STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
DEPARTMENT OF PROFESSIONAL )
REGULATION, )
)
Petitioner, )
)
vs. ) CASE NOS. 89-6489
) 90-2680
ELLIOT F. MONROE, M.D., )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to notice, this cause came on for formal proceeding before P. Michael Ruff, duly-designated Hearing Officer of the Division of Administrative Hearings, in Panama City, Florida.
APPEARANCES
FOR PETITIONER: Mary B. Radkins, Esquire, Senior Attorney Department of Professional Regulation Northwood Centre, Suite 60
1940 North Monroe Street Tallahassee, Florida 32399-0792
FOR RESPONDENT: Elliott F. Monroe, M.D., pro se
2709 Arden
Panama City, Florida 32401 STATEMENT OF THE ISSUES
The issues in this cause concern whether the Respondent committed the various charged violations of Section 458.331(1), Florida Statutes (the Medical Practice Act), as alleged in the two Administrative Complaints at issue and, if so, what, if any, penalty against licensure is warranted.
PRELIMINARY STATEMENT
This cause arose upon the filing of an Administrative Complaint by the above-named Petitioner against the Respondent alleging a violation of Section 458.331(1)(t), Florida Statutes (1980), by his alleged failure to perform a surgical procedure concerning the patient named in Counts I and II, to which that patient had consented, thereby resulting in the necessity for later surgery and chemotherapy when the organs in question became cancerous. It is also alleged that he performed a dilation and curettage (D&C) procedure on the patient without her consent or knowledge; thus, allegedly failing to practice medicine with an acceptable level of care, skill and treatment. The Respondent was charged with regard to the same patient, in Count II of the Complaint, with failure to keep medical records which justified the surgery performed, the failure to perform all of the procedure consented to by the patient and for
performing surgery without the patient's consent in alleged violation of Section 458.331(1)(n), Florida Statutes (1979), now Section 458.331(1) (m), Florida Statutes (1989).
Concerning patient No. 2, referenced in Counts III, IV and V of the Complaint, it is alleged that the Respondent inappropriately administered an excessive amount and concentration of an anesthetic legend drug, commonly called "marcaine" (bipuvacaine), which allegedly resulted in patient no. 2's cardiac arrest and subsequent death. The Respondent is charged with violating Section 458.331(1)(q), Florida Statutes (1983), for administering this drug in excessive and inappropriate quantities, in a manner not in the best interest of the patient; with failure to practice medicine with an acceptable level of care, skill and treatment, a violation of Section 458.331(t), Florida Statutes (1983); and with violating Section 458.331(1)(n), Florida Statutes, now Section 458.331(1)(m), Florida Statutes (1989), in that the Respondent's written medical records for that patient fail to justify the administration of such a large concentration and volume of the drug.
In Count VI, the Respondent is alleged to have practiced below an acceptable level of care, skill and treatment with regard to patient No. 3 by failing to obtain or document the patient's medical history; to utilize appropriate studies to determine fetal status before initiating therapy to prolong the pregnancy, in a patient with pregnancy-induced hypertension; by failing to assess and treat her pregnancy-induced hypertension; and by failing to appreciate her abnormal test results. The Respondent is also charged with violating Section 458.331(1)(q), Florida Statutes (1982) (Count VII), by inappropriately treating the patient with aldomet, lasix, yutopar, and a corticosteriod cream during the course of her hospitalization. The Respondent is charged with multiple failures to keep medical records justifying his course of treatment of this patient in violation of what is now numbered as Section 458.331(1)(m), Florida Statutes (Count VIII).
With regard to Count IX, the Respondent is charged with failing to practice medicine in accordance with the above- mentioned standard with respect to patient No. 4 by allegedly failing to obtain an adequate history or to perform an adequate physical examination. He allegedly failed to attempt vaginal delivery, to adequately treat the patient's lacerated cervix, to obtain her informed consent before sterilization, and failed to adequately treat her in the postoperative recovery period. See Section 458.331(1)(t), Florida Statutes.
The Respondent is charged with inappropriately prescribing or administering legend drugs (antibiotics) to patient No. 4, in violation of Section 458.331(1)(q), Florida Statutes (Count X).
The Respondent is charged in Count XI with violating Section 458.331(1)(n), Florida Statutes (1977), now Section 458.331(1)(m), Florida Statutes, by failing to keep written medical records which would justify his course of treatment of patient No. 4. He allegedly did not document a complete history or physical examination which would justify a cesarean section procedure, allegedly failed to order renal function studies, and allegedly utilized a nasogastric tube while allowing the patient to eat. He is charged with failing to justify changing medications to oral administration and with documenting entries in the discharge summary which contradict her other medical records.
In Count XII, the Respondent is charged with incompetence and negligence in the care and treatment of patient No. 5, a violation of Section 458.1201(1)(m), Florida Statutes (1979), since incorporated into Section 458.331(1)(t), Florida
Statutes, by failing to obtain an adequate history, to perform an adequate physical examination, and to diagnose and chart a course of treatment concerning the patient's need for a D&C. He is charged with failing to correctly document his postoperative report concerning the procedure performed on her left fallopian tube, or to include endometriosis as a diagnosis, and by allegedly failing to adequately assess the condition of the left fallopian tube or the patient's endometriosis.
These charges became DOAH Case No. 89-6489. On March 14, 1990, another Administrative Complaint was filed, which was consolidated for adjudication with the above-referenced Complaint. With regard to that Complaint (90-2680), it is alleged in Count I that the Respondent asserted under oath before the Board of Medicine that he was not working as of June 2, 1989 and that he had practiced medicine for only one day in March of 1989. It is claimed that he asserted on that occasion that he had never practiced at the AKBAR Clinic, thereby allegedly making deceptive, untrue or fraudulent representations in the practice of medicine in alleged violation of Section 458.331(1)(k), Florida Statutes.
In Count II of the second Complaint, the Respondent is charged with misrepresenting or concealing a material fact during a phase of a disciplinary process, in alleged violation of Section 458.331(1)(hh), Florida Statutes, by asserting before the Board of Medicine, during an informal hearing, that he had never seen, talked to, examined, prescribed, or otherwise had business with patients in Florida during 1989, except for one day in March. In Count III of the second Complaint, the Respondent is alleged to have violated Section 458.331(1)(g), Florida Statutes, by failing to perform a statutory or legal obligation placed on a licensed physician in that he prescribed controlled substances with no current DEA (Drug Enforcement Administration) registration. He is charged in Count IV with thus violating Section 458.331(1)(v), Florida Statutes, by allegedly practicing beyond the scope permitted by law. He is charged in Count V with violating Section 458.331(1)(q), Florida Statutes, by practicing other than in the course of his professional practice by prescribing these controlled substances without proper registration. In Count VI, he is alleged to have been guilty of false, deception or misleading advertising by advertising his affiliation with the Apalachicola Bay Community Clinic after his license to practice medicine in Florida had been suspended by the Board of Medicine, in alleged violation of Section 458.331(1)(d), Florida Statutes. In this particular, he is also charged with violating Section 458.331(1)(x), Florida Statutes, by violating a lawful order of the Board of Medicine by advertising his affiliation with that clinic when his license to practice medicine had previously been suspended (Count VII).
The cause came on for hearing as noticed. The testimony and evidence concerning Case No. 90-2680, the seven- count Complaint referenced last above, was presented first. In that case, the Petitioner presented the testimony of eight witnesses and 11 exhibits, 10 of which were admitted into evidence and one of which was withdrawn (Exhibit No. 8). In Case No. 89-6489, the Petitioner presented the testimony of five witnesses and 34 exhibits, one of which was late filed. The Respondent submitted three exhibits. The Respondent presented the testimony of two witnesses. One "court exhibit" was admitted. Additionally, official recognition was taken of the orders related to the Respondent's prior disciplinary action in Texas, Louisiana and Alabama, as well as by the Florida Board of Medicine, and of Chapter 21M, Florida Administrative Code.
The proceedings were transcribed after the hearing. After stipulating to an extended briefing schedule, the parties filed proposed findings of fact and conclusions of law in the form of Proposed Recommended Orders. The proposed
findings of fact contained therein are addressed in this Recommended Order and again specifically ruled upon in the Appendix attached hereto and incorporated by reference herein. The findings of fact made below will relate first to Case No. 90-2680.
FINDINGS OF FACT Case No. 90-2680
At all times pertinent to this proceeding, the Respondent, Elliott F. Monroe, M.D., was licensed as a physician in the State of Florida. He holds license number ME00I9670. He is a Board-certified obstetrician and gynecologist. The Petitioner is an agency of the State of Florida charged with enforcing the provisions of Chapter 458, Florida Statutes, which contain the licensure and practice standards for medical practitioners in Florida.
On June 2, 1989, the Respondent appeared before the Board of Medicine in Tallahassee, Florida, at an informal hearing. That hearing concerned the case of Department of Professional Regulation, Board of Medical Examiners v. Elliott F. Monroe, M.D., DPR Case No. 0099289.
The Respondent gave certain sworn testimony in that informal proceeding. In response to questions by various Board members, the Respondent stated that he was not working as a doctor in Florida, but planned to return to work on approximately June 14, 1989. He indicated, in his testimony, that he was going to practice in Apalachicola, Florida, starting on June 15, 1989. In response to a question by Dr. Skinner of the Board, concerning whether he had practiced in Florida since disciplinary action was taken against his Texas licensure, the Respondent replied that he had covered an emergency room one day in Apalachicola around the first of March; but that was the only practice he had done in Florida so far, meaning since he had returned to Florida from Texas. At the hearing in the instant proceeding, however, the Respondent testified that at the time he gave that testimony concerning working one day in Apalachicola, he was confused and under a great deal of pressure in that prior legal proceeding concerning the future of his licensure and was unrepresented by counsel at the time. Accordingly, he stated that he had inadvertently answered incorrectly, although he had not intended to deceive the Board. The Respondent was allowed to recant the prior answer given in the informal proceeding by stating on the record in the instant proceeding as follows: `VI covered an emergency room several days in Apalachicola in March, April and May." In the course of the Respondent's testimony in the instant proceeding concerning recantation of his earlier statement, he acknowledged upon questioning by the Petitioner's counsel that at the time in question, in March, April and May of 1989, he was seeing and treating patients in Florida. Indeed, prior to the informal proceeding, on April 10, 1989, the Respondent had already stated to two investigators of the Petitioner that he was working in the emergency room of Weems Memorial Hospital in Apalachicola, Florida, two days a week and was specifically working there on March 20, 1989.
The Respondent had been employed at the Weems Memorial Hospital in Apalachicola, Florida, since approximately March 3, 1989 through June 19, 1989. He carried out emergency room and clinical duties at the hospital, including diagnosing and treating patients. His duties also included requesting and reading x-rays, laboratory studies and prescribing and admitting patients to the hospital.
The Respondent signed prescriptions and prescribed medications on March 3, 6 and 20, 1989 on AKBAR Clinic prescription pads. The prescription for patient No. 2 on March 20, 1989 indicates that that patient was seen at the AKBAR Clinic. The Respondent, as to patient No. 2, seen on March 20, 1989, struck the name of Dr. Elkadi and substituted his own name on the prescription, but left intact the AKBAR Clinic letterhead and address on the prescription.
The prescriptions bear a signature purporting to be that of the Respondent and the Respondent acknowledged to Investigator Wheelahan that the signatures on the prescriptions of March 3, 6 and 20, 1989 were his signatures, as testified to by Mr. Wheelahan, without objection.
In Respondent's application for employment at Weems Memorial Hospital dated February 16, 1989, he listed his office address as 4000 E. Third Street, Panama City, Florida 32404. He indicated on that application that he was practicing as a physician with Dr. Ahmed Elkadi. The address given on that application for employment is that of the AKBAR Clinic.
The Respondent held no valid drug enforcement administration (DEA) registration necessary to prescribe and dispense controlled substances for the period from January 29, 1989 to March 23, 1989. His registration had expired inadvertently due to the Respondent being hospitalized for severe medical problems during January and February of 1989, culminating in cardiac surgery. During the period of his expired registration, he prescribed valium, a schedule IV controlled substance, morphine sulfate and cocaine hydrochloride, schedule II controlled substances. The Respondent had reason to know that his registration was in a lapsed status when he wrote the prescriptions in March of 1989 although he had not renewed his registration for the extenuating circumstances relating to his medical disability. He renewed his DEA registration on March 23, 1989.
On June 2, 1989, he was present at the Board of Medicine informal hearing referenced above. He was informed by the Board at that time that his license to practice medicine in Florida would be suspended until all disciplinary action had been completed in Texas. On June 19, 1989, he was informed by Mr. Davis, the Acting Administrator of Weems Memorial Hospital, of the entry of the Board of Medicine's Order of June 15, 1989 suspending his license to practice in Florida. Advertisements announcing that the Respondent was practicing medicine in Apalachicola, Florida, appeared in the Carrabelle- Apalachicola Times on June 15, 22 and 29, 1989. These advertisements, however, were ordered or subscribed prior to the Board's suspension of his licensure. There is no evidence to show that he actually practiced medicine after his suspension, even though the advertisements continued to run for a few days thereafter.
Case No. 89-6489
Counts I and II: Patient No. 1
The Respondent provided medical care and treatment for patient No. 1 (S.C.) from approximately October 11, 1980 through October 18, 1980. She was admitted to the hospital during that time period, and he was her attending physician.
The Respondent diagnosed her condition as involving an "abdominal mass". Ultimately, an operation was planned for this patient, involving a total abdominal hysterectomy (TAH) and a bilateral salpingo-oophorectomy (BS&O). These procedures involved removal of the uterus, both fallopian tubes, and both ovaries. On October 12, 1980, the Respondent obtained from this patient her
informed consent to perform the TAH and the BS&O. The Respondent did not obtain any consent from the patient to perform a D&C. When the Respondent actually performed surgery on this patient, he performed a D&C, as well as a TAH. The Respondent, however, failed to perform a BS&O upon the patient, thus leaving the ovaries and fallopian tubes intact. There is no information in the medical records to indicate whether the Respondent ever informed the patient that the BS&O procedure was not performed nor that he informed her that the D&C procedure was performed. There is no indication in the medical records that the pathology report was ever discussed with the patient nor was it proven that it was not.
The Respondent did not document any symptoms associated with the abdominal mass which he diagnosed. He did not document any complaints by the patient or any reference to an abdominal scar on his physical examination, although the patient had had an earlier appendectomy. Before the surgery was performed, the Respondent did not document in the medical record any justification for his plan to do the BS&O, to which the patient had consented, nor did he document any reason for his abandonment of that procedure during surgery or for his performing of the D&C procedure, to which the patient had not consented.
The patient was under the Respondent's care until approximately October 18, 1980, when she was discharged. Thereafter, on or about June 19, 1985 until June 25, 1985, patient No. 1 was hospitalized under the care of another physician, Dr. Theodore Elchos. This hospitalization was for treatment of a pelvic mass. On or about June 21, 1985, Dr. Elchos performed an exploratory laparotomy upon patient No. 1. This procedure resulted in the removal of the left ovary, right ovary, and the right fallopian tube. The patient's ovaries were biopsied, and the resulting pathology report concerning the ovaries revealed papillary serous cystadenocarcinoma, grade IV, motastic. This was a cancerous condition which eventually resulted in the patient's death.
The Respondent, for unknown reasons, failed to perform the BS&O procedure on patient No. 1. Had he performed the BS&O procedure, the patient's fallopian tubes and ovaries would have been removed thereby, such that the cancer and her death would likely have been prevented. It was not established, however, that the Respondent knew or should have known that the organs were or might become cancerous at the time in 1980 when he performed the TAH and the D&C procedures and failed to perform the planned BS&O procedure. It was likewise not established that the ovaries and fallopian tubes should have been removed at the time and that the doctor was negligent or departed from the appropriate standard of care in failing to remove them. It was proven that he had obtained the patient's consent to remove them through the BS&O procedure, failed to perform the procedure, and failed to document why he initially felt that the procedure was required. When the procedure was not performed, he failed to document in the records why it was not performed and other information concerning the actual condition of the patient's ovaries and fallopian tubes which might have shown a basis for any decision regarding their retention or removal at the time of the 1980 surgery.
Thus, in the above particulars, it was shown by the testimony and the deposition of Dr. Lewis, in evidence as Petitioner's Exhibit 26, that the Respondent failed to practice medicine with that level of care, skill and treatment which a reasonably prudent similar physician recognizes as acceptable under similar conditions and circumstances, although it was not proven by clear and convincing evidence that the failure to remove the fallopian tubes and ovaries was a procedure which was medically necessary at the time and should have been performed nor that the Respondent should have foreseen that they would
become cancerous at a later time. Performance of the D&C procedure was done without the patient's consent, therefore, that also was a departure from accepted standards of medical care, skill and treatment recognized by reasonably prudent similar physicians under similar conditions and circumstances.
Counts III, IV and V: Patient No. 2
The Respondent provided medical care and treatment for patient No. 2 by being the attending physician for her hospital admission from June 4, 1983 through June 6, 1983. On or about June 4, 1983, the patient was admitted to the hospital in active labor. She was 6 to 7 centimeters dilated, and the Respondent was so notified by hospital personnel. When the Respondent arrived to see the patient, the patient was moved to the delivery room. She was by then
centimeters dilated with "bulging membranes, vertex presentation, 0 station". The Respondent initiated an epidural anesthesia on the patient in preparation for a vaginal delivery. This was the patient's third pregnancy. She had had short labors in her prior pregnancies, and all were vaginal deliveries. The Respondent noted in her medical records that her pelvis was adequate for delivery. Her weight at the time was approximately 110 pounds.
Epidural anesthesia involves the insertion of a local anesthetic substance into the epidural space of the spinal column directly through an injection needle or through an inserted catheter. The Respondent in the instant case inserted an epidural catheter and through the catheter administered 12 milliliters of 0.75% concentration marcaine in divided doses of 3 milliliters each.
Marcaine is a trade name for bupivacaine. It is a legend drug used for a local or regional anesthesia. Marcaine is very cardio-toxic in comparison to other local anesthetic agents. In obstetrical cases, it is employed in a very dilute solution. Vaginal deliveries accompanied by an episiotomy surgical procedure are typified by use of a 0.25% concentration solution of marcaine. Cesarean sections typically are performed with the use of a 0.50% solution or a combination of 0.25% and 0.50% can satisfactorily be used.
The physician's desk reference (PDR) is a reference work commonly relied upon by obstetrical physicians. In 1983, the PDR provided that a 0.75% marcaine solution was appropriate, but an upper limit of concentration, for obstetrical use and primarily intended for cesarean section use. Likewise, 12 milliliters dosage of marcaine is at the upper limit, but within general guidelines for dosage in the PDR; however, it must carefully be given in divided dosage for the safety of the patient to avoid cardio-toxic effects.
The persistent cardio-toxic or cardiac arresting effects of marcaine result from its interaction with the "sodium channels" related to the heart's operative nervous system. Because of this reaction relationship, the effect of marcaine in causing heart rhythm problems and, indeed, cardiac arrests is hard to reverse with resuscitative efforts. Consequently, it can be quite hazardous if not properly administered.
An overdose of marcaine can result from the injection of a high concentration, a large volume, or from an inadvertent intravascular injection which occurs when a blood vessel, such as a vein, is penetrated inadvertently when the physician is attempting to inject the marcaine in the epidural space of the spinal column. Injection via epidural catheter for delivery of the drug increases the chances of intravenous injection because it is very easy to insert the catheter directly into an epidural vein or side branch of a vein without
realizing it. Indeed, when the syringe is withdrawn to check for blood-colored fluid before dosing, which would indicate mistaken injection into a vein, a false negative reading is often obtained because the catheter sucks the vein wall against its aperture, thus preventing any bloody show from occurring, even though the catheter has been mistakenly inserted into a vein. When marcaine is mistakenly injected into the vascular system, its absorption is too rapid and can cause serious cardio-toxic effects if other than the most minimal doses are administered. The dosage administered for patient No. 2 was not minimal but, rather, was at the upper limit of acceptable dosages and concentrations. The toxic properties of marcaine on the cardiac and central nervous systems were generally known by physicians in 1983.
The 12 milliliters of a 0.75% concentration dosage was nearly a maximum dosage and was recommended in the PDR for only abdominal operations, such as cesarean sections, which require complete muscle relaxation. The PDR also cautions that the maximum dosage must be individualized after evaluating the size and physical status of the patient, as well as the rate of absorption from a particular injection site.
The Respondent's medical records do not document any justification for utilizing such a high dosage and such a high concentration of this anesthetic for an imminent vaginal delivery (as opposed to a C-section), including consideration of the size of the patient. The Respondent also failed to document a description of the techniques of his anesthesia or anesthetic plan for the patient. There are other anesthetic agents which were generally accepted in such obstetrical procedures at that time and which do not have the characteristic of exhibiting persistent cardio-toxic effects if given inadvertently intravascularly.
Subsequent to the final injection of the marcaine dosage into patient No. 2, the patient had three clonic seizures, after which she experienced respiratory arrest, followed by cardiac arrest. Cardiopulmonary resuscitation was performed upon the patient for approximately one hour before a regular spontaneous peripheral pulse was obtained. Approximately 30 minutes after resuscitation efforts were begun, the Respondent delivered the patient of a live male infant using outlet forceps. Following delivery, patient No. 2 was transferred to the medical intensive care unit. On or about June 5, 1983, the Respondent ordered a neurological evaluation of the patient which revealed probable cerebral hypoxic damage with evidence of only brain-stem function. On or about June 6, 1983, the patient had another cardiac arrest which resulted in the Respondent pronouncing her dead.
The patient was a small person of approximately 110 pounds weight. There was no indication of any untoward obstetrical problem and the patient presented with all indications of an imminent, normal vaginal delivery being appropriate. Under these and the other circumstances delineated above, administration of 12 milliliters of 0.75% marcaine via epidural catheter as an anesthetic agent for a imminent vaginal delivery constituted the administration of a legend drug inappropriately or in excessive or inappropriate quantities not in the best interests of the patient. Further, the unrefuted expert testimony of Dr. Cross reveals that an obstetrician who administers anesthesia himself to his own patient in a hospital setting is held to the same standard of care and practice as an anesthesiologist.
The Respondent thus failed to practice medicine within the level of care, skill and treatment which a reasonably prudent similar physician under the same or similar circumstances and conditions would recognize as acceptable by
utilizing the highly concentrated anesthetic agent for vaginal delivery when such a concentration was usually reserved for use in cesarean sections, and the same consideration is true of the dosage volume of 12 milliliters, which was used. This is especially true under the circumstance that the Respondent chose to administer the drug by epidural catheter, which greatly and unnecessarily increased the chances of the drug being mistakenly and dangerously given intravenously. Although it was not directly proven that the drug was administered directly into a vein, that inference is made under the circumstances delineated in the above findings based upon the unrefuted testimony of Dr. Cross and the fact that the patient immediately suffered three seizures and ultimately death, which is found to have been the direct result of the substandard manner and means of administration of the drug.
Counts VI, VII and VIII: Patient No. 3
From December 2, 1982 until December 16, 1982, the Respondent provided medical care and treatment for patient No. 3 by being the attending physician related to her hospital admission during that time. On or about December 2, 1982, the patient arrived at the hospital with an elevated blood pressure (140/100), with intact membranes. She believed that her labor had started the evening before. The patient stated to the Respondent that she had recently moved to the area and gave the name and location of her previous treating physician, Dr. Hagerty of Lake Ozark, Missouri. She stated that her child delivery date was believed to be December 17, 1982.
The Respondent did not obtain and document an adequate or complete history or physical for the patient within 24 hours of her admission for delivery of her baby. The Respondent did not document historical facts concerning the patient, such as her past and present medications, general health, family history of diseases, drug intake, past illnesses, including hospitalizations, past surgeries, history of cardiac disease, hypertension or smoking, date of last menses, previous prenatal care, if any, and any estimated due date ascertained from previous prenatal care. The Respondent did not document any review of her bodily systems, record any chief complaints or any other noted problems, and failed to obtain either the patient's records from the previous treating physician in Missouri or, due to the apparent imminence of delivery, at least contact the physician for an oral report of her prior problems, care or estimated due date and record information obtained from such contact.
The only history and physical note in the medical records written by the Respondent was for December 11, 1982, nine days after admission. An admission history and physical should be done on all patients admitted to the hospital within 24 hours. This is done to indicate that the physician has reviewed the patient's history, physical status, and has given his impression of the patient's problems and that he has formulated a treatment plan. This also serves to inform other treating personnel of the patient's status at the time of admission and of the treating physician's treatment decisions regarding the patient to that point.
An x-ray taken upon the patient's admission on December 2, 1982 revealed a cephalic presentation of the baby. The radiologist, Dr. Alfred, estimated that the baby was six or seven months in gestation judging from the size. A sonogram was taken on December 3, 1982. The radiologist, Dr. Harbison, estimated gestation of 32.7 weeks based upon biparietal diameter measurements taken by sonogram. The presentation was "vertex" and the placenta was "fundal". The reliance on x-ray and sonogram reports of this nature for a determination of
fetal age can be inaccurate unless femur length and/or abdominal measurements are made. Head measurements alone do not necessarily accurately establish fetal age because the head might not be visible enough to determine perpaveld diameter. Further, fetal growth retardation may have occurred but with a "head sparing" effect, that is, the head may be more normally sized than the rest of the fetal body, thus giving rise to an inaccurate prediction of gestation age based solely upon head measurement in a patient who presents with pregnancy- induced hypertension (PIH). This patient had pregnancy-induced hypertension when she was admitted.
The Respondent made no other efforts to verify the maturation of the baby or the duration of the pregnancy, but accepted the 32-week estimate of fetal age. The Respondent should have measured the fundal height. The Respondent also should have obtained an additional ultrasound study and report with more interpretative information in accordance with the above findings. On or about December 3, 1982, the Respondent diagnosed the patient to have PIH.
PIH is a serious pregnancy complication associated with increased blood pressure in the mother and loss of protein in the urine, as well as potential liver and kidney function problems. The fetus is at risk under this circumstance because of poor blood flow and thus poor nutrition and oxygenation through the placental barrier. Fetal growth may thus be retarded and additional problems for the fetus can result. With PIH in a patient, there is an increased incidence of abruptio placenta, or separation of the placenta. PIH can progress to preeclampsia and eclampsia.
The treatment for PIH or preeclampsia hinges on the maturation of the fetus. If the baby is sufficiently mature, the treatment of choice is immediate delivery before the disease can worsen and cause adverse effects on the mother or the baby. If the fetus is definitely premature, the mother should be transferred to a referral hospital where appropriate intensive care-type neonatal facilities and personnel are available to properly care for such a complicated status, premature infant. There is no indication in the Respondent's medical records that he considered or attempted transfer of the high-risk patient to any other appropriate facility. Indeed, he may have considered it; and, indeed, it may have been impossible to accomplish under the circumstances; but no such circumstances are documented in the Respondent's records.
On or about December 3, 1982, the Respondent prescribed lasix and aldomet for the patient's PIH. Lasix is a legend drug and a potent diuretic. Its use for this patient was inappropriate, as a diuretic can worsen the decreased intravascular volume of blood attendant to PIH and can thus lead to further impairment of the placental blood flow to the infant. This can lead to electrolyte imbalances in the mother and the fetus. Electrolyte studies were ordered by the Respondent but only for one day, December 8, 1982. Repeated studies should have been ordered in order to adequately monitor the condition of mother and fetus. Aldomet is also a legend drug and a hypertensive treatment agent. By lowering the blood pressure with this drug for the mother, nutrients and oxygen to the baby may be impaired by the attendant decreased blood flow through the placental barrier.
On or about December 5, 1982, patient No. 3 experienced vaginal bleeding and uterine contractions for which the Respondent ordered the patient typed and cross-matched for four units of packed red blood cells. The Respondent also ordered the administration of intravenous yutopar to stop the patient's uterine activity. The patient was placed on an external fetal monitor. Yutopar is a drug used to stop premature labor. The continued use of
yutopar at this time for the patient was contraindicated because the patient's bleeding, which could have been the result of an abruptio placenta (separating placenta) and which could be potentially fatal to the fetus was not assessed. The fetal monitor tracings at this time indicated that the baby was in continual difficulty. The treatment of choice at this time would have been to terminate the pregnancy by immediate delivery or to transfer the patient to an appropriate higher level of care, obstetrical specialty facility.
The Respondent's records did not indicate that he monitored the patient's hemoglobin during or following her bleeding episode, that he ordered clotting parameters, that he ordered another ultrasound test to check for evidence of placental separation, that he checked the baby's maturity by amniocentesis, that he tested for placental cells in the vaginal discharge or that he followed the mother's white blood cell count. The Respondent neglected to treat the patient with magnesium sulfate which is indicated to prevent seizures when the blood pressure was elevated as was the patient's. He only administered this drug on one occasion, on December 10, 1982, and then discontinued it for reasons not reflected in the record. The Respondent also failed to order non-stress tests or contraction stress tests to monitor the fetal condition. During this time, however, the external fetal monitor tracings showed generalized decreased variability in fetal heart rate with frequent late decelerations and many prolonged decelerations which indicate obvious fetal distress. The Respondent failed to document any assessment of these fetal monitor tracings, although concern was charted by a nurse, and the Respondent was informed.
The Respondent did not order kidney or liver function tests on patient No. 3 until four days after delivery, although liver and kidney function problems are known to be frequently associated with PIH; and the patient had experienced a very low output of urine on December 6, 1982. No urinalysis was ordered at all.
On December 5, 1982, the medical records note a gross swelling of the patient's vulva. On that date, the Respondent prescribed a corticosteroid cream as treatment for that condition. The condition persisted until delivery. The Respondent did not note in his records an assessment and diagnosis of the medical reason for the swelling for which he prescribed that treatment. On December 5, 1982, he initiated treatment of the patient with celestone (belamethasone), which was continued for five days. This drug is designed to mature the baby's lungs. The maximum effect of this drug is achieved over a two-day span; and since the patient's preeclampsia was persisting with blood pressure rising during this time to 184/140, it would have been appropriate to deliver the baby after a maximum of two days of administration of this drug for purposes of maturing the baby's lungs, in order to lessen the risk of delayed delivery to the baby.
On December 10, 1982, the Respondent prescribed a pitocin infusion for the patient, which was started at or about 11:15 p.m. Then, on or about December 11, 1982, at about 7:13 a.m., the Respondent ruptured the patient's amniotic membrane which revealed a "brown/red amniotic fluid". The Respondent then applied an internal fetal monitor electrode to the presenting part of the infant at this time. On December 11, 1982, at about 8:30 a.m., he initiated an epidural anesthesia for patient No. 3. The exact procedure, time and amount of anesthesia was not documented in his records, however. The Respondent did document in the operative record that the patient had a "saddleblock" as an anesthesia for the cesarean section; however, the anesthesia record, the delivery record, the labor record, and the obstetric recovery room record
documented that an epidural anesthesia was administered, which the Respondent initiated and then re-dosed prior to the surgery. On December 11, 1982, at about 11:32 a.m., the Respondent performed a cesarean section upon the patient; and about 11:36 a.m., delivered a viable, five-pound, female infant.
The medical records reveal that following delivery, the Respondent intubated the infant on two or three occasions and aspirated the glottis. The infant was then ventilated by ambu bag and was transported to the nursery. Some five hours later, the infant was transferred to Sacred Heart Hospital in Pensacola, Florida, by ambulance, which is a neonatal intensive care unit. The Respondent failed to document either the initial assessment of the infant's condition or his resuscitation efforts at delivery.
The Respondent failed to adequately treat the patient during the surgery and delivery in that he failed to have another physician present at the delivery to care for the infant and failed to have a physician assist with the patient's surgery to prevent abandonment of the surgical patient should the infant's resuscitation require a physician's assistance.
Upon performing the cesarean section, the Respondent diagnosed a "50% abruption of the placenta, probably existing since December 5th". The Respondent documented in the discharge summary that "all laboratory data during the hospital admission was within normal limits", however, the only SMAC profile done on December 15, 1982 noted numerous abnormal values. See Dr. Brauner's unrefuted testimony at pages 410-413 of the transcript. It was later determined that the infant suffered seizures and severe mental retardation.
The Respondent thus failed to obtain an adequate or complete history for patient No. 3, failed to perform an adequate physical examination to adequately assess or monitor the PIH, to adequately treat the PIH, failed to order appropriate diagnostic studies to accurately determine fetal status before deciding to initiate a therapy involving prolonging the pregnancy, and failed to adequately assess the patient's laboratory test results. When there was evidence that the baby was not doing well, as shown by the fetal monitor tracings, he failed to immediately deliver the pregnancy. Additionally, the Respondent prescribed and administered mixed or dispensed legend drugs inappropriately or in excessive or inappropriate quantities, which were not in the best interest of the patient by prescribing aldomet for the patient, which could decrease placental perfusion. He prescribed lasix for the patient, which also decreased placental blood flow and would create electrolyte imbalances in both the mother and the baby. He prescribed yutopar to prolong the high-risk pregnancy when fetal monitor tracings showed that the baby was in a distressed condition. He prescribed a corticosteriod cream for the patient as a treatment for a condition which he had neither assessed nor diagnosed at the point of prescribing that drug or after. He thus failed to practice medicine with regard to this patient with the level of care, skill and treatment which reasonably prudent similar physicians recognize as acceptable under the conditions and circumstances delineated above.
The Respondent failed to keep written medical records justifying the course of treatment of the patient. He failed to document an adequate or complete history; to document an explanation concerning his acceptance of the estimated gestational age of the fetus; any justification for the course of treatment of the PIH; any justification for failure to order appropriate diagnostic studies to determine fetal status prior to initiating therapy to prolong the pregnancy. His records contain no justification for prolonging the pregnancy; any assessment of the fetal monitor tracings obtained from the
patient; and no assessment and diagnosis of the swelling of the patient's vulva, which he treated. His records are silent as to any reasons for not transferring the high-risk patient to another more appropriate facility. There is no documented justification for indicating in the record that the patient had a "saddleblock" anesthesia when other medical records reveal that the patient had an epidural anesthesia. He did not document his reasons for stating in the discharge summary that the patient's laboratory test results were all within normal limits nor either an initial assessment of the infant's condition or his resuscitation efforts upon delivery.
Counts IX, X and XI: Patient No. 4
Patient No. 4 was a 21-year old woman experiencing her second pregnancy. On October 8, 1980, she was admitted to the hospital in labor with a term pregnancy. The Respondent was her attending physician and had provided medical care and treatment for her from June 21, 1980 to October 18, 1980. Upon her admission, the Respondent failed to obtain and document an adequate or complete history by failing to document historical facts concerning the patient, such as her past and present medications, general health, family history of diseases, drug intake, history of cardiac disease, hypertension or smoking, history regarding her first labor and pregnancy, and the patient's interest regarding sterilization. Upon her admission on October 8, 1980, the Respondent failed to perform and document an adequate physical examination on the patient by failing to perform a review of the patient's bodily systems, by failing to perform a breast examination, by failing to document an assessment of the patient's vital signs, even though the blood pressure was significantly higher than her prenatal base line, by failing to describe the surgical scar on the patient's abdomen from a prior cesarean section, by failing to assess her reflexes, and by failing to document the presenting part of the infant, the station and degree of effacement of the cervix. If, indeed, the Respondent performed these aspects of a physical examination, they were not documented in the patient's and the Respondent's records.
On October 8, 1980, at approximately 4:15 p.m., the patient was noted by the nurses progress notes to be 4 centimeters dilated. The Respondent prescribed 10 milligrams of valium, and the patient received that by injection at approximately 5:20 p.m. on that date. At about 5:25 p.m., the patient was completely dilated and "bulging". The medical record, however, does not document the presence or absence of a "bloody show" nor the station of the presenting part of the infant. The patient, however, appeared to be progressing rapidly and able to deliver vaginally. The noted pelvic measurements of the patient were all normal, indicating an adequate pelvis size; however, the Respondent circled "inadequate" on her prenatal care sheet. The reason noted on the prenatal care sheet for the patient for the prior cesarean section was "prolonged labor". The Respondent failed to adequately assess, diagnose, and treat the patient's condition by failing to attempt a vaginal delivery when the patient was completely dilated and progressing rapidly. The Respondent did not document any justification for his failure to attempt to deliver the patient vaginally.
On October 8, 1980, at approximately 5:30 p.m., the Respondent obtained a signed consent from patient No. 4's mother to perform a sterilization on the patient during a cesarean section. The Respondent did not obtain an informed consent from patient No. 4 herself to perform a sterilization procedure. At about 5:45 p.m., he initiated an epidural anesthesia on patient No. 4 and at 6:16 p.m., delivered a female infant via cesarean section. The attending anesthesiologist, Dr. Weigle, documented in the medical record
pertaining to this patient that the Respondent "ligated this patient's fallopian tubes knowing full well there was no op permit for tubal ligation". The Respondent then overwrote his denial of Dr. Weigle's entry and noted that he showed the tube to all in the operating room. See Petitioner's Exhibit 13 in evidence.
The Respondent then documented in the operation report that the cesarean section was accomplished without complications with only 100 milliliters of blood lost and that hemostasis was excellent. He documented in the discharge summary of October 21, 1980, however, that "a C-section was done with more than usual bleeding". At 7:00 p.m. on October 8, 1980, the patient was transferred from the operating room to the recovery room in satisfactory condition. At or about 7:05 p.m., however, the Respondent was notified that the patient was bleeding heavily and passing large blood clots from her vagina. The Respondent documented in the record that the patient "became dry" and was observed in the recovery room for more than two hours, at which time she had a gush of blood from her vagina.
On October 8, 1980, at 7:30 p.m., the Respondent treated the bleeding condition by inserting vaginal packing and ordering blood transfusions. At 8:50 p.m., the patient received two units of packed red blood cells. Her blood pressure at that time was 60/40, with her pulse recorded as 120. She was transferred to the operating room where the Respondent placed a kerlix pack in the uterus and the vagina. The patient received two units of blood. At about 9:30 p.m., she was transferred to the recovery room where she received two units of blood. The patient continued to bleed, however, which necessitated her transfer back to the operating room at 10:00 p.m.
The Respondent then proceeded to perform a laparotomy upon the patient at approximately 10:00 p.m. on October 8, 1980. The abdomen was found to be full of blood, and the Respondent diagnosed the source of the bleeding as a lacerated cervix. The Respondent stated in his operative report that "it became obvious from her labor that she had circumferentially ruptured her uterus with a posterior tear down to the vagina" and "...the bleeding was from the vaginal mucosa posterior to the cervix" (discharge summary). In the operative report, the Respondent stated "the cervix has been completely lacerated in a circumferential manner because this patient was allowed to stay in labor while we were waiting for anesthesia". In a letter of February 14, 1987 to the Department of Professional Regulation, in evidence as the Petitioner's Exhibit 19, the Respondent states: "Gulf Coast Hospital operating room personnel would not open a second operating room as it was after hours and the only vacant operating room was in use; therefore, she was allowed to labor. In the process, the patient lacerated her vagina by dilating her cervix to complete at a minus station prior to the time of surgery."
Aside from these notations by the Respondent, there is no indication in the records which would indicate that the patient had ruptured these structures during her labor. There is testimony at pages 549-554 of the transcript indicating a probability that the laceration occurred when the Respondent had to retrieve the infant's head from its deep engagement in the pelvis at the time of the cesarean section. There is, however, no clear and convincing evidence which can establish that the Respondent actually caused the laceration of the cervix nor, on the other hand, that the laceration was caused by the patient being allowed to stay in labor too long while the Respondent was waiting for an anesthesiologist to assist him.
It was so established, however, that the Respondent failed to adequately assess, diagnose, and treat the lacerated cervix by failing to recognize its condition and repair it when he repaired the uterine incision during the initial cesarean section procedure. This ultimately resulted in significant risk to the patient caused by substantial blood loss and attendant significantly lowered blood pressure. These circumstances resulted in the patient having to receive 14 units of blood and 6 units of cryoprecipitate and a second surgical procedure to make the repair, which had been missed during the first procedure.
The Respondent did not adequately treat the patient during her postoperative recovery period by continuing the nasogastric tube after he had allowed the patient to eat, which resulted in a risk of aspiration of food material into the respiratory tract and lungs. Additionally, the Respondent failed to order renal function studies for the patient while treating her with garamycin, an antibiotic which has the potential of causing kidney damage. Additionally, he changed the route of the antibiotic administration from intramuscular administration to the less-effective oral administration route, although the patient remained febrile. On October 17, 1980, he failed to perform and document an adequate physical examination upon the patient by failing to perform a review of the bodily systems, by failing to perform a breast examination, and by failing to document an assessment of the patient's laboratory tests even though the patient had suffered a massive bleeding experience. On December 2, 1980, the Respondent did not adequately document a physical examination upon the patient because his documentation represents only a "standard physical examination" and does not document any assessment of the patient's abdominal scarring even though she was to undergo surgical repair of severe scarring incurred by a prior cesarean section.
Thus, as to patient No. 4, the Respondent failed to obtain an adequate or complete history, failed to perform an adequate physical examination on October 8, 1980, failed to adequately assess, diagnose and treat the patient by failing to attempt a vaginal delivery when she was completely dilated and progressing rapidly, by failing to obtain informed consent from the patient for sterilization prior to the cesarean section, by failing to adequately assess, diagnose and treat the patient's lacerated cervix, and by failing to adequately treat the patient during her postoperative recovery period.
Additionally, the Respondent failed to keep written medical records which justified the course of treatment of the patient by failing to document an adequate or complete history, an adequate or complete physical examination on either October 8, 1980 or October 17, 1980, as well as December 2, 1980. He failed to document any justification for failure to consider or attempt vaginal delivery; to document a justification for continued use of a nasogastric tube after allowing the patient to eat normally; to document any justification for failure to order renal function studies for the patient while treating her with the antibiotic which could potentially cause kidney damage; to document any justification for changing the route of administration of the antibiotic. Additionally, he documented the discharge summary statements in a manner which were contradicted by the medical records of the patient, including the operative report, and failed to reconcile the contradictory statements.
Count XII: Patient No. 5
On or about April 27, 1979 through approximately April 29, 1979, the Respondent provided medical care and treatment for patient No. 5 by being the attending physician for that patient's hospitalization during that time period.
The Respondent did not obtain and document an adequate or complete history of patient No. 5. He did not document historical facts concerning the patient, such as past and present medications, general health, family history of diseases, drug intake, past illnesses, including hospitalization and surgery, history of cardiac disease, hypertension or smoking, history of pregnancies and date of last menses.
The medical records reveal that the patient had an appendectomy at age
and ovarian surgery at age 18. The Respondent did not document the performance of an adequate physical examination upon the patient nor perform such an examination. He failed to perform a review of the patient's bodily systems and merely documented only his "standard" physical examination while also documenting that a laparoscopic tubal ligation procedure would be performed as the treatment plan for the patient.
On April 27, 1979, the Respondent obtained consent from the patient to perform a mini-laparotomy-laparoscopic bilateral tubal ligation with dilation and curettage. In this connection, the Respondent did not adequately assess, diagnose and chart a plan of treatment because he failed to document any diagnosis or treatment plan which would relate to or justify the patient's need for a dilation and curettage. On April 27, 1979, the Respondent performed a dilation and curettage and a laparoscopic tubal ligation. In the operative report, the reference to the tubal ligation omits the word "bilateral". The Respondent did not correlate the treatment rendered to the patient's complaint or condition by failing to document a medical reason for performing the dilation and curettage.
The Respondent did not correctly document the surgical procedure and findings for the patient because the operative report contains the Respondent's documentation that the left fallopian tube was missing. Under the "technique" portion, however, the Respondent documented that the left tube was identified and cauterized in two places. In the operative report, the Respondent also refers to the patient's prior ovarian or tubal surgery, which he did not document or describe in the patient's history and physical report. In an addendum to the operative report and summary sheet, the Respondent documented that a bilateral tubal ligation was performed upon the patient when he had previously documented conflicting information concerning this procedure in the operative report (left fallopian tube missing).
The Respondent documented that he found an area of endometriosis during the course of the laparotomy. The Respondent failed to adequately diagnose the patient by failing to list endometriosis as a diagnosis.
The Respondent failed to adequately assess the patient by failing to visualize the left fallopian tube according to the findings in the operative report and documenting that it was missing and then documenting, under the technique portion of the operative report, that it was cauterized in two places, and also by failing to describe the area of endometriosis which he documented finding upon performing the surgery. The Respondent did not document any justification for his failure to adequately assess the situation involving the left fallopian tube and which would explain the contradictions involved in his entries concerning the procedure allegedly performed on the left fallopian tube or his contradictory observation that the left fallopian tube was missing. The keeping of accurate and complete medical records is important for adequate future medical care of a patient.
In summary, the Respondent failed to obtain an adequate or complete history, failed to perform an adequate physical examination upon the patient, and failed to adequately assess, diagnose and chart a plan of treatment concerning the need for a dilation and curettage. He failed to correlate the dilation and curettage as treatment to the patient's complaints or condition.
He documented an inaccurate operative report, which contained conflicting information about the surgical procedure performed upon the left fallopian tube, and failed to include endometriosis, which was discovered during surgery, as a diagnosis for the patient. The Respondent did not adequately document his assessment of the left fallopian tube, and failed to adequately assess the patient's area of endometriosis discovered during surgery.
CONCLUSIONS OF LAW AS TO CASE NO. 90-2680
The Division of Administrative Hearings has jurisdiction over the subject matter of and the parties to this proceeding.
Pursuant to Section 458.331(2), Florida Statutes, the Board of Medicine is empowered to revoke, suspend or otherwise discipline the licensure of any physician found guilty of the acts enumerated in Section 458.331(1), Florida Statutes.
In a disciplinary proceeding such as this, the burden is on the Petitioner to establish the facts upon which its allegations of misconduct are based. The Petitioner must prove those allegations by clear and convincing evidence. Ferris v. Turlington, 510 So.2d 292 (Fla. 1987).
The "practice of medicine" means diagnosis, treatment, operation or prescription for any human disease, pain, injury, deformity, or other physical or mental condition. See Section 458.305(3), Florida Statutes. The Respondent stated to the Board of Medicine at its informal disciplinary proceeding on June 2, 1989, as found above, that he was not currently practicing medicine but expected to return to work on June 15, 1989; that he had practiced for only one day in Apalachicola, Florida, at about the first of March in the emergency room at Weems Memorial Hospital; and that he had not seen, talked to, examined, prescribed, or otherwise had dealings with patients since his return to Florida in 1989, except for one day in the emergency room. In recanting that statement to the effect that he only practiced one day in the hospital emergency room at the instant hearing, the Respondent explained that he was under a great deal of pressure and inadvertently had stated, in effect, that he practiced only one day when actually he did, indeed, practice several days each month between March and June of 1989 in the emergency room at the Weems Memorial Hospital.
Modifying terms, such as fraudulent, deceptive or untrue, concerning "representations in the practice of medicine for purposes of Section 458.331(1)(k), Florida Statutes, which prohibits such representations, are terms describing conduct or state of mind involving specific intent or scienter. Judging from the circumstances delineated in the above Findings of Fact concerning the Respondent's statement about the stress he was under when he made the statement, concerning the fact that he had been under medical disability involving a severe heart condition and surgery, as well as hepatitis, in the first half of 1989, an inference can be drawn from that earlier testimony, and his statement recanting it at the instant hearing, that he really intended referring to active medical practice rather than limited work in a hospital emergency room two or three days per month when he answered the Board's questions in the negative. It is, therefore, concluded that, especially since deception, untruth, or fraud is a specific-intent type of conduct, the evidence
of record produced by the Petitioner does not establish clearly and convincingly that the Respondent intentionally made deceptive, untrue, or fraudulent statements to the Board on June 2, 1989, especially since he had already freely acknowledged his emergency room work to two Department of Professional Regulation investigators on April 10, 1989 and thus would be unlikely to intentionally conceal it later at the informal hearing.
Thus, although the Respondent was shown to have made inaccurate statements to the Board, it was not shown that they were intentionally deceptive, untrue or fraudulent. It has been shown that, by his practice in the hospital emergency room several days per month, he was actively engaged in the practice of medicine in Florida at times pertinent to the allegations of Counts I and II of this complaint. It has not been proven by clear and convincing evidence that he knowingly misrepresented or concealed material facts during the disciplinary process involved in the informal hearing of June 2, 1989.
A physician licensed in Florida is required to have a registration with the Drug Enforcement Administration (DEA) in order to legally prescribe controlled substances. See Sections 893.02(16), 893.04(1), Florida Statutes, and 21 USC, Section 301. Valium is a Schedule IV controlled substance. Morphine sulfate and cocaine hydrochloride are Schedule II controlled substances. See Section 893.03, Florida Statutes (1989).
The Petitioner has established that the Respondent possessed no valid DEA registration on March 3, 1989 or March 20, 1989, when he prescribed these substances to patients. In fact, his registration had expired on January 31, 1989 and was renewed by him on March 23, 1989. Both shortly before and after the expiration, the Respondent was undergoing severe life-threatening medical problems involving a severe cardiac condition and a resultant surgery and recovery period. During this time, he inadvertently let his registration lapse. Thus, it has been shown by clear and convincing evidence that he technically violated Section 458.331(1)(g), Florida Statutes (Count III) by failing to perform a statutory or legal obligation placed upon a licensed physician although, due to the extenuating circumstances involving his life-threatening medical condition, the resultant treatment, surgery and recovery period for it, no penalty is warranted for making these prescriptions while failing to keep his DEA registration current. The same consideration is true regarding Count IV of this complaint wherein it is alleged that the Respondent violated Section 458.331(1)(v), Florida Statutes, for practicing medicine beyond the scope permitted by law. Here again, no penalty is warranted under the circumstances. Likewise, it has not been demonstrated that by prescribing these controlled substances to these patients while his DEA registration had technically expired, that the Respondent was guilty of prescribing legend drugs inappropriately and not in the best interest of patients and not in the course of his professional practice. There was no showing by clear and convincing evidence that the drugs prescribed and the amounts and concentrations of them and the indications for prescribing them were inappropriate nor that they were not done in the best medical interests of the patients. It was not demonstrated by clear and convincing evidence that they were not done in the course of his professional practice. The drugs were prescribed in the course of his professional practice as a licensed Florida physician using his best judgment to treat his patients. The fact that technically he could not legally prescribe the drugs for a brief period of time does not render the indications for prescribing them and the other circumstances surrounding those patients' conditions and his prescribing of the drugs to alleviate their sufferings to be without the course of his professional practice as a licensed physician. Thus, Count V has not been proven by clear and convincing evidence.
Count VI concerns the charge that the Respondent is guilty of false, deceptive or misleading advertising, as proscribed by Section 458.331(1)(d), Florida Statutes (1989). The Petitioner contends that the Respondent was verbally informed that his license would be suspended at the informal hearing on June 2, 1989 and was informally apprised on June 19, 1989, of the Board's final order suspending his license (formal notice on June 23, 1989). It asserts that, since his advertising of his affiliation with the Apalachicola Bay Community Clinic to practice gynecology and family medicine was published on June 15, 22 and 29, 1989, he was falsely advertising his availability for medical practice beyond the time when he was authorized to practice medicine in Florida.
This allegation has not been proven by clear and convincing evidence. There has been no showing that he harbored any specific intent to falsely, deceptively, or misleadingly make himself available to provide medical treatment through these advertisements, as opposed to the equally-supportable inference that he had earlier placed the advertisements and the advertising period for them merely had not expired until the June 29, 1989 edition. He only having learned of the Board's final order entry on June 19, 1989 (notice by certified mail on June 22, 1989), his failure to halt the advertisement before it normally expired does not show any intent to practice medicine without proper licensure. No evidence of such false, deceptive or misleading intent in advertising has been demonstrated. For instance, it was not shown that he actually attempted to practice medicine after June 15 or 19, 1989. Consequently, Count VI has not been proven by clear and convincing evidence.
The same consideration and conclusion is made concerning the alleged violation of Section 458.331(1)(x), Florida Statutes (1989), regarding the alleged violation of a lawful order of the Board by advertising availability as a practitioner of medicine after June 15, 1989 when the Board entered its final order. The mere fact that he had not cancelled the advertisements early upon learning of the entry of the order on June 19, 1989 (not June 15th) does not itself establish by clear and convincing evidence that he was practicing with a suspended license.
CONCLUSIONS OF LAW AS TO CASE NO. 89-6489
The Administrative Complaint has charged, concerning patient No. 1, that the Respondent failed to practice medicine with that level of care, skill and treatment recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances. The Respondent failed to perform the procedure to which the patient consented, a bilateral salpingo- oophorectomy. He did not document in the record that he informed or explained to her that the procedure was not performed and why. His records do not show why the procedure was or was not medically necessary. Additionally, he performed a D&C procedure which was not authorized by the patient; and the records contain no documentation of the fact that he informed her of performing that procedure nor the medical reasons why it was indicated, if it was. Because of this and because he failed to perform the procedure to which the patient had consented, the BS&O, without explanation in his records, it has been proven by clear and convincing evidence that the Respondent is guilty as charged in Count I of violating Section 458.331(1)(t), Florida Statutes, by departing from the medical practice standard mentioned in the paragraph above. It was not established, however, that he failed to inform the patient that the procedure which she consented to was not performed, the records merely do not show that she was informed. Moreover, although her eventual death from ovarian cancer stemmed from the organs which he failed to remove surgically when the patient
had authorized them to be removed, it was not shown that they were in a cancerous or pre- cancerous condition at the time he performed the surgery or otherwise that the lethal cancer condition resulted directly from his failure to remove the organs at the time of the surgery some five years prior to the patient's death. It was not shown that he should, for some reason, have foreseen that the organs might become cancerous and ignored the risk or that their removal was then medically necessary.
In light of the above Findings of Fact, which are supported by the clear and convincing evidence of record, it has been established that Section 458.331(1)(n), Florida Statutes (1979), now substantially reenacted as Section 458.331(1)(m), Florida Statutes, has been violated by the Respondent's failure to keep written medical records justifying his course of treatment of patient No. 1 by failing to document any reasons for his plan to perform the BS&O procedure, to document any symptoms or complaints by the patient, or to document why he changed his plans and did not perform the planned procedure authorized by the patient. This situation is distinguished from that of Breesman v. Department of Professional Regulations, 567 So.2d 469 (1st DCA 1990), which held that the above statutory section was not violated where a physician failed to document other courses of treatment which he elected not to employ. Here, the Respondent planned the BS&O procedure and then changed his plan during surgery. The basis for the change was unexplained in his records. He did not keep written records containing any description of the patient's fallopian tubes or ovaries, as observed during the operation, nor why he performed a D&C to which the patient had not consented, or why the procedures performed were not discussed with the patient.
Concerning Count III, the Petitioner has shown by clear and convincing evidence, which culminated in the above Findings of Fact, describing in detail the Respondent's practice and treatment related to patient No. 2, that the Respondent is guilty of violating Section 458.331(1)(q), Florida Statutes, by administering the legend drug, marcaine, to patient No. 2 other than in the course of his professional practice. The administering of a legend drug inappropriately (here, by epidural catheter) or in excessive or inappropriate quantities (12 milliliters of a 0.75% solution in a patient described as, and under the circumstances of, the above Findings of Fact) was not in the best interest of patient No. 2 and was thus not within the proper course of the Respondent's professional practice. The inappropriate administration and the excessive concentration and volume of marcaine for patient No. 2 prescribed and administered under the circumstances delineated in the above Findings of Fact constitutes a violation of Section 458.331(1)(t), Florida Statutes, as charged in Count IV, because the Respondent has been proven by clear and convincing evidence to have failed to practice medicine with that level of care, skill and treatment recognized by a reasonably prudent similar physician as being acceptable under those conditions and circumstances in light of the above factual findings pertaining to this patient.
Count V of the complaint involves the charge that the Respondent failed to keep written medical records justifying his course of treatment of patient No. 2. This is a violation of former Section 458.331(1)(n), Florida Statutes (1983), now substantially reenacted as Section 458.331(1)(m), Florida Statutes. The above Findings of Fact, supported by clear and convincing evidence of record, demonstrate that the Respondent failed to document any justification for using a highly-concentrated and dangerous agent, such as marcaine, in a volume which was excessive under the circumstances with which the patient presented (regardless of the allowable maximum dose indicated in a general fashion in the PDR). It was an excessive volume for a patient of this
size and weight and medical circumstance, including the circumstance that she gave every indication of being able to accomplish a routine vaginal delivery and thus clearly did not need such an excessive volume and concentration of this drug, given the attendant risks, delineated in the above Findings of Fact, which, indeed, came to pass.
The Respondent additionally failed to keep any anesthetic record concerning his evaluation of the patient, a description of his anesthetic technique, nor any justification for his anesthetic plan. Unrefuted testimony from an expert anesthesiologist (Dr. Cross) establishes that an obstetrician who prescribes, dispenses, and administers the anesthetic during a surgical, obstetrical procedure is held to the same standard with regard to anesthetizing patients, caring for patients, and documenting the anesthesia portion of his practice with regard to a patient, as is an anesthesiologist.
In Count VI, the Respondent is charged with a violation of Section 458.331(1)(t), Florida Statutes, concerning patient No. 3. As delineated in more detail in the above Findings of Fact, the Respondent failed to take an adequate history and to document the performance of an adequate physical examination of this patient. He failed to correctly assess the patient's laboratory results, to obtain appropriate diagnostic studies and failed to adequately assess, monitor, or treat the patient's pregnancy-induced hypertension, as elaborated in greater detail in the above Findings of Fact. He failed to obtain an adequate or complete history and failed to perform an adequate physical examination. He did not adequately assess or monitor the pregnancy-induced hypertension, failed to adequately treat that condition, failed to order appropriate diagnostic studies to accurately determine fetal status prior to initiating therapy to prolong the patient's pregnancy, failed to adequately assess the patient's laboratory test results, and when there was evidence that the baby was in distress, failed to deliver the pregnancy immediately.
The above Findings of Fact show, based upon clear and convincing evidence, that the Respondent prescribed, dispensed, administered, mixed or otherwise prepared legend drugs inappropriately or in excessive or inappropriate quantities, not in the best interest of the patient, by prescribing aldomet for the patient. This may have decreased placental perfusion or blood flow. Prescribing lasix for the patient also can decrease placental blood flow and create electrolyte imbalances. It was also inappropriate to prescribe yutopar to prolong the high-risk pregnancy and to prescribe a corticosteriod cream for the patient as treatment for her condition (swelling), which the Respondent had never diagnosed nor assessed. This amounts to prescribing, dispensing, administering, etc. legend drugs not in the course of the Respondent's professional practice, in violation of Section 458.331(1)(q), Florida Statutes.
Concerning Count VIII of the complaint, clear and convincing evidence, supportive of the above Findings of Fact, established that the Respondent's written medical records do not justify the course of his treatment of patient No. 3, including, but not limited to, the patient's history, examination test results, and the failure to document any justification for the Respondent's failure to adequately assess, monitor and treat the PIH. They do not contain justification for the failure to order appropriate diagnostic studies to accurately determine fetal status prior to initiating therapy to prolong pregnancy; the failure to assess and diagnose the swelling and the failure to adequately treat the patient during the C-section. They contain inaccurate documentation to the effect that the patient had a "saddleblock" anesthesia, when other medical records reveal that it was an epidural anesthesia. The
records do not document that the patient's laboratory test results were adequately assessed; and there is no documentation of either an initial assessment of the infant or his resuscitation efforts shortly after delivery. This recordkeeping deficit amounts to a violation of Section 458.331(1)(n), Florida Statutes (1981) (now Section 458.331(1)(m), Florida Statutes).
Concerning Count IX of the complaint, for all of the reasons delineated in the above Findings of Fact with regard to patient No. 4, it has been demonstrated that the Respondent failed to practice medicine with that level of care, skill and treatment recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances. This is shown by the failure to obtain an adequate or complete history, to perform an adequate physical examination on the various dates delineated above, to adequately assess, diagnose and treat the patient by failing to attempt a vaginal delivery, and the failure to obtain informed consent from the patient for sterilization prior to C-section. Additionally, the Respondent failed to adequately assess, diagnose and treat the lacerated cervix, and failed to adequately treat the patient during her postoperative recovery period. Thus, a violation of Section 458.331(1)(t), Florida Statutes, has been established by clear and convincing evidence in these particulars.
It has also been so demonstrated that by prescribing the antibiotic, garamycin, without ordering attendant renal function studies (because of the potential for kidney damage) and by changing the route of that medication to a less effective means (oral), even though the patient remained febrile, amounts to prescribing, dispensing, administering, etc. a legend drug, other than in the course of his professional practice and inappropriately, for purposes of Section 458.331(1) (q), Florida Statutes (Count X).
Concerning Count XI, it was established, as shown by the above Findings of Fact, that the Respondent failed to keep written medical records justifying the course of treatment of patient No. 4. He failed to document a complete history of the patient and failed to make an adequate or complete physical examination. He recorded no justification for the failure to attempt to deliver the patient vaginally; to document any justification for continued use of the nasogastric tube after the patient began eating; to document any justification for not ordering renal function studies with the use of the above- named antibiotic and failed to document any justification for changing the route of administration of that antibiotic in a febrile patient. He recorded statements in the discharge summary which are directly contradicted by the Respondent's statements in the medical records; and failed to document any explanation for the contradictory statements contained in these records. This constitutes a violation of Section 458.331(1)(m), Florida Statutes.
Concerning Count XII of the complaint, the Petitioner has demonstrated by clear and convincing evidence, culminating in the above Findings of Fact, that the Respondent is guilty of unprofessional conduct, incompetence, and negligence, in violation of Section 458.1201(1)(m), Florida Statutes (1977), now incorporated into Section 458.331(1)(t), Florida Statutes (1989).
Unprofessional conduct shall include any departure from or the failure to conform to the standards of acceptable and prevailing medical practice within a physician's area of expertise, as determined by the Board, in which proceeding actual injury to a patient need not be established when the same is committed in the course of a physician's practice. There is no question, given the above Findings of Fact, that the Respondent did not conform to standards of acceptable
and prevailing medical practice within his area of expertise in his conduct of the care and treatment of patient No. 5. Thus, he has committed a violation of Section 458.331(1)(t), Florida Statutes.
Having considered the foregoing Findings of Fact, Conclusions of Law, the evidence of record, the candor and demeanor of the witnesses, and the pleadings and arguments of the parties, as well as the disciplinary guidelines and the consideration of aggravating and mitigating circumstances as provided for in Rule 21M-20, Florida Administrative Code, official recognition of which was taken; to wit, the exposure of the patient to injury or potential injury, the number of counts of separate offenses proven, and the disciplinary history of the licensee, it is therefore,
RECOMMENDED that the Respondent be found guilty of violating Subsection 458.331(1)(g), Florida Statutes, as concluded hereinabove, with regard to Case No. 90-2680, but, in consideration of the above-referenced circumstances, that no penalty be imposed. With regard to Case No. 89-6489, it is RECOMMENDED that the Respondent be found guilty of violating the above enumerated subsections of Section 458.331(1), Florida Statutes, as concluded above, and that the Respondent's license to practice medicine in the State of Florida be revoked.
DONE AND ENTERED this 9th day of September, 1991, in Tallahassee, Leon County, Florida.
P. MICHAEL RUFF 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 9th day of September, 1991.
APPENDIX TO RECOMMENDED ORDER IN CASE NOS. 89-6489 and 90-2680
Petitioner's Proposed Findings of Fact Case No. 90-2680 1-5. Accepted.
6. Rejected, as subordinate to the Hearing Officer's findings of fact on this subject matter.
7-8. Accepted.
Rejected, as not in accordance with clear and convincing evidence.
Accepted.
11-12. Accepted.
13. Rejected, as not in accordance with clear and convincing evidence. 14-20. Accepted.
Case No. 89-6489
1-7. Accepted.
8. Rejected, as it was not established with clear and convincing evidence what the patient believed.
9-13. Accepted.
14. Rejected, as not entirely supported by the evidence and as subordinate to the Hearing Officer's findings of fact.
15-28. Accepted.
29-69. Accepted.
70-83. Accepted.
84-95. Accepted.
96. Rejected, as subordinate to the Hearing Officer's findings of fact on this subject matter.
97-103. Accepted.
104-120. Accepted.
Respondent's Proposed Findings of Fact Case No. 89-6489
Accepted, except as to time period noted.
Rejected, as subordinate to the Hearing Officer's findings of fact on this subject matter and as not entirely supported by the evidence.
Rejected, as subordinate to the Hearing Officer's findings of fact on this subject matter and as not entirely supported by the evidence.
Rejected, as subordinate to the Hearing Officer's findings of fact on this subject matter and as not entirely supported by the evidence.
Rejected, as subordinate to the Hearing Officer's findings of fact on this subject matter and as not entirely supported by the evidence.
Case No. 90-2680
Accepted, in part, but subordinate to the Hearing Officer's findings of fact.
Accepted.
COPIES FURNISHED:
Dorothy Faircloth, Executive Director Board of Medicine
Department of Professional Regulation Northwood Centre, Suite 60
1940 North Monroe Street Tallahassee, FL 32399-0792
Jack McRay, Esq.
General Counsel
Department of Professional Regulation Northwood Centre, Suite 60
1940 North Monroe Street Tallahassee, FL 32399-0792
Mary B. Radkins, Esq. Senior Attorney
Department of Professional Regulation
Northwood Centre, Suite 60 1940 North Monroe Street Tallahassee, FL 32399-0792
Elliott F. Monroe, M.D. 2709 Arden
Panama City, FL 32401
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.
=================================================================
AGENCY FINAL ORDER
=================================================================
DEPARTMENT OF PROFESSION REGULATION BOARD OF MEDICINE
DEPARTMENT OF PROFESSIONAL | DPR | CASE | NUMBERs: | 0079194, |
REGULATION, | 0063999, | |||
0081388, | ||||
Petitioner, | 0081390, | |||
0081391, | ||||
-vs- | 8901767, | |||
8905399, | ||||
ELLIOTT F. MONROE, M.D., | 9000576 | |||
DOAH | CASE | NUMBERS: | 89-6489, |
Respondent. 90-2680
LICENSE NUMBER: ME 0019670
/
FINAL ORDER
This cause came before the Board of Medicine (Board) pursuant to Section 120.57(1)(b)10, Florida Statutes, on December 7, 1991, in Miami, Florida, for the purpose of considering the Hearing Officer's Recommended Order (a copy of which is attached hereto as Exhibit A) in the above-styled cause. Petitioner, Department of Professional Regulation, was represented by Larry G. McPherson, Jr., Attorney at Law. Respondent was duly notified of the hearing and was not present.
Upon review of the Recommended Order, the argument of the parties, and after a review of the complete record in this case, the Board makes the following findings and conclusions.
FINDINGS OF FACT
Findings of fact set forth in the Recommended Order are approved and adopted and incorporated herein.
There is competent substantial evidence to support the findings of fact.
CONCLUSIONS OF LAW
The Board has jurisdiction of this matter pursuant to Section 120.57(1), Florida Statutes, and Chapter 458, Florida Statutes.
The Board rejects the Hearing Officer's conclusion of law and analysis regarding Count V, an alleged violation of Section 458.331(1)(q), which is set forth in the last two lines on page 41 of the Recommended Order continuing through to the end of that full paragraph on page 42. In lieu thereof, the Board substitutes the following conclusion of law:
The full language of Section 458.331(1)(q), Florida Statutes, is as follows:
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 legend drugs,
including all controlled substances, inapprop- riately or in excessive or inappropriate quantities is not in the best interest of the patient and is not in the course of the physician's professional practice, without regard to his intent.
Thus, the statute itself provides that if the prescription is inappropriate, it is a violation of the statute as not being in the course of the physician's professional practice. The prescriptions at issue in this case were inappropriate because, as found by the Hearing Officer at Paragraph 7 of the Findings of Fact, Respondent prescribed a controlled substance during a period of time during which he held no valid DEA registration necessary to prescribe and dispense a controlled substance and "Respondent had reason to know that his registration was in a lapsed status.
The remaining conclusions of law set forth in the Recommended Order are approved and adopted and incorporated herein.
There is competent substantial evidence to support the conclusions of
law.
PENALTY
Upon a complete review of the record in this case, the Board determines that the penalty recommended by the Hearing Officer be APPROVED and ADOPTED. WHEREFORE,
IT IS HEREBY ORDERED AND ADJUDGED that
Respondent's license to practice medicine in the State of Florida is REVOKED.
This order takes effect upon filing with the Clerk of the Department of Professional Regulation.
DONE AND ORDERED this 19th day of December , 1991.
BOARD OF MEDICINE
ZACHARIAH P. ZACHARIAH, M.D. CHAIRMAN
NOTICE OF RIGHT TO JUDICIAL REVIEW
A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW PURSUANT TO SECTION 120.68, FLORIDA STATUTES. REVIEW PROCEEDINGS ARE GOVERNED BY THE FLORIDA RULES OF APPELLATE PROCEDURE. SUCH PROCEEDINGS ARE COMMENCED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF THE DEPARTMENT OF PROFESSIONAL REGULATION AND A SECOND COPY, ACCOMPANIED BY FILING FEES PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL, FIRST DISTRICT, OR WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE PARTY RESIDES. THE NOTICE OF APPEAL MUST BE FILED WITHIN THIRTY (30) DAYS OF RENDITION OF THE ORDER TO BE REVIEWED.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing Order has been provided by certified mail to Elliott F. Monroe, M.D., 2709 Arden Drive, Panama City, Florida 32401, by U.S. Mail to P. Michael Ruff, Hearing Officer, Division of Administrative Hearings, The DeSoto Building, 1230 Apalachee Parkway, Tallahassee, Florida 32399-1550; and by interoffice delivery to Larry
G. McPherson, Jr., Chief Medical Attorney, Department of Professional Regulation, 1940 North Monroe Street, Tallahassee, Florida 32399-0792 at or before 5:00 P.M., this 30th day of December , 1991.
DOROTHY J. FAIRCLOTH
| Issue Date | Proceedings |
|---|---|
| Sep. 09, 1991 | Recommended Order sent out. CASE CLOSED. Hearing held 4/19/91. |
| Jun. 04, 1991 | Respondent's Proposed Recommended Order filed. (From Elliott Monroe) |
| May 31, 1991 | (Respondent) Notation of Exceptions filed. |
| May 31, 1991 | Petitioners Proposed Recommended Order filed. |
| Apr. 19, 1991 | CASE STATUS: Hearing Held. |
| Apr. 17, 1991 | Order (Petitioners Motion for Protective Order DENIED) sent out. |
| Mar. 27, 1991 | (respondent) Answer to Motion for Protective Order filed. |
| Mar. 18, 1991 | (Petitioner) Motion for Protective Order filed. |
| Feb. 11, 1991 | Third Notice of Hearing sent out. (hearing set for April 19, 1991: 10:00 am: Panama City) |
| Jan. 17, 1991 | Notice of Related Cases filed. (From Mary Radkins) |
| Jan. 03, 1991 | Transcript (Vols 1-7) filed. |
| Dec. 14, 1990 | Letter to PMR from E. Monroe (re: schedule of availability) filed. |
| Dec. 12, 1990 | Notice of Available Dates filed. (From M. B. Radkins) |
| Dec. 12, 1990 | (DPR) Notice of Late-Filed Exhibit filed. (From Mary B. Radkins) |
| Dec. 06, 1990 | CASE STATUS DOCKETED: Hearing Partially Held, continued to date not certain. |
| Nov. 30, 1990 | Petitioner's Response to Respondent's Motion for Continuance filed. (from M. B. Radkins) |
| Nov. 29, 1990 | Order (Ore Tenus Motion to quash subpoena by the non-party witness, George Lewis, M.D., be and the same is GRANTED) sent out. |
| Nov. 29, 1990 | Order (Respondents Motion for Continuance DENIED) sent out. |
| Nov. 28, 1990 | Respondent's Answer to Petitioner Request to Add Other Allergations to Present Charges and Motion to Quash Request filed. (From E. F. Monroe) |
| Nov. 26, 1990 | (Respondent) Motion for Continuance filed. (From E. F. Monroe) |
| Nov. 21, 1990 | (Petitioner) Motion to Take Official Recognition W/Exhibits A-D filed. (From Marry B. Radkins) |
| Nov. 20, 1990 | Order (Respondents Motion for Change of Venue and the Limitation of Cases to be Heard DENIED) sent out. |
| Nov. 19, 1990 | Petitioner's Response to Respondent's Motion to Change Venue and Limit Cases to Be Heard filed. (From Mary B. Radkins) |
| Nov. 09, 1990 | (respondent) Motion for the Change of Venue and the Limitation of Cases to Be Heard filed. |
| Aug. 28, 1990 | Letter to PMR from Elliott F. Monroe (re: reschuled hearing & requestfor subpoenas) filed. |
| Aug. 14, 1990 | Motion for Continuance rfiled. |
| Aug. 03, 1990 | Second Notice of Hearing sent out. (hearing set for Dec. 4-6, 1990: 10:00 am: Panama City) |
| Jun. 11, 1990 | Notice of Service of Interrogatories And Request for Admissions filed. (From Elliott F. Monroe) |
| Jun. 11, 1990 | Petitioner's Response to Respondent's Interrogatories filed. (From Mary B. Radkins) |
| May 17, 1990 | Petitioner's Response to Initial Order filed. |
| May 14, 1990 | Letter to PMR from Elliott F. Monroe (re: Scheduling hearing after 1st of Sept. 1990) filed. |
| May 07, 1990 | Order sent out. (case is cont.) |
| May 03, 1990 | Order sent out. (case is transferred to PMR) |
| Apr. 30, 1990 | (Respondent) Motion For The Replacement of Hearing Officer and Changeof Venue & Affidavits filed. |
| Apr. 26, 1990 | Petitioner's Response to Respondent's Motion For Replacement of Hearing Officer and Change of Venue filed. |
| Feb. 07, 1990 | Letter to RTB from M. B. Radkins (re: Dr. Monroe sending correspondence to DPR that is directed to RTB) & attachment filed. |
| Dec. 22, 1989 | CC of Ltr. from E. Monroe (re: Time & Place of Hearing) filed. |
| Dec. 22, 1989 | Notice of Service of Interrogatories and Request for Admissions filed. |
| Dec. 20, 1989 | Amended Notice of Hearing sent out. (hearing set for 06/20/90;10:00AM;Panama City) |
| Dec. 18, 1989 | Notice of Hearing sent out. (hearing set for 6/20/90; 10:00am; PC). |
| Dec. 14, 1989 | Response to Initial Order filed. |
| Dec. 04, 1989 | Initial Order sent out. |
| Nov. 29, 1989 | Referral Letter; Administrative Complaint; Notice of Appearance; Election of Rights filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Dec. 19, 1991 | Agency Final Order | |
| Sep. 09, 1991 | Recommended Order | Malpractice when inappropriate concentration of anesthetic, drugs inappropriate for pregnancy; failure to perform tests, history, and evaluate; records violation. |
