on May 9, 1991, Alfred O. Shuler entered his appearance as counsel for Respondent. Mr. Shuler advised that he was aware of the subpoena served on Respondent and that he had advised Respondent to appear and honor the subpoena. Respondent had declined to appear and had left Apalachicola and the state of Florida.
The transcript of the proceedings was filed on May 28, 1991. Both parties timely filed proposed findings of fact and conclusions of law. Respondent's proposed recommended order does not comply with the expressed instructions of the Hearing Officer and with the requirements of Rule 22I-6.031(3), Florida Administrative Code, regarding citations to the record. All proposed findings of fact and conclusions of law have been considered. A specific ruling on each proposed finding of fact filed by DPR is made in the Appendix attached hereto and made a part of this Recommended Order. No specific rulings are made on the proposed findings of fact of Respondent because there are no separate proposed findings of fact upon which rulings can be made. Instead, a ruling is hereby made that all proposed findings of fact of the Respondent are subordinate to the facts actually found in this Recommended Order.
Respondent is and has been at all times material hereto a licensed physician in the state of Florida, having been issued license number ME 0019670.
Respondent is a board-certified obstetrician and gynecologist.
On March 20, 1989, at approximately 1:04 a.m., Patient #1 (Derrick Prince) was presented to the emergency room at Weems Memorial Hospital in Apalachicola, Florida. Prince was a twenty-year-old male suffering from a stab wound to his left thigh that was inflicted by a butcher knife.
Prince was actively bleeding and had lost a large amount of blood, as evidenced by the condition of his clothing, the amount of blood on the walls and floor of the hospital, and blood on his companions.
Prince was placed on a table in the trauma room. When his blood-soaked pants were removed, blood spurted from the wound on his left thigh to a height of one to two and one-half inches.
The emergency room R.N., Ms. Page, controlled the bleeding by direct pressure, first with her hand and then with a towel.
Prince was semiconscious, muttering, "I can't breathe," and was randomly combative. Emergency room personnel had to forcibly restrain him on the table.
Respondent, working as the emergency room physician, was summoned to the trauma room by the nurse.
Hospital personnel attempted to establish Prince's blood pressure and pulse. Ms. Simpson, the L.P.N., could detect no blood pressure or pulse on Prince. Ms. Page, the R.N., could detect no blood pressure or pulse although she checked radial, cubital, and popliteal areas. Mrs. Estes, a paramedic who came in to help, could detect no pulse.
Respondent was advised repeatedly that no blood pressure or pulse could be detected.
Respondent instructed Ms. Simon to call respiratory and laboratory personnel and the Sheriff's Department, which she did. The laboratory director, Tracy Pierce, was called at his home in St. Joe Beach.
When pressure was removed from the wound area, there was little blood on the towel and the wound was not bleeding. Respondent commented to the nurse that she did a good job stopping the bleeding.
The nurse and paramedics attempted to begin intravenous infusion but were unable to establish any IV lines because all veins were concave (collapsed).
The nurse and paramedic interpreted this peripheral vascular collapse as meaning there was no blood volume to keep the veins open. Respondent was advised that no IV could be started because the veins were concave.
Respondent had ordered a suture tray. He explored the wound with his finger and commented that the wound went all the way to the bone.
Respondent commented that the boy would be all right, that he wasn't hurt that bad.
Respondent proceeded to treat Prince by suturing the wound in three layers. He stated he tied off some minor arterial branches during this suturing.
After suturing the wound, Respondent again commented that the boy would be all right because he wasn't hurt that bad.
After suturing the wound and noting no jugular access, Respondent began a cutdown in order to establish an intravenous line.
Ms. Estes, the paramedic, suggested using MAST trousers to help venous pressure, and Respondent agreed. MAST trousers also can act as a tourniquet to control bleeding. The pants were applied and Prince's legs were elevated in an effort to establish a positive venous pressure.
At 1:30 a.m., while Respondent was setting up for a cutdown, Prince had a seizure and respiratory arrest. He was intubated by Respondent. He vomited, was suctioned, and breathed by AMBU bag.
Respondent then inquired, for the first time, about the availability of blood. He was told there was none in the hospital.
Sufficient blood was available and could have been obtained from Gulf Pines South Hospital in St. Joe within 30 minutes had a request been made for Mr. Pierce to bring it with him. Mr. Pierce arrived during the cutdown procedure. Mr. Pierce was the laboratory director for both hospitals.
An intravenous fluid line was finally established via the cutdown and some fluid begun.
The Life-Flight helicopter was ordered at approximately 1:40 a.m.
At approximately 1:55 a.m. Prince suffered a cardiac arrest.
When Life-Flight arrived at 2:40 a.m., it was impossible to transport Prince in his moribund condition.
Resuscitative efforts were employed until approximately 3:00 a.m., when Respondent pronounced Prince dead.
An autopsy conducted by Dr. Thomas Wood, the Medical Examiner, on March 21, 1989, revealed that the stab wound to the left thigh was located six inches above the knee, was seven inches deep, passed by the bone, and completely severed both the femoral artery and vein.
The autopsy also revealed 3 layers of sutures: the first closing the skin and two other layers within the subcutaneous fatty tissue, not more than three-fourths of an inch below the surface.
There was no evidence of any arterial or venous repair.
The cause of death of Derrick Prince was exsanguination from the severed femoral vessels.
After an investigation was initiated, Respondent was interviewed by Investigator Reese. Respondent stated that peripheral pulses were obtained and
the patient's pulse rate was 120 from admission until the time of his respiratory arrest.
Respondent stated to Investigator Reese that two IVs were started but that the patient pulled them out.
Statements of Ms. Page and Ms. Estes written immediately after the incident indicate that no IVs were started, not because the patient pulled them out, but because all veins were collapsed.
Respondent stated to Investigator Reese that he had to leave the patient after suturing the wound to examine a family member across the hall.
At no time did Respondent leave the emergency room.
Respondent stated to Investigator Reese that there was no indication that the femoral vessels had been cut, as he had checked the wound and that is not the direction the femoral artery runs.
Respondent believed the wound was not life-threatening, that after the bleeding was stopped and the wound sutured the patient was in pretty good shape and was going to be fine.
Respondent was not aware the femoral vessels had been severed until informed at the circuit court hearing of June 6, 1989.
Respondent reported in his medical record the patient "became shocky" at approximately 1:30 a.m., after the suturing.
The massive blood loss, disorientation and combativeness, peripheral vascular collapse, and lack of vital signs all indicate Prince was in shock when admitted and Respondent did not recognize this fact.
Respondent instead believed Prince to be a combative drunk and his course of treatment indicates this perception.
The emergency room physician should prioritize his actions in such a way that the most critical factor is treated promptly and other, less dangerous factors are given lesser priority.
The correct treatment of this patient would have been for Respondent to direct all efforts of the E.R. team toward immediately reestablishing Prince's blood volume, then blood replacement. The wound itself could have been easily controlled by pressure, tourniqueted by the MAST pants, or even left for later care.
Rather than misdirecting his attention to suturing the wound, Respondent should have performed the cutdown or placed a CVP catheter to start IV fluids as soon as it was evident that the nurses could not start the IVs and Respondent should have ensured that blood was being obtained as soon as possible.
Respondent's suturing of the wound was ineffective in any case, as only superficial layers were stitched, and the wound remained unexplored.
Respondent did not practice with the acceptable level of care, skill and treatment of a reasonably prudent similar physician under similar conditions
and circumstances in that Respondent did not correctly assess Prince's physical condition and therefore misdirected his attention to suturing the wound instead of establishing intravenous access for immediate fluid replacement.
Respondent's entire written medical record consists of his "Emergency Room Note."
Respondent has documented no detailed history or physical examination: there is no documentation of the amount of blood loss, of the spurting blood, of the initial assessment of the patient's shock, or of consideration that the massive bleeding could have been from the great vessels and life threatening; there is no record that Respondent ever felt for pulses or obtained a pulse, no record of any neurological assessment or vascular status of the left leg distal to the wound, no conjunctival color noted, and no justification for giving his attention to the wound rather than immediately attempting to replace the lost blood volume; there is no note of a request for blood, how it could be or why it was not obtained. In short, prior to the cardiac arrest, there are no medical records written by Respondent which justify the course of treatment he followed with Prince.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction of the parties to and subject matter of these proceedings. Section 120.57(1), Florida Statutes.
Pursuant to Section 458.331(1), Florida Statutes, the Board of Medicine is empowered to revoke, suspend, or otherwise discipline the license to practice medicine of any physician in the state of Florida found guilty of the acts enumerated in Section 458.331(1), Florida Statutes.
In a disciplinary action such as this proceeding, the burden is on the Board to establish the facts upon which its allegations of misconduct are based. The Petitioner must prove its allegations by clear and convincing evidence. Ferris v. Turlington, 510 So.2d 292 (Fla. 1987).
The Administrative Complaint in this case charges Respondent with two violations. Count I alleges that Respondent violated Section 458.331(1)(t), Florida Statutes, failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances, in that he failed to recognize the obvious symptoms of shock in the patient due to massive blood loss and to direct his attention to the immediate replacement of the lost blood volume, but instead misdirected his attention to suturing the thigh wound, which was by that time unnecessary or could be treated by other means, and thereby lost invaluable time.
Both expert witnesses who are practicing or have practiced in small hospitals similar to Weems without the resources of the more sophisticated medical centers, found that Respondent fell below the standard of care when he did not direct his initial efforts to the most critical need, i.e., an immediate cutdown or CVP catheter to reestablish some blood volume while blood was being brought to the hospital. No extraordinary medical skill or expertise in emergency medicine was needed for this.
Both expert physicians perceived that Respondent felt he was dealing with a belligerent drunken man with a deep but not critical stab wound. Until
the seizure and respiratory collapse, Respondent did not appreciate that Prince was exhibiting all the symptoms of deepening shock, although the nurses and paramedic were quite aware and acted accordingly.
Even Respondent's efforts to repair the wound were ineffective. It was obvious to all witnesses that a tremendous amount of blood had been lost from somewhere. Although Respondent stated he tied off a small arterial bleeder, no evidence for this was found at autopsy. From whence came this quantity of blood? As Respondent failed to explore the wound fully he did not discover the severed vessels or, evidently, ever understand that that was the cause of death until told at the circuit court hearing. His superficial suturing bears this out.
Respondent has made too many statements which are contradicted by other witnesses to find him credible. He said no blood pressures were taken and that peripheral pulses were found, at a rate of 120, from time of admission to seizure. He stated two IVs were begun and a total of about 1500 ccs infused before the patient pulled them out. He said he had to leave the emergency room after suturing to care for another patient across the hall. All of these statements have been specifically contradicted by testimony or records.
Based on the foregoing, Petitioner has established by clear and convincing evidence that Respondent is guilty of Count I as charged.
In Count II of the Administrative Complaint Respondent is charged with a violation of Section 458.331(1)(m), Florida Statutes, in that he failed to keep written medical records which justify the course of treatment he followed with Prince.
Petitioner has proven this count by clear and convincing evidence.
Respondent's only medical record is the one-page emergency room note, mostly devoted to the resuscitative efforts of the Code Team after Prince arrested. The inadequacy of this record is obvious when contrasted with the written statements of Ms. Page, Ms. Estes, and Ms. Simon which are part of the permanent medical record.
Respondent did not address in his written record an initial physical assessment of the patient: the tremendous amount of blood lost, the pulsing wound which then ceased to bleed, the peripheral vascular collapse, the probability that one or more of the great vessels of the leg had been severed because of the symptoms and location of the wound, or any consideration that the symptoms of shock were apparent from the time Prince was brought into the emergency room.
Respondent has not documented any blood pressure, pulses, respirations, or other vital signs such as conjunctival color or neurological status of the leg distal to the injury.
The reasoning for keeping good medical records is, at least in part, so that "neutral third parties can observe what transpired during the course of treatment of the patient." Robertson v. Department of Professional Regulation,
574 So.2d 153, 156 (Fla. 1st DCA 1991). It is clear that Respondent's records in this case do not provide that insight.
The recommendation in this case is reached after consideration of the Disciplinary Guidelines of the Board of Medicine and Aggravating and Mitigating
Circumstances of Rule 21M-20, Florida Administrative Code, and of Respondent's prior discipline in Texas, Louisiana, and Alabama, as well as the action of the Florida Board of Medicine placing Respondent's license on suspension by the Order of June 15, 1989.
Aggravating and Mitigating Circumstances as stated in Rule 21M-20, which are relevant to this case, allow for consideration of a) exposure of the patient or public to injury or potential injury, b) legal status at the time of the offense, c) number of times the same offense has previously been committed, and d) the disciplinary history of the licensee in any jurisdiction.
In this case, the experts could not say whether a medically correct response might have saved the patient's life. Prince may have been past the point at which even adequate blood replacement would not have changed the outcome. It remains, however, that the patient died.
At the time of this offense, Respondent was under a stayed 5-year suspension from practice in the state of Texas, placed on probation for that period, and prohibited from engaging in obstetrics or other hospital procedures and practices unless and until approved by the Texas Board. This Order was filed in October 1987.
The offenses in Texas involved multiple counts of violations of the standard of acceptable medical care.
Examination of the disciplinary history of Respondent establishes that, beside the Texas stayed suspension, Respondent's license to practice medicine is revoked in Louisiana and Alabama and is suspended in Florida.
In addition there are before the Division of Administrative Hearings, pending recommended orders, two cases, Nos. 89-2680 and 90-6489, comprised of eight separate factual situations.
