Other articles submitted with the late-filed exhibits were not offered and admitted into evidence at the hearing. Accordingly, these articles are disregarded. Those to be late-filed exhibits which Respondent failed to submit are deemed withdrawn.
Proposed findings have been submitted by the Petitioner. Treatment accorded those proposed findings are generally accepted, except as noted in the Appendix attached hereto and made a part hereof.
Having fully considered all evidence presented, I submit the following.
At all times relevant hereto, Respondent was licensed as a medical doctor by the Florida Board of Medicine. Respondent graduated from the University of Tehran in 1961; interned at Grace Hospital in Detroit, Michigan, in 1961-62; took Residency in Internal Medicine in 1962-65; and a Fellowship in Cardiology in 1965-67, the latter two in Detroit hospitals. He is not board- certified in Cardiology.
Patient #1 (hereinafter designated as "Patient") was referred to Respondent by Dr. Barker, the company physician for General Electric Company in Largo, Florida, where Patient was employed on July 23, 1976. Patient's chief complaint was a recent weight gain, tiredness, headaches and high blood pressure. Following a physician examination of the patient, the impression of hypertension was recorded (Exhibit 2), laboratory tests were performed which included a thyroid profile; and Hydrodiruil, 50 mg., was prescribed.
At a second visit one week later (July 30) Hypothyroidism was documented, a thyroid scan was ordered and Patient was told to return in one week. Patient was thereafter seen by Respondent on August 10, 1976; September 7, 1976; October 12, 1976; January, March, July and October 1977; January, April, June and November 1978; February, May and December 1979; March, June and September 1980; January, April, July and October 1981; January, April, July, September, October, November and December 1982; February, March, April, May, August, September, October, November and December 1983; January, March, April (3), June, August and November 1984; February, May, August and November, 1985; February, April, May, June, July and October 1986; January, February and March (2), 1987.
In January 1982 Patient reported pain in the right shoulder and neck region. In July he reported chest pain and was prescribed nitroglycerin. In November he again reported three to five minute chest pains.
No significant changes were reported in 1983. Patient was taking Synthroid daily during this period. Although not reported in doctor's notes, on December 4, 1984, a routine electrocardiogram reviewed by Dr. Paul Phillips was reported as abnormal (Exhibit 2, page 72).
On the May 13, 1986, visit, a stress test was ordered for Patient which was administered 5/21/86. The test was stopped after 6.2 minutes because the exercise resulted in leg fatigue and shortness of breath. The report (Exhibit 2, page 55) shows: I. Limited aerobic capacity; II. Normal resting and exercise EKG, and III. No detectable symptomatic ischemic heart disease.
A subsequent EKG taken January 7, 1987, viewed by the same doctor, was reported as abnormal (Exhibit 2, page 26). The January 15, 1987 entry in Exhibit 2 states EKG with no change. No additional tests were ordered.
During the period after January 1987, the patient began experiencing more chest pains and inability to withstand exertion, although Respondent's notes for the February 23, 1987, visit states "EKG normal, walks three miles a day with no problem in the past two weeks." This information can only have come from the patient and tends to refute the patient's wife's testimony that Patient was experiencing severe chest pains in February 1987.
On the other hand, the wife testified that in February 1987 they visited a son in Atlanta, Georgia, and the patient and his son went to the park to exercise. The first day the patient walked briskly without discomfort, but his pulse did not rise. The following day when he attempted the same walk, the pain was so severe he could not walk.
On March 2, 1982, as noted in Exhibit 2, Patient still complained of lower sternal discomfort. An echocardiogram was ordered which, as best I can read the handwritten notes (Exhibit 2, page 40) indicates normal findings.
Patient returned to Respondent's office on March 10, 1987, complaining of chest pains on and off. Procordia was ordered, and Patient was directed to return in one week.
On March 11, 1987, Patient went to work as usual. When he didn't telephone his wife to say he had arrived safely, the wife called the patient who reported he had great difficulty walking from his parked car to the office and that he was in a lot of pain.
On March 12, 1987, Patient did not go to work. Sometime that morning, either Patient or his wife telephoned Respondent but were unable to reach him. Word was left for Respondent to call. The call from Respondent came around 10 p.m., March 12, and Patient was advised to go to the hospital.
Patient was admitted to the emergency room at Humana Hospital, St. Petersburg, Florida, at 11:53 p.m., March 12, 1987, after arriving at 10:45 p.m. On March 13, 1987, Patient had occasional chest pains and cardiac enzymes were elevated. He was medicated with Inderal, Isurdil, Xanax, Morphine and Zantac. The hospital medication chart (Exhibit 3, page 15) shows Patient was administered Nitroglycerine at 0330, 0805 and 1830; that he was administered Morphine Sulphate at 0923 and 1530; Demoral at 0810; Lasix at 1930; and Heparin at 1940. Exhibit 3 on page 16 indicates Patient received Inogral, Isordil, Maalox, Zomax, Zantac and Tigen, but does not indicate when. Exhibit 3, Page 17 indicates Patient received D5W, Dopamine, Heparin, Lanoxin and Varapimal on March 13, 1987.
The patient remained in the Emergency Room until 2030, March 13, due to no bed available. He apparently suffered a massive heart attack around 7:45
p.m. while in the Emergency Room.
Nurses notes for March 13, 1987, indicates Patient was sleeping during the early morning hours, was given Nitroglycerine at 0330 for chest pain and Morphine Sulphate at 0400; at 0730. Patient appeared in no discomfort; at 0805. Patient complained of pressure sensation in midsternal area and was medicated with Nitroglycerine but continued to complain of chest discomfort and was given Demoral; at 0930 Patient complained of heart burn after eating breakfast relieved with burping; at 1010 Patient complained of slight chest pressure, given Nitroglycerine; seen by Respondent and wife at 1045 and 1400; 1530 complained of pain and was given Morphine Sulphate; 1815 vomited two basins full; 1830 Patient sweating profusely (diaphoretic), given Nitroglycerine, and at 1845 Morphine Sulphate for chest pain and discomfort; at 1850 an emergency EKG was done and Respondent was paged; at 1905 EKG reviewed and Dopamine drip began; at 1920 Dopamine drip increased 10 cc.; 1930 Lasix administered; 1940 Heparine administered, 7500 units IVP; 2000 Dopamine increased to 15 cc.; 2015 Lanoxin given and Dopamine increased to 25 cc.; 2030 patient vomited approximately 500 cc. reddish fluid; 2035 Verapamil given; 2110 Lanoxin 25 mg. repeated and Dopamine increased to 35 cc.; 2125 patient extremely restless, respiration labored - Valium and Atropine given; and code called.
Discharge summary shows that at 1945 Patient developed acute respiratory distress, profuse perspiration and no chest pain. The patient was intubated, subclavian catheter was inserted in the right atrium, Patient was given full CPR, Epinephrine injection and intravenous bicarbonate. Patient expired at 2219.
Petitioner's expert witness opined that prior to January 1987 Respondent's treatment of the patient met the prescribed standard of care for physicians, but subsequent thereto it did not. This opinion is predicated upon the worsening of Patient's condition in January, February and March 1987. Although there was an abnormal EKG in 1984, no evidence was presented that this EKG changed when subsequent EKGs were taken.
Respondent's notes state no change in the EKGs taken through January 15, 1987. The entry made January 15, 1987, specifically found no change in EKG. Abnormal EKGs were reported in 1984 and on January 7, 1987. No evidence was presented to contradict the July 15, 1987, entry that there was no change in the EKG.
The increase in cardiac enzymes found March 13, 1987, is evidence that damage to the heart muscle had occurred. Petitioner's expert faults Respondent for not ordering an angiogram at this time to determine the condition of the blood vessels to and from the patient's heart.
Despite the fact that Patient was at Humana Hospital which did not have a cardio-cath lab, Petitioner's expert opined that the patient should have been transferred to a tertiary care hospital in the area with such facilities. Respondent, on the other hand, contends that invasive procedures at that time would have been fatal to this patient.
In his testimony Respondent opined that the patient had chronic stable angina before he was even forty. Further, that the patient fit in the category of the population with a single coronary artery disease that have a malignant course; that this patient, who had this type of artery disease, was foredoomed to die, and nothing could have saved him, and that any invasive procedure would have resulted in the death of the patient. Respondent contends that the autopsy report confirms this opinion.
Despite this testimony a majority of the publications presented by Respondent as late-filed exhibits contained discussions regarding the treatment of patients with unstable angina.
Petitioner's expert witness opined that the rapidly deterioration of the patient on March 11, 1992, clearly demonstrated the patient needed to be hospitalized and invasive procedures initiated to determine the condition of the patient's arteries. It is the failure to initiate such procedures that rendered the treatment of this patient below the minimum acceptable standards of treatment recognized by a reasonably prudent similar physician as being acceptable under similar circumstances and conditions.
Petitioner's witness further opined that the physician's records regarding this patient were insufficient to justify the course of treatment of the patient. This opinion was based upon the fact he found Respondent's records "rather limited, often almost illegible, and did not really reflect the collection of subjective and objective data that could lead one then to follow the process of evaluation and management of either gastrointestinal problems or cardiac problems." He further concluded that these records did not reflect a cardiac diagnosis of the patient.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties to, and the subject matter of, these proceedings.
Under the provisions of Section 458.331(2), Florida Statutes, the Board of Medicine is empowered to revoke, suspend, or otherwise discipline the license of a medical doctor of, inter alia, the following violations of Section 458.331(1), Florida Statutes:
(m) Failing to keep written medical records justifying the course of treatment of the patient, including, but not limited to, patient histories; examination results;
test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations.
* * *
(t) Gross or repeated malpractice or the failure to practice medicine with that level of care, skill and treatment which is recognized by a reasonably prudent similar physician as being acceptable
under similar conditions and circumstances.
* * * As used in this paragraph "gross malpractice" or the "failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances," shall not be construed so as to require more than one instance, event, or act. Nothing in this paragraph shall be construed to require that a physician be incompetent to practice medicine in order to discipline pursuant
to this paragraph.
In these proceedings the Petitioner has the burden of proving the allegations by clear and convincing evidence. Ferris v. Turlington, 510 So.2d 292 (Fla. 1987).
Here Petitioner was trained in Cardiology and held himself out as a Cardiologist, although not board certified. As such, he is required to exercise the care and skill of a cardiologist in treating patients.
Respondent contends that, from the autopsy report and the history of this patient, nothing could have been done on March 12 and 13 to save this patient. No further expert opinion to support this conclusion was presented, including those excerpts from medical journals submitted as late-filed exhibits by Respondent. Petitioner's expert witness opined that had steps been taken March 12 or 13 to ascertain the condition of the patient's coronary blood vessels, steps could have been taken to save this patient's life, either by angioplasty or open heart surgery.
While neither opinion can be sustained with certainty, it is clear that on March 12, 1987, the patient was exhibiting classical symptoms of an impending cardiac accident and required hospitalization and diagnostic tests to determine the condition of the blood vessels leading to and from his heart. Although he was hospitalized, no invasive procedures were ordered to ascertain the condition of these blood vessels. Failure to conduct these tests, under the circumstances, constitutes gross malpractice as defined above.
With respect to the charge of failure to maintain medical records adequate to justify the course of treatment of the patient, the evidence is somewhat weaker. Part of the problem stems from an inability to read some of the physician's handwritten notes. Otherwise, the patient's history is fairly well documented, as are examination results, records of drugs prescribed, and reports of consultations and hospitalizations. For this charge, Petitioner has failed to sustain its burden.
Rule 21M-20.001, Florida Administrative Code, establishes disciplinary guidelines to be imposed on physicians who are found to be in violation of the various provisions of Section 458.331(1), Florida Statutes. For violation of Section 458.331(t), the recommended penalty ranges from two years probation to revocation and an administrative fine from $250 to $5000.
From the foregoing, it is concluded that Si H. Azar violated the provisions of Section 458.331(1)(t), Florida Statutes, in diagnosing and treating patient J.V. between January 1987 and March 13, 1987, and that he is not guilty of violating Section 458.331(1)(m), Florida Statutes.
