposed finding of fact submitted by the parties has been made as reflected in an Appendix to the Recommended Order.

FINDINGS OF FACT

Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of fact are made:

1. Donald Trentalange (Trentalange), the deceased husband of the Petitioner, Carol Trentalange, was employed as a teacher of emotionally handicapped children by the Sarasota District School Board, and had in excess of

   16 years of creditable service in the FRS as of the date of his death on November 2, 1990. By virtue of her husband's length of service and compensation level, Mrs. Trentalange was eligible to receive an Option No. 3 benefit which provided her with a monthly retirement benefit for life in the amount of

   $431.00. At her death the benefit would cease.

   
   

2. Trentalange had been diagnosed with myeloproliferative disorder and myeloid metaplasia on November 24, 1987, by Dr. Coutinho (Coutinho), and he continued to follow Trentalange and the course of the disease from that time forward. Trentalange did not suffer any flare-ups of the disease prior to July 24, 1990. Although Myeloproliferative syndrome was the diagnosis of Coutinho, it was more consistent with myelofibrosis, a disorder of the bone marrow which leads to the formation of fibrous tissue in the bone, as well as the liver, the spleen and other blood producing organs. The result is that the bone marrow is basically destroyed, and then the fibrous tissue sets in and may be transformed into leukemia after several years.

   
   

3. In April, 1989, Trentalange had a fight with a student and was injured in his lower back which resulted in back problems. Trentalange came under the treatment of Dr. Hidalgo who prescribed muscle relaxants. Trentalange took three or four of the pills and developed a headache. Trentalange discontinued using the muscle relaxants and called Dr. Hidalgo who advised him to discontinue taking the pills. Trentalange then began seeing a chiropractor; but, his back continued to get worse.

   
   

4. Trentalange was seen in the emergency room of Doctors Hospital of Sarasota (Hospital) on July 24, 1990 by Dr. Zetts. Trentalange was complaining of abdominal pains in the right upper quadrant and epigastric area. It was also noted that his sclerae were slightly yellow. His liver function tests were slightly elevated.

5. Trentalange was seen by Coutinho on July 26, 1990, and Coutinho noted that the liver function tests were higher than previous liver function tests. Coutinho diagnosed Trentalange's condition as possible cholestatic jaundice secondary to erythromycin. Another physician had prescribed erythromycin, an antibiotic, for some type of infection, possibly bronchitis. Coutinho told Trentalange to discontinue the use of erythomycin. On Trentalange's visit of August 6, 1990, Coutinho notes that the possible cholestatic jaundice due to erythromycin had resolved, based on the improvement of the liver function tests. Coutinho also advised Trentalange to avoid using erythomycin. Although Petitioner contends that on this visit Trentalange advised Coutinho that he was allergic to tylenol and motrin and that Coutinho advised Trentalange to avoid using tylenol and motrin, there is no indication of this in Coutinho's medical records. Apparently, Coutinho did not associate a reaction to tylenol or motrin as the source of Trentalange's problem.

   
   

6. Trentalange's back condition progressed to the point where back surgery was required, and on September 5, 1990, Dr. Tally performed a lumbar laminectomy for a herniated disc. Upon discharge, Dr. Tally prescribed percocet which Trentalange took for pain. Percocet contains a large percentage of acetaminophen which is the main component of tylenol. Valium was prescribed for Trentalange by Dr. Tally as a relaxant.

   
   

7. On September 24, 1990, Coutinho saw Trentalange who complained of tiredness, fever and pain in his stomach. There is competent substantial evidence to show that Trentalange had been vomiting on September 23, 1990, even though Coutinho's medical records indicate no history of vomiting. However, there is insufficient evidence to show that Mr. Trentalange had been vomiting for the previous seven days as contended by the Petitioner in her testimony at the hearing which was inconsistent with her deposition testimony wherein she testified that Trentalange had started vomiting on the day before he saw Coutinho on September 24, 1990. At this visit on September 24, 1990, Coutinho diagnosed Trentalange's condition as acute gastritis with mild dehydration.

   
   

8. Trentalange continued to have pain and on September 25, 1990, he was admitted to the Hospital for continued abdominal pain in the epigastric region and vomiting. On admission to the Hospital he appeared somewhat dehydrated.

   
   

9. Trentalange was hospitalized with evidence of decompensation of hepatic function (large volume ascites - abnormal collection of fluid in abdominal cavity), hepatosplenomegaly, SGOT 2730, SGPT 2410 and elevated prothrombin time. The hematocrit had risen to 58%. The admission BUN (blood urea nitrogen) was 43 mg% and creatinine was 2.2 mg%.

   
   

10. It was felt that Trentalange was somewhat "volume depleted" (dehydrated), with resulting pre-renal azotemia. His urinalysis was normal.

    
    

11. A normal kidney that is suffering from pre-renal azotemia (dehydrated induced kidney dysfunction) will respond rapidly once the dehydration is corrected. The exact opposite happened in this case. Trentalange was treated with intravenous fluids, initially kept NPO (nothing passed orally); however, despite this intravenous fluid repletion, Trentalange suffered progressive renal insufficiency.

    
    

12. There was insufficient evidence to show that when a person with myelofibrosis becomes dehydrated it increases the risk of having thrombosis of the liver or that dehydration causes more problems for people with myelofibrosis than those without myelofibrosis.

13. On September 27, 1990, the creatinine was 3.6 mg%, with BUN 76 mg%. The presumptive diagnosis of hepatorenal syndrome was made, given the course of progressive renal failure in a setting of advanced liver dysfunction. The balance of Trentalange's stay in the Hospital is more consistent with hepatorenal syndrome which is regarded as a preterminal fatal condition.

    
    

14. On September 28, 1990, myleran (chemotherapy) was prescribed in the dosage of 2mg twice daily in an effort to improve liver function, which was suspected to be the result of liver involvement with extramedullary erythropoiesis.

    
    

15. On October 2, 1990, the BUN rose to 170 mg% with creatinine of 3.3 mg%. On October 3, 1990, the dosage of myleran was increased to 2mg three times a day. On October 5, 1990, the BUN was 156 mg% with creatinine of 3.4 mg%.

    
    

16. Myleran was discontinued on October 8, 1990, at which time the BUN was

    150 mg% with creatinine of 3.3 mg%. Apparently, there never was a significant degree of remission of the myeloproliferative disorder so that the hepatorenal syndrome never reversed.

    
    

17. Trentalange's blood pressure, pulse rate, low urine output, increased BUN and increased creatinine all suggest that he was not dehydrated on admission to the Hospital or that if he was dehydrated it was only a mild dehydration.

    
    

18. Trentalange was made "no CRT" (cardiovascular resuscitation technique) with family approval on October 5, 1990, and was discharged on October 20, 1990.

    
    

19. Trentalange was admitted back into the Hospital on October 22, 1990 for terminal care. Trentalange expired on November 2, 1990.

    
    

20. Postmortem examination was made, and the cause of death, as found by medical examination, was "myeloproliferative disorder - myeloid metaplasia and myelofibrosis with complication including thrombosis of hepatic vein, progressive hepatic failure and hepatorenal syndrome".

    
    

21. Hepatic vein thrombosis is the result of a blood clot forming in the main vein leading out of the liver back into general circulation. It is a rare disorder, and when it occurs it leads to the death of the liver and kidney, and eventually the death of the individual. Approximately one-third of the time it is associated with myeloproliferative syndrome because with this disorder there are abnormalities of the platelets which causes an individual to undergo thrombosis.

    
    

22. Hepatic vein thrombosis (Budd-Chiari Syndrome) produces symptoms of pain in the upper right quadrant and epigastric area, swelling of abdomen (large volume of ascites), some degree of nausea which may be accompanied by vomiting, and some degree of dehydration is not unusual. This condition waxes and wanes and most likely the first manifestations of this disorder were in the first visit to the Hospital on July 24, 1990, when Trentalange was noted to have yellow sclerae and was complaining of abdominal pain and had elevated liver function tests.

    
    

23. The record shows that at both hospitalizations on September 5, 1990 and on September 25, 1990, Coutinho continued to refer to the diagnosis of July 24, 1990 as possible cholestatic jaundice secondary to erythromycin. There is

    no mention by Coutinho of any possible allergic reaction by Trentalange from the use of motrin or tylenol or any drug containing acetaminophen.

    
    

24. Although the record reflects that as early as August 21, 1990 Trentalange had advised Dr. Tally that he was allergic to tylenol, motrin and erythromycin and the Hospital on September 5, 1990 (Petitioner's Composite Exhibit 1, Tab 3, Physician's Order Sheet and Pre-Op Check List), there is insufficient competent substantial medical evidence to establish facts to show that Trentalange ever suffered an allergic reaction from the use of tylenol or motrin or any medicine containing acetaminophen such as percocet.

    
    

25. Likewise, there is insufficient competent substantial evidence to establish facts to show that the nausea, vomiting and possible dehydration suffered by Trentalange resulted from his use of tylenol, motrin, percocet, or any drug containing acetaminophen or that the nausea, vomiting and dehydration lead to the hepatic vein thrombosis and ultimately his death.

    
    

    CONCLUSIONS OF LAW

    
    

26. The Division of Administrative Hearings has jurisdiction over the parties to, and the subject of, this proceeding pursuant to Section 120.57(1), Florida Statutes.

    
    

27. Section 121.021(14), Florida Statutes, defines "death in line of duty" to mean death arising out of and in the actual performance of duty required by a member's employment during his regularly scheduled working hours or irregular working hours as required by the employer.

    
    

28. There is no dispute that Trentalange's injury received as a result of a fight with a student in April 1989 was a job-related injury. However, for the Petitioner to be entitled to in line of duty benefits on the retirement account of her late husband, Donald Trentalange, under the Florida Retirement System, Chapter 121, Florida Statutes, she has the burden of establishing by a preponderance of the evidence facts necessary to show that her husband's death was a direct result or natural consequence of the injury received as a result of the fight with the student in April 1989. Florida Department of Transportation

1. J. W. C. Company, Inc., 393 So. 2d 778 (1 DCA Fla. 1981). The Petitioner has failed to sustain her burden in this regard.

   
   

   RECOMMENDATION

   
   

   Based on the foregoing Findings of Fact and Conclusions of Law, it is, accordingly,

   
   

   RECOMMENDED that the Respondent enter a Final Order denying Petitioner, Carol Trentalange in line of duty benefits on the retirement account of her husband, Donald Trentalange, deceased, under the Florida Retirement System.

   DONE and ORDERED this 1st day of July, 1992, in Tallahassee, Florida.

   
   

   
   

   WILLIAM R. CAVE

   Hearing Officer

   Division of Administrative Hearings The DeSoto Building

   1230 Apalachee Parkway

   Tallahassee, FL 32399-1550

   (904) 488-9675

   
   

   Filed with the Clerk of the Division of Administrative Hearings this 1st day of July, 1992.

   
   

   APPENDIX TO RECOMMENDED ORDER

   
   

   The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on the proposed findings of fact submitted by the parties in this case.

   
   

   Specific Rulings on Proposed Findings of Fact Submitted by the Petitioner

   
   

   1. This first paragraph of proposed finding of fact 1 is adopted in substance in Finding of Fact 19, as modified. The second paragraph is more of a question than a finding of fact, except the last sentence which is rejected as not being supported by competent substantial evidence in the record.

      
      

   2. Adopted in substance in Finding of Fact 2, as modified.

      
      

   3. The first paragraph of proposed finding of fact 3 is adopted in substance in Finding of Fact 4, as modified. The second and third paragraphs are more of a restatement of testimony and argument than a finding of fact. Paragraph 4 is rejected as not being supported by competent substantial evidence in the record. However, if the medication is limited to erythromycin, then see Finding of Fact 5.

      
      

   4. The first through the fourth sentence are adopted in Finding of Fact

1. The balance is neither material nor relevant.

   
   

   1. Most of proposed finding of fact 5 is a restatement of testimony or argument to support the finding in the third paragraph; however, that proposed finding of fact is rejected as not being supported by competent substantial evidence in the record.

      
      

   2. Rejected as not being supported by competent substantial evidence in the record.

      
      

   3. The first paragraph is more of a restatement of testimony or opinions to support the finding in the second paragraph than a finding of fact. The second paragraph is rejected as not being supported by competent substantial evidence in the record.

      
      

   4. Rejected as not being supported by competent substantial evidence in the record.

Specific Rulings on Proposed Findings of Fact Submitted by the Respondent

1.-3. Adopted in substance in Findings of Fact 1-3, respectively, as modified.

1. Adopted in substance in Findings of Fact 4 and 5, as modified.

   
   

2. Adopted in substance in Finding of Fact 6, as modified.

6.-9. Proposed findings of fact 6, (no #7), 8 and 9 are more of a restatement of testimony and opinions than findings of fact, except for the last sentence of 9 which is adopted in substance in Finding of Fact 17.

10.-11. Proposed findings of fact 10 and 11 are more of a restatement of testimony, opinions and argument than findings of fact except the last sentence of 11 which is adopted in Finding of Fact 7.

12.-17. Proposed findings of fact 12 through 17 are more of a restatement of testimony, opinions and argument than findings of fact except the last sentence of 17 which is adopted in substance in Finding of Fact 21, as modified.

18.-28. Proposed findings of fact 18 through 27 are more of a restatement of testimony, opinions and argument than findings of fact, except 28 which is adopted in substance in Findings of Fact 22 through 24.

COPIES FURNISHED:

James A. Sheehan, Esquire

341 Third Street, South Sarasota, FL 33701

Stanley M. Danek, Esquire Division of Retirement Cedars Executive Center 2639 North Monroe Street Building C

Tallahassee, FL 32399-1560

A. J. McMullian, III, Director Division of Retirement

Cedars Executive Center 2639 North Monroe Street Building C

Tallahassee, FL 32399-1550

John A. Pieno, Secretary Augustus D. Aikens, Jr.

435 Carlton Building General Counsel Tallahassee, FL 32399-1550 435 Carlton Building

Tallahassee, FL 32399-1550

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions to this Recommended Order. All agencies allow each party at least 10 days in which to submit written exceptions. Some agencies allow a larger period within which to submit written exceptions. You should contact the agency that will issue the final order in this case concerning agency rules on the deadline for filing exceptions to this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.

Docket for Case No: 91-006305

Orders for Case No: 91-006305