04d 107 STATEOF FLORIDA i] 7} 3s 2 DEPARTMENT OF HEALTH oe 33 04 HAR -3 PH 2:54 S 2 DEPARTMENT OF HEALTH, divc: & BS AMIS gs es PETITIONER, Ao HIST RA: “ = 8 PRAGA LI i) > v. CASE NO. 2001-09917 5 2 2002-08785 2002-20094 ALTON EARL INGRAM, M.D., RESPONDENT. / ADMINGSTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Heaith, by and through its undersigned counsel and files this Administrative Complaint before the Board of Medicine against the Respondent, Alton Earl Ingram, M.D., and in support thereof alleges: 1. Petitioner is the state department charged with regulating the practice of and Chapter 458, Florida Statutes. medicine pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; 2. At all times material to this Complaint, Respondent was a licensed physician within the State of Florida and was issued license number ME 72621. 3. Respondent is board certified in plastic surgery. 4. Respondent's address of record is 780 Northeast Sixty-Ninth Street, Apartment 2506, Miami, Florida 33138. FACTS PERTAINING TO PATIENT O.M. (Complaint No. 2002-20094) 5. On or about July 24, 2002, Patient O.M., a forty-two year-old female, presented to the Respondent's office at the Cosmetic Surgery Center to inquire about having a face and neck lift, facial peel and abdominal scar revision performed. The Respondent agreed to perform the requested procedures and surgery was scheduled for July 29, 2002. 6. On or about July 29, 2002, Patient O.M. presented to the Respondent's office for the scheduled surgery. Following a brief pre-operative physical examination by the Respondent, Registered Nurse Luanne Minerley-Wiesenthal transported Patient O.M. to the surgery suite. At approximately 9:00 a.m., Nurse Minerley-Wiesenthal established intravenous access by a 24-gauge left hand catheter and #20 catheter in the right foot as the main intravenous avenue. 7. The Respondent was assisted during the surgery by Nurse Minerley- Wiesenthal, who administered anesthesia to Patient O.M. pursuant to the Respondent's instructions. At approximately 9:05 a.m., Nurse Minerley-Wiesenthal administered Valium, Robinal, Fentanyl, Ketamine and Ancef to Patient O.M. 8. Ketamine is a nonbarbiturate rapid-acting anesthetic administered either by intravenous or intramuscular injection. Ketamine should be used by or under the direction of physicians experienced in administering general anesthetics and in maintenance of an airway and in the control of respiration. Ketamine should be administered in a slow infusion (over sixty seconds). A rapid dose of Ketamine can cause respiratory depression. 9. At approximately 9:30 a.m. the Respondent commenced the surgery. Nurse Minerley-Weisenthal administered a dose of 2.5 mg of Versed to Patient O.M. at 9:45 a.m., at 10:05 a.m., and again at 2:10 p.m. 10. Versed is a benzodiazepine-type preoperative sedative, which is administered intramuscularly or intravenously. The potential known side effects for Versed include respiratory depression, respiratory arrest, hypoxic encephalopathy and even death. The initial intravenous dose for sedation in a normal adult should not exceed 2.5 mg. 11. The Respondent instructed Nurse Minerley-Wiesenthal to give Patient O.M. a continuous infusion of Diprivan by drip. As a result, the Respondent was unable to monitor the infusion of Diprivan given to Patient O.M. Due to the level of sedation, Patient O.M. was unable to respond purposefully to verbal commands and/or tactile stimulation. , 12. Diprivan is an intravenous sedative-hypnotic agent used for the induction and maintenance of anesthesia and/or sedation for surgery. During sedation with Diprivan, patients have demonstrated hypotension, oxyhemoglobin desaturation, apnea, airway obstruction, and oxygen desaturation, especially following a rapid intravenous dose of a large volume of the drug. Administration of Diprivan requires controlled infusion and therefore syringe pumps or volumetric pumps are recommended. 13. During Patient O.M.’s surgery, at approximately 2:30 p.m., Patient O.M. stopped breathing. Resuscitative efforts, including CPR and insertion of an intubation tube, were begun by the Respondent and his staff. Patient O.M.'s left hand IV was non- functional forcing the Respondent to establish a jugular IV to administer emergency medication to Patient O.M. 14. The Respondent called a private ambulance service instead of contacting Emergency Medical Services through 9 1 1. 15. At approximately 3:25 p.m., Patient O.M. was unresponsive and breathing with assistance when a private ambulance arrived to assist. 16. The Respondent requested that the paramedics transport Patient O.M. to Broward General Medical, which was 6.7 miles away, instead of Memorial General Hospital, which is 2.9 miles away. 17. Patient O.M. arrived at Broward General Medical Center’s emergency room with respiratory failure and hypoxia. 18. On August 7, 2002, Patient O.M. died with a principal final diagnosis of postoperative hypoxemic encephalopathy (lack of oxygen to the brain). 19. The registered nurse, Luanne Minerley-Wiesenthal, who administered the Diprivan to Patient O.M. was not trained in the administration of general anesthesia and was not a Certified Registered Nurse Anesthetist (C.R.N.A.). The Respondent knew or should have known that Nurse Minerley-Wiesenthal was not a C.R.N.A. 20. The Respondent's anesthesia records relating the surgical procedure performed on Patient O.M. do not reflect the time of day during which medications were administered to Patient O.M. 21. In addition, Patient O.M’s anesthesia records do not show the -exact quantity of Diprivan administered to Patient O.M., the length of the infusion of Diprivan, the total dose administered and whether any type of pump was used. 22. The standard of care for the use of Diprivan, Ketamine and/or Versed requires the presence of a C.R.N.A. or an M.D. Anesthesiologist. ve 23. A reasonable and prudent similar physician would not have delegated the authority to administer either Diprivan, Ketamine and/or Versed to a registered nurse. 24. The standard of care required the Respondent to have a Certified Registered Nurse Anesthetist or M.D. Anesthesiologist monitoring the administration of anesthesia for Level III office surgery. Where the Respondent delegates the responsibility for administration of the anesthesia for Level II office surgery, the standard of care requires monitoring of the level of sedation so that the patient has the ability to respond purposefully to verbal commands and/or tactile stimulation. COUNT ONE — STANDARD OF CARE IN RELATION TO PATIENT O.M. 25. Petitioner realleges and incorporates paragraphs one (1) through twenty- four (24) as if fully set forth herein this Count One. 26. Respondent failed 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, in one or more of the following ways: a. Ordering the administration of Diprivan by continuous drip without having a C.R.N.A. or M.D. Anesthesiologist present to supervise the dosage; b. Administering an amount of anesthetic agent which prevented Patient O.M. from being able to respond purposefully to verbal commands and/or tactile stimulation; c. Failing to establish an appropriate intravenous access; d. Failing to contact Emergency Medical Services through 9 1 1; and/or e. Persuading the Paramedic Staff to transport the patient to a hospital located twice as far away from the surgery center. 27. Based on the foregoing, Respondent has violated Section 458.331(1)(t), Florida Statutes, by failing 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. COUNT TWO — RELATING TO THE MEDICAL RECORDS OF PATIENT O.M. 28. Petitioner realleges and incorporates paragraphs one (1) through twenty- four (24) as if fully set forth herein this Count Two. 29. Respondent failed to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or billing for each diagnostic or treatment procedure and that justify the course of treatment of the patient, in one or more of the following ways: . a. Failing to keep accurate records as to the time of day any and all anesthetic agents were administered; and/or b. Failing to accurately record in the medical records the length of time relating to the infusion of anesthetic agent, the dose used, the total dose administered and whether a pump was used. 30. Based on the foregoing, Respondent violated Section 458.331(1)(m), Florida Statutes, by failing to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or billing for each diagnostic or treatment procedure and that justify the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations. COUNT THREE-ADMINISTERING LEGEND DRUGS TO PATIENT O.M. 31. Petitioner realleges and incorporates paragraphs one (1) through twenty- four (24) as if fully set forth herein this Count Three. 32. Respondent prescribed, dispensed, administered, mixed, or otherwise prepared a legend drug, including any controlled substance, other than in the course of the physician’s professional practice, in that Respondent administered excessive or inappropriate quantities of anesthetic to Patient O.M. 33. Based on the foregoing, Respondent violated Section 458.331(1)(q), Florida Statutes, by prescribing, dispensing, administering, mixing, or otherwise preparing a legend drug, including any controlled substance, other than in the course of the physician's professional practice. For the purposes of this paragraph, it shall be legally presumed that prescribing, dispensing, administering, mixing, or otherwise preparing a legend drug, including all controlled substances, inappropriately or in excessive or inappropriate quantities is not in the best interest of the patient and not in the course of the physician’s professional practice, without regard to his or her intent. COUNT FOUR — DELEGATION OF RESPONSIBILITY RELATING TO PATIENT O.M. 34. Petitioner realleges and incorporates paragraphs one (1) through twenty- four (24) as if fully set forth herein this Count Four. . 35. Respondent delegated professional responsibilities to a person when the licensee delegating such responsibilities knew or had reason to know that such person was not qualified by training, experience, or licensure to perform them, in that the Respondent delegated the administration of sedatives and/or anesthetic agents during Patient O.M.’s procedure to a registered nurse, whom he knew or had reason to know was not licensed as a Certified Registered Nurse Anesthetist. 36. Based on the foregoing, Respondent violated Section 458.331(1)(w), Florida Statutes, by delegating professional responsibilities to a person when the licensee delegating such responsibilities knows or has reason to know that such person is not qualified by training, experience, or licensure to perform them. FACTS PERTAINING TO PATIENT D.W. (Complaint No, 2002-08785) 37. On or about March 12, 2002, Patient D.W., a thirty-nine year-old female, first presented to the Respondent's office to inquire about having breast augmentation surgery. As part of her initial visit, the Respondent required Patient D.W. to complete a patient information questionnaire. 38. On or about March 21, 2002, Patient D.W. presented to the Respondent's medical office for a scheduled bilateral breast augmentation surgery. The Respondent began the surgery at approximately 9:00 a.m. with Registered Nurse Pam Rohm assisting. At that time, the Respondent knew or should have known that Nurse Rohm was not a C.R.N.A. 39. Intra-operatively, Nurse Rohm administered Versed 7.5 mg, 1% Lidocaine with Epinephrine 20 cc, and Diprivan 500 ml. 40. Lidocaine with Epinephrine is administered by injection for localized anesthesia. 41. The Respondent ordered Nurse Rohm to give Patient D.W. a continuous infusion of Diprivan by drip rather than by controlled infusion. 42. As a result of the administration of Diprivan by drip rather than by controlled infusion the Respondent was unable to monitor the infusion of Diprivan given to Patient D.W. 43. At approximately 9:30 a.m., Patient D.W’s heart rate and blood pressure abruptly increased to 160 bpm and 180 bpm, respectively. 44. After several minutes, the Respondent was able to stabilize Patient D.W. through medication. The Respondent then continued with the surgery. 45. At approximately 10:05 a.m., Patient D.W’s heart rate abruptly dropped to 45 bpm, and within a few minutes, spontaneously increased to normal levels. The Respondent proceeded with the surgery. 46. At approximately 10:10 a.m., Patient D.W.’s heart rate and blood pressure decreased suddenly, and she stopped breathing. The Respondent stopped the surgery and began to resuscitate Patient D.W. 47. Subsequently, Patient D.W. was transported by ambulance to Memorial Hospital Hollywood's emergency room, where she was stabilized. 48. Nurse Rohm, who administered the Diprivan to Patient D.W,, was not trained in the administration of general anesthesia, was not trained to manage patients in deep sedation or under general anesthesia and was not a Certified Registered Nurse Anesthetist. 49. A reasonable and prudent similar physician would not have delegated the authority to administer either Diprivan, Ketamine and/or Versed to a registered nurse. 50. The standard of care required the Respondent to have a Certified Registered Nurse Anesthetist or M.D. Anesthesiologist monitoring the administration of anesthesia for Level III office surgery. Where the Respondent delegates the responsibility for administration of the anesthesia for Level II office surgery, the standard of care requires monitoring of the level of sedation so that the patient has the ability to respond purposefully to verbal commands and/or tactile stimulation. COUNT FIVE — STANDARD OF CARE RELATING TO PATIENT D.W. 51. Petitioner realleges and incorporates paragraphs one (1) through four (4), eight (8), ten (10), twelve (12), twenty-two (22) through twenty-four (24) and thirty- seven (37) through fifty (50) as if fully set forth herein this Count Five. 52. Respondent failed 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, in one or more of the following ways: 10 a. Ordering the administration of Diprivan by continuous drip without having a C.R.N.A. or M.D. Anesthesiologist present to supervise the dosage; and/or b. Administering a level of anesthetic agent which prevented Patient O.M. from being able to respond purposefully to verbal commands and/or tactile stimulation. 53. Based on the foregoing, Respondent has violated Section 458.331(1)(t), Florida Statutes, by failing 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. COUNT SIX — DELEGATION OF RESPONSIBILITY RELATING TO PATIENT D.W. 54. Petitioner realleges and incorporates paragraphs one (1) through four (4), eight (8), ten (10), twelve (12), twenty-two (22) through twenty-four (24) and thirty- seven (37) through fifty (50) as if fully set forth herein this Count Six. 55. Respondent delegated professional responsibilities to a person when the licensee delegating such responsibilities knew or had reason to know that such person was not qualified by training, experience, or licensure to perform them, in that the Respondent delegated the administration of sedatives and/or anesthetic agents during Patient D.W.'s procedure to a registered nurse, whom he knew or had reason to know was not licensed as a Certified Registered Nurse Anesthetist. ff] 56. Based on the foregoing, Respondent violated Section 458.331(1)(w), Florida Statutes, by delegating professional responsibilities to a person when the licensee delegating such responsibilities knows or has reason to know that such person is not qualified by training, experience, or licensure to perform them. FACTS PERTAINING TO PATIENT D.K. (Complaint No. 2001-09917) 57. On or about April 16, 2000, Patient D.K., a fifty-three year-old female, first presented to the Respondent to inquire about having plastic surgery to the areas of her face surrounding her eyes. 58. After the initial appointment, Patient D.K. elected to also have liposuction performed on her midsection during the surgery already scheduled for her face. 59. On or about May 2, 2000, the Respondent performed an upper and lower lid blepharoplasty and an abdominal liposuction on Patient D.K. 60. While the Respondent was infiltrating liposuction fluids into Patient D.K/’s abdomen in preparation for performing the liposuction procedure, the Respondent noticed a “bulging” in Patient D.K.’s abdomen, which may have been caused by the Respondent improperly entering the abdominal cavity. The Respondent examined the bulge by palpating it and aspirating fluid from it. Based on his examination of the bulge, the Respondent ruled out the possibility that the bulge represented a hernia, The Respondent proceeded with the liposuction procedure. 61. |The Respondent made no notes regarding any treatment of Patient D.K. during the post-operative hours. Patient D.K. was discharged home on or about May 2, 2000. 12 62. On or about May 3, 2000, Patient D.K. developed persistent nausea and vomiting with abdominal! pain. 63. The Respondent examined Patient D.K. once postoperatively on May 4, 2000, at his medical office. Patient D.K. informed the Respondent that she was able to pass gas but had not been able to have a bowel movement. 64. On or about May 6, 2000, Patient D.K. was admitted to a local emergency room with severe abdominal pain and nausea. Patient D.K. had not experienced a bowel movement since her surgery on or about May 2, 2000. Patient D.K. was given a preliminary diagnosis of small-bowel obstruction. 65. Subsequently, Patient D.K. underwent surgical exploration at the hospital. During the exploratory surgery, an incarcerated hernia was discovered and repaired and a portion of Patient D.K.’s small bowel was surgically removed. 66. A reasonable and prudent similar physician would have properly assessed the bulge in Patient D.K.’s abdomen and discontinued the elective surgery and/or would have completed the procedure without entering the abdominal cavity. COUNT SEVEN — STANDARD OF CARE RELATING TO PATIENT D.K. 67. Petitioner realleges and incorporates paragraphs one (1) through four (4), and fifty-seven (57) through sixty-six (66) as if fully set forth herein this Count Seven. - 68. Respondent failed 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, in one or more of the following ways: a. Failing to recognize Patient D.K.’s hernia pre-operatively; b. Failing to properly assess or evaluate the abdomen wall defect before continuing with an elective surgery; c. Performing liposuction improperly by entering the abdominal cavity; d. Failing to properly address and recognize Patient D.K’s symptoms of - nausea and lack of a bowel movement as a possible bowel obstruction secondary to herniated gut at the wall defect; and/or e. Failing to refer Patient D.K. to a general surgeon regarding the possibility of interrupted intestinal transit. 69. Based on the foregoing, Respondent has violated Section 458.331(1)(t), Florida Statutes, by failing 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. COUNT EIGHT — MEDICAL RECORDS RELATING TO PATIENT D.K. 70. Petitioner realleges and incorporates paragraphs one (1) through four (4), and paragraphs fifty-seven (57) through sixty-six (66) as if fully set forth herein this Count Eight. ) 71, Respondent failed to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or billing for each diagnostic or 14 treatment procedure and that justify the course of treatment of the patient, in that he failed to document the immediate post-operative hours on May 2, 2000. 72. . Based on the foregoing, Respondent violated Section 458.331(1)(m), Florida Statutes, by failing to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or billing for each diagnostic or treatment procedure and that justify the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations. WHEREFORE, the Petitioner respectfully requests that the Board of Medicine enter an order imposing one or more of the following penalties: permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate. + SIGNED this_S~ day of___Avaust , 2003. John O. Agwunobi, M.D., M.B.A. FI LE D Secretary, Department of Health DEPARTMENT OF HEALTH om a cuerk E c Pena Co ACK sl £ {G2 cree oloma Kim M. Kluck Assistant General Counsel Florida Bar No.: 0040967 DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 (850) 488-4451. (850) 414-1989 FAX kmk Reviewed and approved by: / WAS (initials) & 5/63 (date) PCP: sury 25, 20 03 PCP Members: ’ El-Bahri, Miguel, Long Ingram, DOH Case Nos. 2001-09917, 2002-08785, 2002-20094 ’ NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed.

Docket for Case No: 04-000709PL

Orders for Case No: 04-000709PL