vs. ) CASE NO. 88-4967
JORGE L. CAMB0, M.D., )
Respondent. )
This matter was heard by William R. Dorsey, Jr., the hearing officer designated by the Division of Administrative Hearings, in West Palm Beach, Florida, on February 3, 1989. A transcript of the proceeding was filed and the parties have filed proposed findings of fact and conclusions of law. Rulings on proposed findings of fact are made in the Appendix to this Recommended Order.
Mary B. Radkins, Esquire Department of Professional
For Respondent: Robert H. Springer, Esquire
The issue is whether Dr. Cambo failed to practice medicine with the level of skill recognized by reasonably prudent similar physicians as acceptable under the circumstances in his care of a patient who allegedly was having a heart attack. Dr. Cambo had the patient transferred from John F. Kennedy Memorial Hospital to Humana Hospital of the Palm Beaches. The patient died shortly after the transfer. The Count alleging that Dr. Cambo had exercised influence over a patient for financial gain (Count II) was dismissed at the opening of the hearing.
Dr. Cambo is licensed by the Board of Medicine, holding license number 48428, and was licensed at all times pertaining to the events alleged in the Administrative Complaint.
L. M., a 67 year old male, arrived at the emergency room of John F. Kennedy Memorial Hospital in Atlantis, Florida, at 12:08 p.m., on April 15, 1987. L. M. had been a resident at the Atlantis Nursing Home. L. M. spoke Finnish; he did not speak English. He had had an amputation of a portion of his right leg two weeks earlier due to gangrene caused by peripheral vascular disease. The staples from this amputation were still visible. He had had a stroke, had irregularities in a prior E.K.G. and generally was in poor health. His current medications included ecotrin, motrin, vasotic, lopressor, halcion and catapress. He had indicated that he had chest pain to the nursing home staff and to the Fire-Rescue technicians by signing.
When he arrived at the emergency room L. M. was described as cyanotic, diaphoretic and hypotensive. His breathing was labored. He was examined by the emergency room physician, Randall Wolff. L. M.'s chest pain, labored breathing and cyanotic appearance were consistent with cardiogenic shock. Dr. Wolff ordered certain diagnostic tests which included a complete blood count, a chest x-ray, and arterial blood gases. An E.K.G. was performed at approximately 3:00
p.m. that afternoon. L. M.'s urine color that afternoon was indicative of infection. Test results showed an elevated white blood count, and immature white blood cell forms. These are consistent with an active infection from the recent amputation or a myocardial infarction. Dr. Wolff thought the patient should have been admitted to J.F.K. because of his chest pain and abnormal vital signs.
Dr. Cambo was contacted by the emergency room staff because Dr. Cambo was on call for the health maintenance organization which provided L. M.'s medical care. Dr. Cambo came to the hospital at about 2:40 p.m. and saw L. M. and other HMO patients. No treatment for L. M., other than oxygen, had been ordered by Dr. Wolff. Apparently, Dr. Wolff did not regard L. M.'s condition as serious. Dr. Cambo conducted a physical examination of L. M., who by that time denied having chest pain by signing. The examination revealed that the right stump had no femoral pulse, while the left leg had 2+ femoral pulse. His blood pressure was on the low side of the normal range. Dr. Cambo also reviewed L. M.'s test results, including the 3:00 p.m. E.K.G. tracing. Dr. Cambo then telephoned Dr. Jerome Vincente, the primary care physician who had managed the care of patient L. M. while L. M. was being served by the International Medical Center No. 90 in West Palm Beach. During that telephone call Dr. Cambo and Dr. Vincente compared the 3:00 p.m. E.K.G. tracing with a prior E.K.G. tracing from
L. M.'s records at International Medical Center. The prior E.K.G. tracing was similar to that taken at 3:00 p.m. Dr. Cambo's reading of the 3:00 p.m. tracing led him to diagnose inferior wall ischemia and marked T anterior wall ischemia. Taken in isolation, the 3:00 p.m. tracing would indicate that L. M. might be having a heart attack. After the comparison Dr. Cambo made of the prior tracing, Dr. Cambo concluded that L. M.'s current cardiac condition was not abnormal for him, and decided to transfer L. M. to Humana Hospital for the purpose of achieving continuity of treatment, i.e., so that he would be seen at Humana by his regular physicians. Dr. Cambo believed L. M. had an infection resulting from the recent amputation and had circulatory problems which had resulted in gangrene that had caused the amputation.
Dr. Cambo returned to J.F.K. Hospital at 3:30 p.m. to see HMO patients, including L. M. who had not yet been transferred to Humana Hospital. Dr. Cambo again examined L. M. and after reviewing the progress notes of L. M. maintained by the J.F.K. Hospital nursing staff, he determined that L. M.'s condition had not changed since 3:00 p.m.
Dr. Cambo left J.F.K. Hospital between 5:30 p.m. and 6:00 p.m. with the instruction that L. M. be transferred to Humana. Due to the delay encountered in obtaining transportation, Dr. Cambo ordered that the patient continue to receive oxygen and that he receive I.V. fluids.
Between 6:30 p.m. and 7:30 p.m. Dr. Cambo contacted the nursing staff at the J.F.K. Hospital emergency room on two occasions. Each time he was told that L. M.'s condition remained the same and had not altered since his arrival at the emergency room shortly after noon.
The Atlantis Ambulance Service arrived at J.F.K. Hospital at about 7:45
p.m. to transport L. M. to Humana Hospital.
At about 11:00 p.m. on April 15, 1987, patient L. M. died from an anterior wall myocardial infarction at Humana Hospital.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over this matter. Section 120.57(1), Florida Statutes.
A physician is subject to discipline under Section 458.331(1)(t), Florida Statutes, if he
... is guilty of gross or repeated malpractice or 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. . . As used in this paragraph "gross malpractice" or "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" shall not be construed so as to require more than one instance, event, or act.
The evidence is not persuasive that Dr. Cambo is guilty of failure to meet applicable standards of practice. The opinion of the emergency room doctor (Dr. Wolff) that the patient should have been admitted to J.F.K. Hospital is one useful piece of information in determining whether Dr. Cambo's decision to transfer the patient was appropriate, but it is not determinative. The testimony of Dr. Cohen interpreting the E.K.G. taken of the patient at 3:00 p.m. as showing a heart attack requiring immediate admission to J.F.K. Hospital is overcome by the evidence from Dr. Cambo and Dr. Vincente that they discussed the patient's prior E.K.G., and that the emergency room E.K.G. was essentially identical. This comparison led Dr. Cambo to conclude that the patient was not having an acute cardiac incident, but rather had had a chronic cardiac abnormality for some time. This conclusion was reasonable under the circumstances.
All of the testimony proffered by the Department to show that Dr. Cambo's care fell below the applicable standard of care is based, in substantial part, upon entries in the nurses' notes (Tr. 96, 114; Van Eldik depo. at 29). Those notes are not credible. They have, unfortunately, been altered after the
fact. There are several indications of this. The first page of notes begins at noon and runs through 7:45 p.m., and includes entries for 5:30 p.m., 6:30 p.m., 7:00 p.m. and 7:45 p.m. For no apparent reason, the second page of notes begins with 5:30 p.m. and contains notes for 6:30 p.m., 7:30 p.m. and 7:45 p.m. The non-chronological nature of these notes gives rise to serious question about their accuracy. Dr. Van Eldik, one of the experts for the Department, also found the ordering of the notes inexplicable (Van Eldik deposition, pp.18-19).
At the hearing, it became obvious that counsel for the Department and counsel for Dr. Cambo had xerox copies of the first page of the nurses' notes which were not identical. During the hearing, the Hearing Officer required that the hospital produce the original notes. Comparing those original notes during the hearing with the copies of the notes in the files of counsel for the Department revealed that the notes had been amended to include additional notations expressing concern over the patient's condition at a time after the notes had been copied by the Department. Those notes had been subpoenaed and copied long after the events the notes purport to record. Consequently, the testimony of the experts for the Department, which rely to a significant extent upon the nurses' notes to conclude that the patient was in a much more serious condition than Dr. Cambo seems to have realized, and that Dr. Cambo acted despite warnings in the nurses' notes, cannot be credited. The more credible testimony is that of Dr. Cambo, and of Dr. Musaffi. Based upon the physical examinations of the patient over the course of the day, the results of the tests ordered by Dr.
Wolff on April 15th, the prior E.K.G. tracing, and the portion of the nurses' notes which were actually available to Dr. Cambo, the patient was not too ill to be transferred, and it was in the patient's interest to transfer him in order to obtain continuity of care.
Had the nurses' notes which were offered into evidence actually been the notes available to Dr. Cambo, it would have been improper for him to have transferred the patient, but he did not have that information when he saw the patient at 5:30 p.m. and when he called between 6:30 p.m. and 7:30 p.m. to check on the patient's status.
RECOMMENDATION
It is RECOMMENDED that the charges contained in Count I of the Administrative Complaint be dismissed. Count II of the Administrative Complaint was dismissed by the Department at the final hearing and requires no further action by the hearing officer or the Board of Medicine.
DONE and ENTERED this 3rd day of April, 1989, in Tallahassee, Leon County, Florida.
WILLIAM R. DORSEY
Hearing Officer
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-1550 904/488-9675
Filed with the Clerk of the Division of Administrative Hearings this 3rd day of April, 1989.
APPENDIX
Rulings on the proposed findings of fact.
Findings proposed by Department of Professional Regulation.
Covered in finding of fact 1.
Covered in finding of fact 2.
Covered in finding of fact 3.
Covered in finding of fact 2 and 3.
Covered in finding of fact 2.
Rejected as unnecessary.
Covered in finding of fact 3.
Covered in finding of fact 3.
Covered in finding of fact 2.
To the extent appropriate covered in finding of fact
3 and 4.
Covered in finding of fact 3.
Covered in finding of fact 3.
Rejected because the programming of the data scope to produce the quoted printout was not proven to be accurate. What is most important is the judgment of the physicians who examined the patient and were in a much better position to evaluate the significance of the results, not only of the E.K.G., but of all testing.
Covered in finding of fact 4. The proposed finding that L. M. communicated non-verbally due to aphasia is rejected because it is equally likely that he could not communicate because English was not his primary language.
Rejected as inconsistent with the Hearing Officer's view of the evidence.
Rejected because the testimony of Dr. Cambo and Dr. Vincente indicates that the E.K.G. was not clearly indicative of myocardial infarction in this patient.
Covered in finding of fact 4.
Rejected as unnecessary and because there is no way to know whether the patient's blood pressure was low due to cardiogenic shock or the medication he was taking.
Rejected is inconsistent with the Hearing Officer's view of the evidence.
Rejected as inconsistent with the Hearing Officer's view of the evidence.
Rejected as inconsistent with the Hearing Officer's view of the evidence.
Rejected as unnecessary and irrelevant. There is no indication that the patient suffered from any problem because of the absence of written instructions for care to be given during the transfer.
Rejected as inconsistent with the Hearing Officer's view of the evidence.
Covered in finding of fact 5.
Rejected because there was no argument between Dr. Wolff and Dr. Cambo about admitting the patient to
J.F.K. The nursing notes, from which this inference is derived, are unreliable. Dr. Wolff did not testify to any such argument.
Rejected as irrelevant.
Rejected as unnecessary.
Rejected as unnecessary.
Rejected, the patient's breathing was not labored at 6:30 p.m. To the extent the nurses notes might indicate otherwise, they are rejected as unreliable.
Rejected because the second page of the nurses notes is an after-the-fact creation.
Rejected because the second page of the nurses notes is an after-the-fact creation.
Rejected because the nurses notes have been found to be unreliable.
Covered to the extent necessary in finding of fact 9.
Covered to the extent necessary in finding of fact 9.
Rejected as unnecessary.
Rejected as unnecessary.
Rejected as inconsistent with the Hearing Officer's view of the evidence.
Rejected as inconsistent with the Hearing Officer's view of the evidence.
The findings proposed by the Respondent are not submitted in numbered paragraphs. The burden of the proposed findings of Dr. Cambo have been accepted.
ROBERT H. SPRINGER, ESQUIRE 3003 SOUTH CONGRESS AVENUE SUITE 1A
