vs. )
Respondent. )
Case No. 03-4530N
Pursuant to notice, the Division of Administrative Hearings, by Administrative Law Judge William J. Kendrick, held a final hearing in the above-styled case on June 10, 2004, by video teleconference, with sites in Tallahassee and Orlando, Florida.
At issue is whether Aaron Smith, a minor, qualifies for coverage under the Florida Birth-Related Neurological Injury Compensation Plan.
On November 13, 2003, Dawn Smith and Taryn Smith, on behalf of and as parents and natural guardians of Aaron Smith (Aaron), a minor, filed a petition (claim) with the Division of Administrative Hearings (DOAH) for compensation under the Florida Birth-Related Neurological Injury Compensation Plan (Plan).
DOAH served the Florida Birth-Related Neurological Injury Compensation Association (NICA) with a copy of the claim on December 5, 2003, and on April 5, 2004, NICA filed a Motion for Summary Final Order, predicated on the opinion of its experts that Aaron's neurologic abnormalities were likely acquired in utero, rather than from oxygen deprivation or mechanical injury occurring during labor, delivery, or resuscitation.
On April 22, 2004, an Order was entered denying NICA's Motion for Summary Final Order, and a hearing was scheduled for June 10, 2004, to resolve whether the claim was compensable. At hearing, Dawn Smith testified on her own behalf, and Respondent's Exhibit 1 (the medical records filed with the petition), Exhibit
2 (additional medical records), Exhibit 3 (an affidavit and report by Donald C. Willis, M.D.), and Exhibit 4 (an affidavit
and report by Michael S. Duchowny, M.D.) were received into evidence.1 No other witnesses were called, and no further exhibits were offered.
The transcript of the hearing was filed July 19, 2004, and the parties were accorded 10 days from that date to file proposed orders. Neither party elected to file such a proposal.
Petitioners, Dawn Smith and Taryn Smith, are the natural parents and guardians of Aaron Smith, a minor. Aaron was born a live infant on December 29, 1998, at Baptist Medical Center, a hospital located in Jacksonville, Florida, and his birth weight exceeded 2,500 grams.
The physician providing obstetrical services at Aaron's birth was Wilford Paulk, M.D., who, at all times material hereto, was a "participating physician" in the Florida Birth-Related Neurological Injury Compensation Plan, as defined by Section 766.302(7), Florida Statutes (1997).2
Aaron's birth
The medical records related to Aaron's birth are meager, but reveal that at or about 6:59 a.m., December 29, 1998,
Mrs. Smith (with an estimated delivery date of December 18, 1998, and the fetus at 41 and 4/7 weeks gestation) presented to Baptist Medical Center, in labor. At the time, Mrs. Smith's membranes
were noted as intact, and contractions were noted at a frequency of 3-6 minutes.
Mrs. Smith was administered an epidural anesthesia at 9:30 a.m., and at 10:55 a.m., her membranes were artificially ruptured, with clear fluid noted. Thereafter, at 6:28 p.m., dilation was noted on complete, and at 6:47 p.m., Aaron was delivered, with vacuum assist.
At delivery, Aaron breathed spontaneously, and initial newborn assessment revealed no abnormalities. Apgar scores were recorded as 8 and 9, at one and five minutes, respectively.3
Following delivery, Aaron was transported to the newborn nursery, where he was received at 7:30 p.m. Newborn admission assessment, as well as the physician's subsequent assessment on December 30, 1998, did not reveal any significant abnormality, and Aaron was discharged to his mother's care on December 31, 1998. Overall, the medical records related to Aaron's birth do not reveal any evidence of fetal compromise or injury during the course of Mrs. Smith's labor or Aaron's delivery and brief postnatal course at the hospital.
Aaron's subsequent development
In early February 1999, at five weeks of age, Aaron was hospitalized, with symptoms consistent with the onset of seizure activity, and an electroencephalogram (EEG) revealed "electrographic seizures arising independently out of the left
and right hemisphere." At the time, diagnostic evaluation by William Turk, M.D., a pediatric neurologist associated with Nemours Children's Clinic, including a normal cranial MRI scan, failed to reveal an etiology for Aaron's seizure disorder, and he was started on Phenobarbitol.
Aaron apparently did well on Phenobarbitol until early March 1999, when his mother noted several events, characterized by staring and repetitive arm jerking on the right side lasting
30 seconds, consistent with the recurrence of seizure activity.
At the time, March 3, 1999, Aaron was seen in follow-up by Dr. Turk, whose examination revealed the following:
On physical examination, he is a large appearing young man whose weight of 7.5 kilograms is greater than the 95th percentile as is his height of 63.3 m. Head circumference of 42.6 cm continues to track slightly greater than the 98th percentile.
His general physical examination was otherwise, unrevealing On
neurological examination, his pupils are equal, round and reactive to light. His extraocular movements were full. Fleeting glimpses of his retina and discs were unrevealing. His facial movements were symmetric and his gag was intact. Motor exam revealed equal and symmetrical muscle bulk, tone and strength. Deep tendon reflexes were diffusely brisk with flexor plantar responses. He withdrew symmetrically to noxious stimuli. No involuntary movements were noted. He would alert, socialize and follow the examiner visually with a responsive smile. His fontanel was soft.
Dr. Turk's impression and recommendations were, as follows:
Impression: Aaron is a 2 month-old with a partial complex seizure disorder of unknown etiology. He overall, has done well on Phenobarbitol until several recent breakthrough seizures. I suspect his Phenobarbitol level is subtherapeutic given his dose and relatively rapid weight gain. He appears to be doing well developmentally.
Recommendations: I feel it would be reasonable to increase his Phenobarbitol to bring him into what will be the therapeutic range . . . . We have asked him to return for a formal follow-up visit in two months. He is a young man who is statistically . . . at significant risk for neurodevelopmental concerns, although he does appear to be doing well in the short run. I have asked his parents to particularly observe him for any evidence of myoclonic seizures. I anticipate when he becomes approximately 6 months of age, we will refer him to a local developmental program for assessment and enrollment.
Aaron continued on Phenobarbitol, but was otherwise quite healthy, with apparent normal developmental progress until July 8, 1999, when, at 6 months of age, Dr. Turk noted "emerging developmental concerns." At the time, Mrs. Smith reported that "[i]n terms of his development, he still does not sit, and . . . he has somewhat more difficulty rolling over." On examination, Dr. Turk noted:
On physical exam, his weight of 11.3 kg is greater than the 95th percentile, as is his weight of 74.8 kg, and head circumference of
47 cm. He was alert appearing, and at times briefly social . . . . On neurological examination, his pupils are equal, round and
reactive to light. His extraocular movements were full. Occasionally, he was noted to have some brief rapid horizontal nystagmus [an involuntary rapid movement of the eyeball] which occurred in primary gaze. No opsoclonus was noted. No other cranial nerve abnormalities were noted. Motor exam revealed equal and symmetrical muscle bulk, tone and strength. Deep tendon reflexes were 2+ and symmetrical. His plantar reflexes were flexor. He had no tremulousness nor myoclonus. He withdrew briskly and symmetrically to noxious stimuli. He could not sit independently.
IMPRESSION: Aaron remains a problematic young man. He has been free of overt partial complex seizures. His nystagmoid eye movements, I suspect, are not representative of subtle seizure activity Over
time, I am increasingly concerned that we are seeing the emergence of what will be a pattern of significant developmental delay in this young man. Unfortunately, as you know, this occurs commonly in children with early onset seizure disorders . . . .
PLAN: Aaron will continue on his current dose of Gabapentin and Phenobarbital . . . .
I feel strongly it would be appropriate for Aaron to see a pediatric ophthalmologist, both for a dilated funduscopic examination to see if his retina can give us any clues as to the etiology of his seizures, as well as evaluate his nystagmoid movements . . . .
As recommended, Aaron was seen for an ophthalmologic evaluation on July 20, 1999, by Robert Hered, M.D., a pediatric ophthalmologist associated with Nemours Children's Clinic. Following examination, Dr. Hered concluded that:
Aaron has developed pendular nystagmus. The nystagmus is somewhat more rapid than is typically seen with sensory nystagmus. I do
suspect problems with the optic nerves, however. His examination suggests moderate bilateral optic nerve hypoplasia [incomplete development of the optic nerve]. I have recommended a follow-up eye examination in 6 months to reassess his vision status and the appearance of his optic nerves.
Follow-up eye examination by Dr. Hered on December 14, 1999, confirmed the presence of moderate bilateral optic nerve hypoplasia and, due to a degree of visual impairment, Aaron was referred to the Division of Blind Services. In the interim, a cranial MRI scan on August 6, 1999, ordered by Dr. Turk "to redefine his intracranial anatomy and optic pathway" was normal or, stated otherwise, unrevealing as to the etiology of Aaron's neurodevelopmental difficulties. Specifically, the MRI scan was read, as follows:
Comparison with previous assessment dated 2/99.
There has been no change in the appearance of the intracranial contents. The supratentorial, as well as the posterior fossa contents are again well delineated.
There is no evidence for a mass lesion or shift of midline structures. A structural or signal abnormality cannot be demonstrated.
There is no evidence of ventriculomegaly or abnormal increase in extra-axial fluid.
Aaron continued to be followed by Dr. Turk at regular intervals, who, apart from developmental delay, noted normal gross motor development. Specifically, Dr. Turk's neurological consultation of May 9, 2001, noted the following:
Aaron was seen in follow-up neurological consultation. He is a 2-4/12 year old with developmental delay and seizures. He also has macrosomia. We have followed him and, overall, he continues to be problematic. He has had no behavior suggestive of seizures since last seen . . . .
The other issue in this young man is his developmental status. His progress is extremely slow. He has essentially no intelligible speech and extremely-limited social interactions. His mother reports he is extremely ritualistic in his behavior and plays with a very limited repertoire of toys. He does receive OT, PT, and speech therapy at the Lighthouse Center which he attends daily.
His review of systems is otherwise noncontributory. There have been no recent psychosocial changes.
On physical exam, he was a fussy young man who was whining when I entered the exam room but did have one interval where he appeared relatively calm and content. He had poorly developed social interactive skills and made poor eye contact. He has a large-appearing body with a head circumference of 52 cm, greater than the 95th percentile as is his weight of 17.8 kg. His height of 94 cm is on the 80th percentile . . . .
On neurological examination, his pupils were equal, round, and reactive to light. His extraocular movements were full, and he had no apparent nystagmus today. His right disc was pale, as previously noted. His facial movements were symmetrical. He did respond to auditory stimuli, and his gag was present. Motor exam revealed equal and symmetrical muscle bulk, tone, and strength. Deep tendon reflexes were 2+ and symmetrical with flexor plantar responses. His gait was narrow based and steady. He did withdraw briskly and symmetrically to noxious stimuli and no tremulousness was noted.
IMPRESSION: Aaron is a 28 month old with a history of developmental delay and seizures. His seizures are well controlled on his current medication. As you will recall, we are in the process of a transition from Tegretol to phenobarbital. Developmentally as this young man has grown older, it is apparent that he has symptoms that may place him on the autistic spectrum; however, as you know, this can be a difficult diagnosis in young children particularly with significant cognitive delays . . . .
RECOMMENDATIONS: Aaron's phenobarbital will be decreased to 15/30 mg, and he will continue on his current dose of Tegretol pending [further testing] . . . .
We did discuss numerous developmental issues including those of possible autism. He does appear to be well networked into appropriate supportive services, at the present time. As you know, applying a label of autism little alters our approach to management; particularly in young children.
Finally, this young man could appear to be an appropriate candidate to have a pediatric genetic consultation. He does have some dysmorphic features including a bifid uvula, he has significant developmental delay, and mild macrosomia . . . .
Of note, subsequent genetic testing failed to reveal evidence of significant abnormalities or an etiology for Aaron's neurodevelopmental difficulties.
In so far as the record reveals, Dr. Turk last saw Aaron on December 30, 2002, and, pertinent to this case, reported the results of his consultation, as follows:
Aaron was seen in neurological follow up consultation. He is an extremely complex 4-
year-old with multiple neurodevelopmental concerns who I have not seen in nearly one year. When we last saw him in February, there had been a question of a recent subtle seizure in the setting of a febrile illness. Since that time, he has had no seizures . . .
Developmentally, he is making some progress. He still has many self-stimulatory behaviors and no intelligible speech. He does have significantly improved social interactive skills. His mother reports he has been diagnosed as having PDD. He receives physical, occupational and speech therapy at the Lighthouse Center. There is no clear history of any regression. Behaviorally, he is extremely active and very rigid, strongly preferring routines . . . .
On physical examination, he was an active young man. His weight is 22 kg which is greater than the 95th percentile. Height was
106.7 cm and is on the 85th percentile. His head circumference is 55 cm which is slightly greater than the 98th percentile where it was previously been noted General
physical examination revealed a somewhat large-appearing cranium with slightly coarsened features . . . . On neurological examination, he had full extraocular movements. Despite an extensive effort, I could not adequately visualize his discs.
Facial movements and sensation, auditory localization, gag, palate and tongue movements were normal. Motor exam revealed equal and symmetrical muscle bulk, tone and strength. Deep tendon reflexes were 2+ and symmetrical. Plantar responses were flexor. No tremor, dysmetria or ataxia was noted. He did have, at times, prominent self- stimulatory behaviors. His gait was steady. He had no intelligible speech. He would make occasional eye contact with the examiner.
IMPRESSION: Aaron is a 4-year-old with a history of significant developmental delay. Overall, as we have observed this young man,
he appears to fall in the autistic spectrum. He also has a septooptic dysplasia and apparently has had no evidence of an endocrinopathy. He has had seizures that are now well-controlled with his last event being one year ago . . . .
Notably, neither Dr. Turk nor any other physician who attended Aaron has expressed any opinion regarding the etiology of his neuodevelopmental difficulties or the significance, if any, of his mental and physical limitation.
The opinions of Doctors Willis and Duchowny
Following the filing of the claim in this case, NICA provided copies of the medical records related to Aaron's birth to Donald Willis, M.D., an obstetrician who practices maternal- fetal medicine, to review and to resolve whether, in his opinion, the records supported a conclusion that Aaron suffered an injury during the course of birth. NICA also arranged for
Michael Duchowny, M.D., a pediatric neurologist, to examine Aaron and to resolve whether, in his opinion, Aaron's neurologic presentation was consistent with a brain or spinal cord injury caused by oxygen deprivation or mechanical injury during birth, and whether Aaron was permanently and substantially mentally and physically impaired.
Here, the opinions of Doctors Willis and Duchowny, in the form of an affidavit and report by each, Respondent's Exhibits 3 and 4, respectively, are hearsay and, as noted in
Endnote 1, were received into evidence subject to the limitations of Section 120.57(1)(c), Florida Statutes (2003). ("Hearsay evidence may be used for the purposes of supplementing or explaining other evidence, but it shall not be sufficient in itself to support a finding unless it would be admissible over objection in civil actions.") Dr. Willis' opinion, that "[t]here was no apparent obstetrical incident that resulted in this child's injury," is consistent with the conclusion one would draw from the medical records and to that extent is corroborative or cumulative. Dr. Duchowny's opinion, that "Aaron's neurologic examination reveals findings consistent with childhood autism," is likewise corroborative or cumulative of the opinion of Aaron's treating pediatric neurologist; however, Dr. Duchowny's opinion that childhood autism is developmentally based, and begins in intrauterine life, prior to the onset of labor and delivery, is not corroborative of any competent proof and cannot support a finding of fact. As for Aaron's difficulties, Dr. Duchowny's neurologic evaluation is consistent with the conclusions reached by Dr. Turk, but, like Dr. Turk, he does not express an opinion as to the significance of Aaron's neurodevelopmental difficulties.
Coverage under the Plan
Pertinent to this case, coverage is afforded by the Plan for infants who suffer a "birth-related neurological injury"
defined as an "injury to the brain or spinal cord . . . caused by oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation in the immediate postdelivery period in a hospital, which renders the infant permanently and substantially mentally and physically impaired."
§ 766.302(2), Fla. Stat. See also §§ 766.309 and 766.31, Fla. Stat.
Here, Mrs. Smith did not dispute Aaron's autistic diagnosis, but was concerned that "the seizure activity he experienced through the first year of his life probably caused a lot of developmental delay." (Transcript, page 10) Mrs. Smith also notes that during delivery, her "blood pressure and heart rate went down really fast and so did Aaron's[,] . . . at that point it was really crucial for Aaron to be delivered [,] . . . his head was in the birth canal for about a minute and a half before they could find the . . . vacuum that would work to pull him out [,] . . . and when he came out he was blue . . . [a]nd it took . . . a few seconds for him to even come around and start to cry." (Transcript, pages 10 and 11) Notably, Mrs. Smith did not offer an opinion as to whether the events of labor and delivery caused an injury to Aaron's brain or spinal cord and, if she had done so, any such testimony would have been legally insufficient to support a finding that Aaron suffered an injury to the brain or spinal cord caused by oxygen deprivation or mechanical injury
during the course of labor, delivery, or resuscitation.
See, e.g., Vero Beach Care Center v. Ricks, 476 So. 2d 262, 264 (Fla. 1st DCA 1985)("[L]ay testimony is legally insufficient to support a finding of causation where the medical condition is not readily observable.") Moreover, Mrs. Smith offered no testimony regarding the significance of Aaron's neurologic difficulties.
Consequently, since the record fails to contain competent proof that Aaron suffered an "injury to the brain or spinal cord . . . caused by oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation in the immediate post-delivery period . . . that rendered . . . [Aaron] permanently and physically impaired," the proof fails to support the conclusion, as appears more fully in the Conclusions of law, that Aaron suffered a "birth-related neurological injury," as required for coverage under the Plan. § 766.302(2), Fla. Stat.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties to, and the subject matter of, these proceedings. § 766.301, et seq., Fla. Stat.
The Florida Birth-Related Neurological Injury Compensation Plan was established by the Legislature "for the purpose of providing compensation, irrespective of fault, for birth-related neurological injury claims" relating to births occurring on or after January 1, 1989. § 766.303(1), Fla. Stat.
The injured "infant, her or his personal representative, parents, dependents, and next of kin," may seek compensation under the Plan by filing a claim for compensation with the Division of Administrative Hearings. §§ 766.302(3), 766.303(2), 766.305(1), and 766.313, Fla. Stat. The Florida Birth-Related Neurological Injury Compensation Association, which administers the Plan, has "45 days from the date of service of a complete claim . . . in which to file a response to the petition and to submit relevant written information relating to the issue of whether the injury is a birth-related neurological injury."
§ 766.305(3), Fla. Stat.
If NICA determines that the injury alleged in a claim is a compensable birth-related neurological injury, it may award compensation to the claimant, provided that the award is approved by the administrative law judge to whom the claim has been assigned. § 766.305(6), Fla. Stat. If, however, NICA disputes the claim, as it has in the instant case, the dispute must be resolved by the assigned administrative law judge in accordance with the provisions of Chapter 120, Florida Statutes.
§§ 766.304, 766.307, 766.309, and 766.31, Fla. Stat.
In discharging this responsibility, the administrative law judge must make the following determination based upon the available evidence:
Whether the injury claimed is a birth- related neurological injury. If the claimant has demonstrated, to the satisfaction of the administrative law judge, that the infant has sustained a brain or spinal cord injury caused by oxygen deprivation or mechanical injury and that the infant was thereby rendered permanently and substantially mentally and physically impaired, a rebuttable presumption shall arise that the injury is a birth-related neurological injury as defined in s. 766.302(2).
Whether obstetrical services were delivered by a participating physician in the course of labor, delivery, or resuscitation in the immediate post-delivery period in a hospital; or by a certified nurse midwife in a teaching hospital supervised by a participating physician in the course of labor, delivery, or resuscitation in the immediate post-delivery period in a hospital.
§ 766.309(1), Fla. Stat. An award may be sustained only if the administrative law judge concludes that the "infant has sustained a birth-related neurological injury and that obstetrical services were delivered by a participating physician at birth."
§ 766.31(1), Fla. Stat.
Pertinent to this case, "birth-related neurological injury" is defined by Section 766.302(2), Florida Statutes, to
mean:
. . . injury to the brain or spinal cord of a live infant weighing at least 2,500 grams at birth caused by oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation in the immediate post-delivery period in a hospital, which renders the infant permanently and substantially mentally and physically
impaired. This definition shall apply to live births only and shall not include disability or death caused by genetic or congenital abnormality.
As the claimant, the burden rested on Petitioners to demonstrate entitlement to compensation. § 766.309(1)(a), Fla. Stat. See also Balino v. Department of Health and Rehabilitative Services, 348 So. 2d 349, 350 (Fla. 1st DCA 1977) ("[T]he burden of proof, apart from statute, is on the party asserting the affirmative issue before an administrative tribunal.")
Here, given that the proof failed to demonstrate, more likely than not, that Aaron suffered an injury to the brain or spinal cord caused by oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation, and that Aaron was permanently and substantially mentally and physically impaired, it must be resolved that the record developed in this case failed to demonstrate that Aaron suffered a "birth-related neurological injury," within the meaning of Section 766.302(2), Florida Statutes. §§ 766.302(2), 766.309(1), and 766.31(1), Fla. Stat. See also Florida Birth-Related
Neurological Injury Compensation Association v. Florida Division of Administrative Hearings, 686 So. 2d 1349 (Fla. 1997)(The Plan is written in the conjunctive and can only be interpreted to require both substantial physical and mental impairment.); Humana
of Florida, Inc. v. McKaughan, 658 So. 2d 852, 859 (Fla. 5th DCA
1995)("[B]ecause the Plan . . . is a statutory substitute for common law rights and liabilities, it should be strictly construed to include only those subjects clearly embraced within its terms."), approved, Florida Birth-Related Neurological Injury Compensation Association v. McKaughan, 668 So. 2d 974, 979 (Fla. 1996).
Where, as here, the administrative law judge determines that ". . . the injury alleged is not a birth-related neurological injury . . . he [is required to] enter an order [to such effect] and . . . cause a copy of such order to be sent immediately to the parties by registered or certified mail."
§ 766.309(2), Fla. Stat. Such an order constitutes final agency action subject to appellate court review.
§ 766.311(1), Fla. Stat.
ORDERED that the petition for compensation filed by Dawn Smith and Taryn Smith, on behalf of and as parents and
natural guardians of Aaron Smith, a minor, be and the same is hereby denied with prejudice.
DONE AND ORDERED this 20th day of August, 2004, in Tallahassee, Leon County, Florida.
WILLIAM J. KENDRICK
Filed with the Clerk of the Division of Administrative Hearings this 20th day of August, 2004.
1/ Respondent's Exhibit 1 and 2 were marked as exhibits at hearing and were provided to Petitioners post-hearing. There being no objection, Respondent's Exhibits 1 and 2 received into evidence. (See letter of June 15, 2004.) Respondent's Exhibits
3 and 4 are hearsay, and not otherwise admissible over objection in a civil action. Consequently, they were received into evidence subject to the limitations imposed by Section 120.57(1)(c), Florida Statutes (2003)("Hearsay evidence may be used for the purpose of supplementing or explaining other evidence, but it shall not be sufficient in itself to support a finding unless it would be admissible over objection in civil actions.")
2/ All citations are to Florida Statutes (1997), unless otherwise indicated.
3/ The Apgar scores assigned to Aaron are a numerical expression of the condition of a newborn infant, and reflect the sum points gained on assessment of heart rate, respiratory effort, muscle tone, reflex response, and color, with each category being assigned a score of 0 through a maximum score of 2. As noted, at one minute, Aaron's Apgar score totaled 8, with heart rate, respiratory effort, muscle tone, and reflex response being graded
at 2 each, and color being graded at 0. At five minutes, Aaron's Apgar score totaled 9, with heart rate, respiratory effort, muscle tone, and reflex response being graded at 2 each, and color being graded at 1.
Injury Compensation Association 1435 Piedmont Drive, East, Suite 101 Post Office Box 14567
Wilford Paulk, M.D.
836 Prudential Drive, No. 1001
Ms. Charlene Willoughby Department of Health
A party who is adversely affected by this final order is entitled to judicial review pursuant to Sections 120.68 and 766.311, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings are commenced by filing the original of a notice of appeal with the Agency Clerk of the Division of Administrative Hearings and a copy, accompanied by filing fees prescribed by law, with the appropriate District Court of Appeal. See Section 766.311, Florida Statutes, and Florida Birth-Related Neurological Injury Compensation Association v.
Carreras, 598 So. 2d 299 (Fla. 1st DCA 1992). The notice of appeal must be filed within 30 days of rendition of the order to be reviewed.
