STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, BOARD ) OF MEDICINE, )

)

Petitioner, )

)

vs. ) Case No. 01-1305PL

)

JOHN ROZANSKI, )

)

Respondent. )

)

RECOMMENDED ORDER

Robert E. Meale, Administrative Law Judge of the Division of Administrative Hearings, conducted the final hearing in Miami, Florida, on July 26, 2001.

APPEARANCES

For Petitioner: John E. Terrel, Senior Attorney

Agency for Health Care Administration Post Office Box 14229

Mail Stop 39-A

Tallahassee, Florida 32317-4229

For Respondent: Paul R. Regensdorf

Akerman, Senterfitt & Eidson, P.A. Las Olas Centre II, 16th Floor

350 East Las Olas Boulevard Fort Lauderdale, Florida 33301

STATEMENT OF THE ISSUE

The issue is whether Respondent practiced medicine within the applicable standard of care, as required by Section

458.331(1)(t), Florida Statutes, and, if not, what penalty should be imposed.

PRELIMINARY STATEMENT

By Administrative Complaint dated April 27, 1999, Petitioner alleged that, on January 4, 1993, H. T., aged 58 years, presented to Respondent for a preoperative cardiovascular evaluation to determine his cardiovascular stability for back surgery scheduled for the next day. Respondent allegedly performed an electrocardiogram and exercise stress test and cleared H. T. for surgery.

The Administrative Complaint alleges that H. T. underwent back surgery on January 5, 1993. The Administrative Complaint alleges that, during surgery, H. T. suffered a lack of oxygen to the brain and that H. T. consequently suffered a postoperative coma, from which he did not recover. H. T. died on January 22, 1993.

The Administrative Complaint alleges that an autopsy uncovered cardiovascular disease, "[a]lthough not directly related to the cause of . . . H. T.'s death." The Administrative Complaint alleges that a reasonably prudent similar physician would have interpreted H. T.'s electrocardiogram and exercise stress test as indicating cardiovascular disease and would not have cleared H. T. for surgery before performing further cardiovascular testing.

The Administrative Complaint alleges that Respondent therefore violated Section 458.331(1)(t), Florida Statutes, by failing to practice medicine with the level of care, skill, and treatment that is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances.

At the hearing, Petitioner called two witnesses and offered into evidence eight exhibits: Petitioner Exhibits 1-8.

Respondent called one witness and offered into evidence two exhibits: Respondent Exhibits 1-2. All exhibits were admitted.

The court reporter filed the transcript on August 30, 2001.

Petitioner filed a proposed recommended order on September 19, 2001. Respondent did not file a proposed recommended order.

FINDINGS OF FACT

1. At all material times, Respondent has been a licensed physician, holding license number ME 30404. He earned his medical degree in 1974. Respondent has been Board-certified in the specialty of internal medicine since 1977 and in the subspecialty of cardiovascular disease since 1981.

2. At the time of the incident in question, Respondent was a staff cardiologist with the Cleveland Clinic Florida, which is located in Fort Lauderdale. At present, he is an attending cardiologist with the Broward General Medical Center, which is located in Fort Lauderdale.

3. H. T., a 58 year-old male, was scheduled for a spinal fusion on January 5, 1993, at the Cleveland Clinic Florida. This back surgery was expected to take 8-10 hours. Although the surgery was not an emergency, H. T. was suffering from complex pain that was worsened by standing, walking, and bending forward and was intensifying with time. Dissatisfied with his current level of functioning, H. T. was a suitable candidate for back surgery, based on his symptoms and diagnosis.

4. On December 30, 1992, H. T., now suffering "severe" lower back pain, reported to the Cleveland Clinic Florida for a preoperative evaluation. He took a resting electrocardiogram (EKG). The computer program that interpreted the results identified a possible inferior myocardial infarction of an undetermined age and a possible left atrial enlargement. Another cardiologist with the Cleveland Clinic Florida,

   Dr. Vincent Font, examined the computer-generated interpretation and did not reject it.

5. The radiology report from the December 30, 1992, examination was completed by Dr. Robert J. Hyman of the Cleveland Clinic Florida. The report notes that H. T.'s heart was enlarged.

6. Due to the results of the preoperative evaluation done on December 30, 1992, H. T. had to obtain a cardiac clearance before his back surgery on January 5, 1993. Thus, on January 4,

   1993, H. T. presented to Respondent at the Cleveland Clinic Florida to obtain a cardiac clearance.

7. On January 4, 1993, H. T. provided Respondent with a history of 60 pack-years of cigarette smoking, which had been discontinued two months earlier. Respondent's blood pressure was 196/98. He stood five feet, eleven inches, and weighed 192 pounds. Based on the values considered normal at the time,

   H. T.'s blood pressure was somewhat elevated and his weight was somewhat excessive. However, H. T.'s only significant cardiac risk factors were his history of cigarette smoking and, to a lesser extent, his age.

8. Respondent administered a stress EKG on January 4, 1993. The report states:

   This patient had uneventful pre-exercise maneuvers and then had a sub-maximal level exercise performance limited by left leg pain. He exercised for 6 min. according to the modified Bruce protocol. Patient attained a maximum heart rate of 124 bpm which was 76% of the maximum predicted heart rate of 162 bpm. There was exaggerated blood pressure reaching a maximum of 242/104 during peak exercise. Test was terminated because of leg and back pain. There was no ventricular hypertrophy with upsloping ST segment depression of about 2 mm. in the inferior and lateral leads, consistent with secondary changes due to LVH. Post-exercise recovery phase was uneventful.

   
   

9. Respondent added the following clinical impressions to the report:

   1. No chest pain during exercise.

   2. Adequate functional capacity limited by left leg pain.

   3. Abnormal EKG due to left ventricular hypertrophy with secondary ST T-wave abnormalities.

      
      

10. The most important part of Respondent's physical examination of H. T. was his observation of the exercise stress test. At no time during or after the test did H. T. exhibit any sign of cardiac insufficiency, such as shortness of breath or pallor. Nor did H. T. experience any pain in the front of his chest.

11. Respondent also examined H. T.'s medical records, in which H. T. reported a cerebrovascular accident, seizures, and a transient ischemic attack. However, this history was contradicted by other history provided by H. T. ten weeks earlier, at which time H. T. had denied any history of convulsions or strokes. Discussing the history with H. T., Respondent learned that H. T. had erroneously indicated that he had suffered these three conditions.

12. After examining the relevant information, Respondent concluded that, within a reasonable degree of medical probability, H. T. was appropriate, from a cardiac perspective, for serious orthopedic surgery. In his consultation report,

    Respondent noted that H. T. denied any history of hypertension, and Respondent suggested that H. T.'s blood pressure was high due to anxiety over surgery. The report also notes that H. T. denied chest pain at rest or under exertion and also denied shortness of breath or other symptoms of heart failure.

13. Regarding the electrocardiogram, the consultation report states that H. T. displayed a normal sinus rhythm and his septal Q-saves were consistent with early left ventricular hypertrophy, which was consistent with possible mild hypertensive heart disease.

14. Regarding the stress EKG, the consultation report states that H. T. achieved exaggerated blood pressure response with frequent premature atrial contractions, although these were of minor significance. The report notes that the EKG pattern was characteristic of left ventricular hypertrophy with secondary ST T-wave abnormality. The report suggests that H. T. have his blood pressure rechecked.

15. Central to Respondent's cardiac clearance of H. T. for extensive back surgery was the fact that the stress EKG subjected H. T. to more stress than he would experience during and after surgery, the test adequately raised H. T.'s blood pressure, and the EKG returned to normal once H. T.'s blood pressure returned to normal. Respondent placed considerable emphasis on H. T.'s cardiac response to six minutes' stress,

    under the modified Bruce protocol, without experiencing pain. Respondent terminated the test due to leg pain that was consistent with the symptoms to be alleviated by the back surgery.

16. After Respondent cleared H. T. for back surgery, the surgery took place on January 5, 1993. H. T. emerged from 11 hours of surgery in stable condition. When he awakened postoperatively, H. T. followed commands and spoke with his wife. However, early the next morning, H. T. suffered respiratory depression. His treating physician withdrew the morphine that H. T. had been receiving; after responding well,

    H. T. again exhibited respiratory depression, rapidly followed by respiratory arrest.

17. H. T. fell into a coma, secondary to a deprivation of oxygen to the brain. However, he did not exhibit signs of an acute myocardial infarction and never displayed any signs suggesting that he had not tolerated the surgery well from a cardiac perspective. After the withdrawal of certain life- support interventions, H. T. died on January 22, 1993.

18. An autopsy took place about seven hours after H. T. died. The autopsy found that all three major vessels constituting the coronary arteries were more than 90 percent occluded. However, a serial section of the myocardium did not reveal definite recent or remote infarcts. The medical examiner

    concluded that there was "no clear cut finding to explain the course of [H. T.]" and that further examination of abnormalities in the heart and brain would be necessary.

19. Subsequent examination of the heart resulted in findings of, among other things, "severe" coronary atherosclerosis with 90 to 95 percent narrowing and concentric left ventricular hypertrophy.

20. A cardiologist performing a cardiac clearance must take the patient's history, perform a physical examination, examine relevant medical records, and finally evaluate the patient and stratify the cardiac risk posed by the subject surgery. Respondent performed all of the necessary steps of a cardiac clearance in evaluating the likelihood that H. T. could undergo extensive back surgery without serious cardiac complications.

21. The abnormalities in H. T.'s EKG during the stress test most likely suggested the presence of left ventricular hypertrophy, not a myocardial infarction. Left ventricular hypertrophy is consistent with several other factors suggestive of longstanding hypertension.

22. Moreover, a cardiac clearance for noncardiac surgery is generally appropriate if the patient, as did H. T., completes six minutes of the stress test, elevates his blood pressure and pulse, experiences no chest pain, and displays no

    pallor. The cardiac clearance of such a patient is appropriate even though he suffers from an underlying cardiac disease.

23. The postmortem findings of atherosclerotic disease do not establish functional cardiac disease. The postmortem findings cannot assess the extent of occlusion of vessels under pressure, as opposed to vessels no longer under pressure. Also, the postmortem findings do not assess the vulnerability of the plaque.

24. Petitioner has failed to prove that Respondent's cardiac clearance of H. T. deviated from the applicable standard of care. H. T. required intensive back surgery to obtain relief from severe pain. The abnormalities reported in the resting EKG did not suggest a recent myocardial infarction. The abnormalities in the stress EKG likely revealed a thickening of the left ventricle, probably resulting from hypertension. These findings did not necessitate additional cardiac testing before clearing H. T. for extensive back surgery.

25. Most significantly, H. T. underwent the rigors of the stress EKG without significant cardiac symptoms. An experienced cardiologist, Respondent assessed H. T.'s cardiac function under conditions that approximated the stress of the spinal fusion. Later, undergoing the surgery, Respondent suffered no cardiac problems. Even if Petitioner had proved an underlying cardiac condition, such as severe occlusion or a myocardial infarct,

    Petitioner did not prove that these conditions precluded H. T. from obtaining much-needed back surgery prior to resolving any and all underlying cardiac conditions.

    CONCLUSIONS OF LAW

    
    

26. The Division of Administrative Hearings has jurisdiction over the subject matter. Section 120.57(1), Florida Statutes.

27. Section 458.331(1)(t), Florida Statutes Petitioner may discipline Respondent's license if he is guilty of

    . . . the failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances.

    
    

28. Petitioner must prove the material allegations by clear and convincing evidence. Department of Banking and

    Finance v. Osborne Stern and Company, Inc., 670 So. 2d 932 (Fla. 1996) and Ferris v. Turlington, 510 So. 2d 292 (Fla. 1987).

29. Petitioner has failed to prove that Respondent deviated from the applicable standard of care in providing Respondent with a cardiac clearance for extensive back surgery.

RECOMMENDATION

It is

RECOMMENDED that the Board of Medicine enter a final order dismissing the Administrative Complaint against Respondent.

DONE AND ENTERED this 5th day of November, 2001, in Tallahassee, Leon County, Florida.

ROBERT E. MEALE

Administrative Law Judge

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

(850) 488-9675 SUNCOM 278-9675

Fax Filing (850) 921-6847 www.doah.state.fl.us

Filed with the Clerk of the Division of Administrative Hearings this 5th day of November, 2001.

COPIES FURNISHED:

Tanya Williams, Executive Director Board of Medicine

Department of Health 4052 Bald Cypress Way

Tallahassee, Florida 32399-1701

William W. Large, General Counsel Department of Health

4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701

Theodore M. Henderson, Agency Clerk Department of Health

4052 Bald Cypress Way Bin A02

Tallahassee, Florida 32399-1701

John E. Terrel, Senior Attorney Agency for Health Care Administration Post Office Box 14229

Mail Stop 39-A

Tallahassee, Florida 32317-4229

Paul R. Regensdorf

Akerman, Senterfitt & Eidson, P.A. Las Olas Centre II, 16th Floor

350 East Las Olas Boulevard Fort Lauderdale, Florida 33301

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this recommended order. Any exceptions to this recommended order must be filed with the agency that will issue the final order in this case.

Docket for Case No: 01-001305PL

Orders for Case No: 01-001305PL