The Issue The issue is whether Respondent's Florida license to practice medicine should be revoked for malpractice under section 458.331(1)(t), Florida Statutes (2006).
Findings Of Fact Respondent is licensed to practice medicine in Florida, holding license number ME 66823. He is a radiologist and is certified by the American Board of Orthopedic Radiology and Diagnostic Radiology. On June 17, 2004, the Board of Medicine (Board) disciplined Respondent's medical license by issuing a letter of concern, imposing a $15,000 fine, assessing $4,010.59 in costs, requiring eight hours of continuing medical education, and prohibiting him from treating or prescribing medication to members of his family. On or about October 4, 2006, while working at Drew Medical, Inc., Respondent performed a diagnostic procedure called an intravenous pyelogram (IVP) without tomograms for Patient G.P., who had complained of right-side pain and had a history of kidney stones. An IVP without tomograms is a series of time- lapse x-rays using a dye material to provide radiographically contrasting images to detect a stone in a kidney or ureter. The resulting x-ray images revealed a partial obstructing stone in the right-side kidney/ureter area, which Respondent detected and reported. One of the resulting x-ray images contained an anomaly having the classical appearance of an abdominal aortic aneurysm, including conspicuous tissue displacement and rim calcification. It had an elongated, water balloon-type appearance with calcifications on one of the walls. It was alarming or life- threatening in size, such that it could cause death by bleeding. Respondent did not mention the aneurysm in his report or recommend any further evaluation of the anomaly. Although he was tasked to look for kidney stones, Respondent's failure to report the aneurysm or recommend any further evaluation of the anomaly fell below the level of care, skill, and treatment that is recognized by reasonably prudent, similar physicians as being acceptable. Patient G.P. was admitted to Orlando Regional Hospital with a ruptured abdominal aortic aneurysm on October 6, 2006. Attempts were made to repair the rupture, but they were not successful. The patient died on October 12, 2006. By his conduct in disappearing without a trace, despite the diligent efforts of DOH to find him, and not participating in any manner in the hearing he requested to dispute the Administrative Complaint, Respondent effectively abandoned his license to practice medicine in Florida.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Medicine enter a final order finding Respondent guilty of medical malpractice, revoking his medical license, and imposing a $10,000 administrative fine. DONE AND ENTERED this 25th day of July, 2012, in Tallahassee, Leon County, Florida. S J. LAWRENCE JOHNSTON Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 25th day of July, 2012. COPIES FURNISHED: Greg S. Marr, Esquire Department of Health Bin C-65 4052 Bald Cypress Way Tallahassee, Florida 32399-3265 Robert Dean Marshall, M.D. Apartment 310 400 East Colonial Drive Orlando, Florida 32803 Robert Dean Marshall, M.D. 5987 Southwest Moore Street Palm City, Florida 34990 Jennifer A. Tschetter, General Counsel Department of Health 4052 Bald Cypress Way, Bin A-02 Tallahassee, Florida 32399-1701 Joy Tootle, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701
The Issue Whether disciplinary action should be taken against Dr. Vizcarra's Florida license to practice medicine for violating Sections 458.33l(1)(m), (q) and/or (t), Florida Statutes, as alleged in the Administrative Complaint against Dr. Vizcarra?
Findings Of Fact The Petitioner is the state agency charged with the responsibility to prosecute administrative complaints against licensed physicians in the State of Florida. Eulogio Vizcarra, M.D., is, and has been at all times relevant to this proceeding, a licensed physician in the State of Florida. Dr. Vizcarra's license number is ME 0030012. On January 2, 1984, Dr. Vizcarra saw patient S.L. for the first time. S.L. was diagnosed by Dr. Vizcarra as suffering from tension headaches and hypertension. Dr. Vizcarra continued to see S.L. from January, 1984, until at least June 6, 1987. Throughout the period of time that Dr. Vizcarra treated S.L., including the period of June 14, 1986, through June 6, 1987, S.L. complained of, and was diagnosed as suffering from, numerous ailments, including hemorrhoids, nasal conjunction, lacerations, back pain, abdominal cramps, sore throat, diarrhea, gastrointestinal bleeding, laryngitis, chest pain, tooth ache, rhinitis, upper respiratory tract infection, viral syndrome, impotence and a ganglion cyst. During the time that Dr. Vizcarra treated S.L., including the period of June 14, 1986, through June 6, 1987, S.L. was seen by Dr. Vizcarra and other physicians on numerous occasions. The primary and most repeated diagnosis of S.L. by Dr. Vizcarra during the period of time that Dr. Vizcarra treated S.L. was migraine headaches and hypertension. In January of 1984, when S.L. first saw Dr. Vizcarra, S.L. was initially given Amitriptyline, a prophylactic drug, for his migraine headaches. The use of Amitriptyline, or other prophylactic drugs, was not continued by Dr. Vizcarra in his treatment of S.L., however. In April, 1984, Dr. Vizcarra referred S.L. to Dr. Kohler, a neurologist, for tests concerning S.L.'s migraine headaches. Dr. Vizcarra also referred S.L. to Dr. Loucshmann (phonetic) in April, 1984, for treatment of his migraine headaches and his hypertension. Neither physician continued to see S.L. after April, 1984. Dr. Vizcarra referred S.L. to other physicians: (1) Dr. Hernandez saw S.L. in May, 1986, for hemorrhoids; Dr. Baker, a cardiologist, saw S.L. in July, 1986, for chest pain; (3) Dr. Desai, a general surgeon, saw S.L. in August, 1986, for hemorrhoids and in June, 1987, for abdominal pain; and (4) Dr. Bonzon saw S.L. from January, 1987, through April, 1987, for the removal of a ganglion cyst. Dr. Vizcarra did not, however, refer S.L. to any other physician after April, 1984, for treatment of, or testing concerning, S.L.'s migraine headaches. During the period of time from June 14, 1986, through June 6, 1987, S.L. also was seen by various emergency room physicians, including Dr. Sklar, Dr. Amadio and Dr. Adams. All of these physicians listed Dr. Vizcarra as the "family physician" or as the "physician notified" on their record of S.L.'s visit. Finally, S.L. was seen in July and August, 1986, by Dr. Adom. Dr. Vizcarra's medical records concerning S.L. include information concerning S.L.'s treatment by the physicians listed in findings of fact 9-12. During the period of time from June 14, 1986, through June 6, 1987, Dr. Vizcarra prescribed over 60 injections of Talwin, Nubain and Stadol for S.L. S.L. also received injections of these drugs from some of the other physicians S.L. was seen by during this period of time. S.L. was also given approximately 25 to 30 prescriptions for Tylox and Darvocet, as well as other analgesic medications, during the period of time at issue in this proceeding. S.L. also received prescriptions for these drugs from some of the other physicians S.L. was seen by during this period of time. Talwin, Nubain, Stadol, Tylox and Darvocet (hereinafter referred to as the "Five Legend Drugs") are narcotic analgesic medications. They are all legend drugs and have the potential for addiction. Dr. Vizcarra indicated that he prescribed the Five Legend Drugs given to S.L. in order to relieve the pain that S.L. was suffering from. The rapid relief of pain with narcotic analgesics is acceptable only on an infrequent basis. Dr. Vizcarra's use of the Five Legend Drugs during the period of June 14, 1986, through June 6, 1987, was excessive. Dr. Vizcarra's use of the Five Legend Drugs during the period of June 14, 1986, through June 6, 1987, constituted an inappropriate use of legend drugs. Dr. Vizcarra failed to provide proof that he made an adequate medical assessment of S.L.'s condition or the possible consequences of S.L.'s exposure to the Five Legend Drugs prescribed for him by Dr. Vizcarra or the other physicians who treated S.L. from June 14, 1986, through June 6, 1987. The medical records maintained by Dr. Vizcarra fail to justify his treatment of S.L. during the period of June 14, 1986, through June 6, 1987. Dr. McCoy's testimony concerning whether Dr. Vizcarra's treatment of S.L. constituted a violation of Section 458.331(1)(t), Florida Statutes, was based upon Dr. McCoy's review of Dr. Vizcarra's medical records. Dr. Vizcarra provided further details concerning his treatment of S.L. during the hearing which were not included in his medical records. Dr. McCoy did not hear this testimony. Therefore, Dr. McCoy's opinions concerning whether Dr. Vizcarra's treatment of S.L. constituted a violation of Section 458.331(1)(t), Florida Statutes, did not take into account all of the evidence.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Eulogio Vizcarra, M.D., be found guilty of having violated Sections 458.331(1)(m) and (q), Florida Statutes. It is further RECOMMENDED that the portion of the Administrative Complaint against Dr. Vizcarra alleging that he violated Section 458.331(1)(t), Florida Statutes, be dismissed. It is further RECOMMENDED that Dr. Vizcarra be subjected to the following penalties: Payment of an administrative fine in the amount of $2,500.00; Placement on probation for a period of one year. Dr. Vizcarra should be placed under the indirect supervision of a Board of Medicine physician who should receive copies of all prescriptions for controlled substances written by Dr. Vizcarra during his probation. Quarterly reports should be made by the monitoring physician to the Board of Medicine's probation committee; and Attendance of twenty-one hours of Continuing Medical Education in courses concerning appropriate drug prescribing, in addition to Continuing Medical Education hours required for license renewal. DONE and ENTERED this 24th day of April, 1989, in Tallahassee, Florida. LARRY J. SARTIN 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 24th day of April, 1989. APPENDIX The Petitioner has submitted proposed findings of fact. It has been noted below which proposed findings of fact have been generally accepted and the paragraph number(s) in the Recommended Order where they have been accepted, if any. Those proposed findings of fact which have been rejected and the reason for their rejection have also been noted. The Petitioner's Proposed Findings of Fact Proposed Finding Paragraph Number in Recommended Order of Fact Number of Acceptance or Reason for Rejection 1 2. 2 14, 16 and 18. 3 This summary of testimony supports findings of fact 15-18. 4-5 Argument and summary of positions. 6 19. COPIES FURNISHED: Joseph Harrison Senior Attorney Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 John R. Weed, Esquire 605 South Jefferson Street Perry, Florida 32347 Ms. Dorothy Faircloth Executive Director Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Kenneth Easley General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
Findings Of Fact Respondent immigrated to the United States in 1974. He began practicing medicine in Orlando in 1977, specializing in obstetrics and gynecology. His medical doctor's license issued by the Florida Board of Medical Examiners has been in force at all times relevant. In October, 1977, Respondent began treating Ms. Patricia King for menstrual pain and an infection. In January, 1978, King requested that Respondent prescribe Dilaudid 1/ for pain. He did so, and thereafter through April, 1978, prescribed an approximate total of 333 Dilaudid tablets for King. According to the Physician's Desk Reference, Dilaudid is an opiate which can create psychic and physical dependence. Dilaudid is indicated for the relief of moderate to severe pain such as that due to surgery, cancer, soft tissue and bone trauma, biliary colic, myocardial infarction, burns, or renal colic. None of these conditions was present in regard to King or any other patient discussed herein. During the early months of 1978, Respondent became aware that King was addicted to Dilaudid but continued to prescribe this drug for her on the representation that she would seek therapy for her addiction. She also informed Respondent that she was selling some of the Dilaudid tablets and offered to share the proceeds with him. King usually left 25 or 50 at his office in payment for his cooperation. Respondent denies that he asked for this money, totaling $450 to 500, but admitted that he did not return it. During this period, Mr. Billy Pressley began bringing women to Dr. Agrawal ostensibly for treatment. However, Respondent did little more than write prescriptions for Dilaudid and other controlled substances for these individuals. In some cases Pressley did not even bring the purported patient, but merely came to Respondent's office to pick up prescriptions for controlled substances in the names of third persons. In early 1978, Respondent attempted to discontinue his relationship with Pressley and King. However, he was intimidated by their threats and fear of exposure, and continued to write the prescriptions they demanded. On April 19, 1978, police were summoned to Respondent's home to investigate a broken screen. Subsequently, Pressley and King arrived and were arrested by the police and charged with extortion. As a result of the investigation, Respondent was charged with "Delivery of Dilaudid, A.C.S." and entered a plea of Nolo Contendere in the Circuit Court of Orange County. By order issued on April 13, 1979, Respondent was placed on 12 years probation, adjudication of guilt withheld. He thereafter moved to Okeechobee where he has practiced medicine at the Florida Community Health Center without incident. The investigation of Respondent revealed that during March and early April, 1978, he issued two or more dilaudid prescriptions to a Ms. Lynn Elland or others in the name of Elland. Respondent admitted to police that he gave Billy Pressley a Dilaudid prescription for Lynn Elland on April 2, 1978. According to this statement, Pressley provided Respondent with extra money in order to obtain prescriptions for controlled substances. Between approximately February 3 and 24, 1978, Respondent issued prescriptions to Pressley for Quaalude, 2/ 300 mg., 30 tablets, Dilaudid, 4 mg., 60 tablets and Preludin, 3/ 75 mg., 30 tablets. Further, Respondent provided Pressley with a prescription for Dilaudid in the name of Ms. Kim Taekaberry. Between January and April, 1978, Respondent issued approximately four additional prescriptions for Dilaudid, 4 mg., totaling about 90 tablets, in the name of Kim Taekaberry. Respondent acknowledged to police his awareness that Pressley was using Taekaberry in order to obtain Dilaudid prescriptions. Between late January and mid-February, 1978, Respondent issued two prescriptions for Dilaudid, 4 mg., totaling 45 tablets, in the name of Molly Lynch. Respondent acknowledged to police officers that Pressley was also using Lynch to obtain Dilaudid. Between February and April, 1978, Respondent issued approximately four prescriptions for Dilaudid, 4 mg., totaling about 99 tablets, to Ms. Kimberly Skinner. Respondent could not recall whether Skinner had been a patient or the reason he prescribed this medication for her. Between late January and early February, 1978, Respondent issued approximately two prescriptions for Dilaudid, 4 mg., totaling about 30 tablets to Ms. Linda Cleary. Similarly, the Respondent could not recall why he prescribed this medication for Cleary. Between approximately February 2, 1978, and March 21, 1978, Respondent prescribed Preludin, 75 mg., 60 tablets, and Quaalude, 300 mg., 20 tablets to Mr. Gunter Bachman. The Respondent acknowledged in his initial confession to police that he did not maintain patient records for Bachman. Further, it should be noted that Respondent's practice in obstectrics and gynecology would not have involved the treatment of male patients. Between February 24 and April 11, 1978, Respondent issued five prescriptions for Dilaudid, totaling approximately 70 tablets, to Mr. Robin Connelly. Respondent advised police that Connelly complained of chest pains and informed Respondent that he took Dilaudid. Considering the nature of the Respondent's practice, his claim that he was treating Connelly for chest pains is not credible. Further, Respondent's admission to police that on March 28, 1978, he gave Connelly a prescription in the name of Kathy Hosford without examining Ms. Hosford further discredits his explanation of the Connelly chest pains prescription. Between January 3 and March 3, 1978, Respondent issued approximately twelve prescriptions of Dilaudid, 4 mg., totaling approximately 289 tablets, to Mr. Nick Dearie. Respondent admitted to police that Dearie gave him extra money to provide these prescriptions.
Recommendation From the foregoing, it is RECOMMENDED that Respondent be found guilty of Counts 1, 5, 8, 11, 14, 17, 20, 23, 29, and 32 as charged. It is further RECOMMENDED that all other counts be dismissed. It is further RECOMMENDED that the Board of Medical Examiners issue a reprimand to Respondent based on the findings herein. It is further RECOMMENDED that the Board of Medical Examiners place Respondent on probation, under the supervision of a designated physician, for a period of five years. It is further RECOMMENDED that the Board of Medical Examiners withdraw Respondent's authority to prescribe medication controlled under the provisions of Chapter 893, Florida Statutes, by restriction of his license for a period of five years. It is further RECOMMENDED that Respondent be required to successfully complete a course of study in pharmacology prior to removal of his license restriction. RECOMMENDED this 22nd day of October, 1981, in Tallahassee, Florida. R. T. CARPENTER, Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 22nd day of October, 1981.
The Issue Whether Respondent violated Subsections 458.331(1)(q), 458.331(1)(t), 458.331(1)(nn), 458.347(4), and 456.072(1)(o), Florida Statutes (2001), and Florida Administrative Code Rule 64B8-30.008, and, if so, what discipline should be imposed.
Findings Of Fact At all material times relevant to this proceeding, Coker was a licensed physician assistant with an additional qualification as a prescribing physician assistant in the State of Florida, having been issued license number PA3151. A physician assistant is a dependent practitioner, who practices under a supervising physician. A physician assistant acts as a supplement or extension of the supervising physician and is trained to do histories and physicals, to diagnose, and to treat patients. In Florida, a physician assistant is permitted to prescribe certain medications after completion of a prescriptive practice seminar and an application process. Beginning in June 2001, Coker began working as an independent contractor for Dr. Rosetta V. Cannata, an anesthesiologist who practices in pain management. Dr. Cannata was Coker's supervising physician. Dr. Cannata maintained an office in Englewood, Florida, and decided to expand her business to adult entertainment clubs in Tampa, Florida. The purported purpose was to provide medical services to persons who were working in the adult entertainment business. She made arrangements with various clubs to provide space to her at the clubs for use as examining rooms. Dr. Cannata and Coker began seeing patients at adult clubs such as the Pink Pony and Diamond's Men's Club. Patients other than those from the adult entertainment business began to come to the clubs to see Dr. Cannata and Coker. Dr. Cannata opened an office on Martin Luther King, Jr. Boulevard in Tampa to take care of the increased business. Coker saw patients at the new office and also continued to see patients at the adult clubs. In 2001, the Hillsborough Sheriff's Office began an investigation of Coker's activities in Tampa. Jaceson Yandell (Yandell) was the lead investigator. Yandell used a confidential informant (CI) to make contact with Coker. On July 14, 2001, the CI took Detective Dan Mathis (Mathis),1 an undercover officer, to Diamond's Men's Club to see Coker. Mathis and the CI were fitted with either recording or transmitting devices so that their conversations with Coker were recorded. Yandell was stationed in a nearby vehicle, which contained devices that could receive and record the transmission of the conversation between Mathis and Coker. Mathis was introduced to Coker by the CI as Dee Tucker. Coker asked Mathis to fill out a medical history form. Mathis filled out the form, indicated no to all the questions, and stated that he was not currently taking any medication, had no previous surgeries, and was not allergic to any medications. He did not list a name for his medical doctor. After asking Mathis his height and weight and whether he was allergic to any medicine, Coker asked, "What am I seeing you for today, Dee?," and the following conversation took place: Mathis: I ain't got nothing wrong with me. CI: Tell him what you want, shit that's the only way you're gonna get it. Mathis: Some Z's.2 Coker: So you are having some anxiety is what you're telling me? Mathis: Yeah, yeah. CI: Say yes. Mathis: Yes. Coker: Has this been going on long? Mathis: Shit. Well, it's been a long. It's been a while. I've been kinda acting like that. Coker also asked Mathis whether he had ever been in the military, had a car wreck, or been injured in anyway, including any football injuries. Coker also asked him whether he had a family history or had any surgeries. Mathis replied negatively to all of these inquiries. Mathis did advise Coker that his mother, who had smoked for 45 years, had recently died of hypertension and congestive heart failure at the age of 62. Coker did not check Mathis' heart, lungs, ears, nose, throat, or glands. Coker took Mathis' blood pressure and found that it was high, and advised Mathis that he needed to take medication for the high blood pressure. He prescribed hydrochlorothiazide for the high blood pressure and ordered some laboratory work to rule out causes for the elevated blood pressure. Coker also advised Mathis to eat more foods that were high in potassium. Coker had two prescription pads. One pad contained prescription forms that were pre-signed on the physician's signature line, and the other pad contained prescription forms that were not pre-signed. Coker wrote the prescriptions for the hydrochlorothiazide and the laboratory work on the prescription forms that were not pre-signed. Coker prescribed 30 two-milligram bars of Xanax for Mathis for anxiety. The prescription could be refilled two times. The prescription was written on one of the pre-signed prescription forms. During the July 14 office visit, there was no discussion of the possible cause of Mathis' anxiety, no discussion of a plan of treatment for the anxiety, and no discussion of alternative treatments for anxiety, such as counseling. The only discussion of directions of use or warnings concerning Xanax was that taking Xanax in the bar, rather than pill form, could save the patient money, because the bar could be broken into smaller doses and that Coker would prefer that a patient not take a whole bar unless it was necessary. Xanax contains Alprazolam which is a schedule IV controlled substance. Mathis did not see Dr. Cannata during his July 14 office visit. Coker did not leave the examining room or make any telephone calls during Mathis' office visit. Mathis paid Coker $50 for the visit. After leaving the Diamond's Men's Club, Mathis went to the vehicle where Yandell was located and gave Yandell the prescriptions. On August 17, 2001, Mathis returned alone to Diamond's Men's Club to see Coker. Mathis was wired with a transmitting device so that the conversation between Coker and Mathis was recorded. Coker took Mathis' blood pressure and found it to be lower. Other than taking Mathis' blood pressure, Coker did not perform any physical examination of Mathis. Mathis advised Coker that he had an injury due to bench pressing and that he felt some discomfort when he bench-pressed during a work out. Coker did not ask Mathis how often he experienced the pain, nor did he ask Mathis if he was taking any other medication for the pain. Coker and Mathis discussed the use of anabolic steroids, and Coker discouraged the use of steroids. During the August 17, 2001, office visit, Coker did not ask Mathis how the Xanax was working, did not inquire whether Mathis was still experiencing anxiety, did not discuss alternatives to Xanax, did not discuss the causes of anxiety or ways to address the anxiety, did not discuss a medical diagnosis with Mathis, and did not discuss a plan of treatment. On August 17, 2001, Coker wrote Mathis a prescription for 30 two-milligram bars of Xanax, which could be refilled two times, and a prescription for Lortab, which could be refilled one time. Lortab contains Hydrocodone which is a Schedule III controlled substance. Coker wrote the prescriptions on prescription forms which had been pre-signed on the line for the physician's signature. Mathis did not see Dr. Cannata on the August 17, 2001, visit, and Coker did not leave the room. Other than a telephone call to his family, Coker did not talk on the telephone during Mathis' visit. Mathis paid Coker $50 for the office visit and left the adult club. He met Yandell at a predetermined location and turned over the prescriptions to Yandell. On August 21, 2001, Mathis and another undercover officer, Detective Peggy Grow (Grow), met with Coker at an office located on Martin Luther King, Jr. Boulevard in Tampa. Mathis and Grow were outfitted with transmitting and recording devices so that the conversations of Mathis, Coker, and Grow were recorded. Grow was introduced to Coker as Peggy Lane.3 As an undercover officer, Grow played the role of a call girl or escort. Upon meeting Grow, Coker explained that he was a physician assistant and worked with Dr. Cannata, who was an anesthesiologist. He stated that the practice included primary care, pain management, and management of anxiety and depression. He asked Grow to fill out a medical history questionnaire. She checked no to all the questions except for the use of alcohol and tobacco. Grow did not list the name of her medical doctor and told Coker that she had not seen a doctor in a long time. Coker asked Grow the reason for her visit, and the following conversation took place: Grow: I just need something to keep going. I work a lot of hours, you know, sometimes I'm up real late and then you know I get up again and, sometimes, you know, it's hard. Coker: Okay. Define keep me going 'cause I don't prescribe any kind of amphetamines or any speed or anything like Mathis: I told you doc. He, he, he's straight. Tell him you want some Zees. Coker: Tell me . . . Grow: I want some Zees. Coker: Xanax. Okay. Xanax is an anti- anxiety. Okay? Grow: Will that help like stress and stuff like that? Coker: Oh, absolutely. Grow: Okay. I think that keeps . . . Coker: Any time dealing with anxiety. It's actually a wonderful medicine and it works very well. Grow: Okay. Coker: Um, it either can be dosed, you can, like I always prescribe the bars because you can break them into four pieces or you can break them into two pieces or you can take the whole thing. It just depends on what your need is. Grow: Okay. Coker: Okay? And I have folks, you know, I tell them take it as needed. Um, but usually it's just an anxiety kind of thing, so . . . you know, you got to talk English to me otherwise I don't understand. The medical records which Coker generated for Grow contained the following notes, as they related to Grow's anxiety: CHIEF COMPLAINT: Describes being tense, on edge, tremulous, difficulty relaxing, tachycardia-palpitations, dyspnea, symptoms present for "years." * * * PLAN: advised Referral - To therapist of choice for chronic recurring anxiety Advised If hyper-ventilating, then teach "brown paper lunch bag" re-breathing technique. Avoid caffeine and plan for regular physical activity. Practicing a relaxation exercise regularly as well. Discussed stress reduction. Grow did not describe the symptoms listed above, and Coker did not give the advice listed above. Grow told Coker that she had never had any surgeries and that she had taken some of Mathis' Xanax. Coker took Grow's blood pressure, listened to her heart and lungs, and checked the glands on her neck. Coker gave Grow a prescription for Xanax and advised her not to drink, drive, or operate machinery while she was taking the Xanax. He told her the prescription included one refill and not to call him saying that she needed another refill. He told her to "[g]o get some of his (meaning Mathis)." Coker wrote the prescription for Xanax on a prescription form which had been pre-signed on the physician's signature line. During Grow's visit on August 21, 2001, Mathis asked Coker about giving him a prescription for Vicodin. Coker explained that Vicodin was the same medication as the Lortab, which he had prescribed to Mathis on Mathis' last visit. Mathis explained that the Lortab was actually for him, and Coker asked him for whom was the Vicodin. Mathis replied that it was for himself, after which the following conversation took place: Coker: Well, see I can't give them to you then 'cause I gave script for a hundred on the 17th. Grow: How about me? Coker: Yeah, I can give them for her. Mathis: Well, do that. Alright, I get, I get ah Craig hooked up. Coker: For your, your neck pain, huh? Mathis: Yeah. Coker: After the motor vehicle accident two weeks ago. There had been no mention of Grow having any neck pain until Coker stated that it was for her neck pain. There is nothing in the recorded conversation between Grow and Coker from which Coker could make a determination that Grow had neck pain resulting from a motorcycle or motor vehicle accident. Coker invented the symptoms for Grow to give support for a prescription for pain medication. Coker asked Mathis, not Grow, about the Vicodin prescription in the following conversation: Coker: Which Vicodins are we talking about here, Dee? Mathis: A stronger one. Coker: Well, if you want the tens you have to go really with the Lortabs 'cause you're going to get generic anyhow. Mathis: I'm going to get generic? Coker: Right. Mathis: As opposed to what? Coker: Well, if I wrote it for Vicodin HP, which is not generic, then you pay a lot of money. Mathis: I ain't paying it. I ain't worried about that. Coker: What I'm saying somebody's going to pay a lot of money versus . . . the thing about it is it's no difference than the generic. Mathis: Is, I mean, Craig going to be able to take of that, I'm not as far as . . . Based on the recorded conversations between Mathis and Coker, it is clear that Mathis wanted the Vicodin prescription for someone named Craig, and that Coker was going to prescribe the pain medication for Grow in order to get around the problem that it was too soon for Coker to give Mathis another prescription for pain medication. On August 21, 2001, Coker gave Grow a prescription for 50 Lortab, which could be refilled one time. The prescription was written on a prescription form, which was pre-signed on the physician's signature line. During the August 21 office visit, Grow did not see Dr. Cannata; Coker did not leave the room; and Coker did not make any telephone calls. On August 24, 2001, Grow and another undercover officer, Detective Heinz Bachman (Bachman),4 went to Diamond's Men's Club to see Coker. Both Grow and Bachman were outfitted with electronic devices that allowed the conversations during the visit to be monitored and recorded. Grow introduced Bachman to Coker as Hank Richardson. When Coker asked Bachman the reason for the visit, Bachman told him pain. Grow told Coker that Bachman wanted some Vicodin. Coker asked Bachman what kind of pain he had, the cause of the pain, and the duration of the pain. Bachman told Coker that he had injured his back a week ago while throwing a fish net. Coker asked Bachman if he had had any surgeries, was on any medication, was allergic to any medicine, or smoked. Bachman answered all the questions in the negative. Bachman also filled out a medical history questionnaire, indicating no to all the questions. Later, when he told Coker that he had back pain, the form was changed to reflect that condition. Bachman did not list the name of his medical doctor. Coker took Bachman's blood pressure and listened to his lungs and heart with a stethoscope. Bachman was requested to stand up. Coker then palpated Bachman's lower back and asked if that was where he had pain. Bachman replied that it was. Coker told Bachman that he was going to give him a prescription for pain medicine and that Bachman should take an anti-inflammatory, over-the-counter medication and put ice on his back. Coker advised Bachman that if the pain did not go away that Bachman should come back for a shot of cortisone. Coker told him not to drink, drive, operate machinery, or drive a boat while he was taking the medication. During the visit, Grow asked Coker if he could give Bachman some Xanax during the following conversation: Grow: Very cool. While's we're here can, can you give him one for Zees for me and Dee [Mathis] to take? Coker: Ah-yi-yi-yi-yi-yi-yi Grow: Can you give him some Zees? Coker: Maybe. Grow: Okay. Okay. (Laughs.) Coker: (Laughs.) Grow: Well, you gotta ask, right? Coker: Ay-yi-yi-yi-yi-yi Grow: You told me last time to ask. Bachman did not tell Coker that he was experiencing any anxiety or any symptoms of anxiety or stress. Coker did not ask what might be causing Bachman to have anxiety or describe a plan of treatment for anxiety. Coker did tell Bachman that the Xanax was for mild anxiety. It is clear that Bachman was not experiencing anxiety and that the reason for prescribing Xanax was for Grow's use and not Bachman's. Coker wrote a prescription for Bachman for 50 Lortab with no refill, and a prescription for 60 Xanax with one refill. Both of the prescriptions were written on prescription forms which had been pre-signed on the physician's signature line. During the visit, Bachman did not see Dr. Cannata, and Coker did not leave the room or discuss anything with Dr. Cannata. Bachman paid Coker $50 for the visit. On September 27, 2001, Grow went to see Coker and brought along another undercover officer, Anthony Bordonaro (Bordonaro).5 Both Grow and Bordonaro were outfitted with electronic devices that allowed the conversations during the office visit to be recorded. Grow told Coker that she was there for refills of her prescriptions. Coker asked her how her back and neck were, to which she replied the "same." He asked if she were okay with her medications and she said "Love 'em." Coker took Grow's blood pressure and listened to her heart. He felt her neck and palpated her back. Coker found a knot in her back area, and suggested that she have some massage therapy, stating that he was also a massage therapist. He wrote prescriptions for Grow for 45 Xanax with one refill and for 50 Lortab with one refill. Coker asked Bordonaro his height and weight. Bordonaro stated he was not taking any medications and that he was allergic to penicillin. He told Coker that he piloted tug boats, had hurt his arm in a fall on a boat, and had to have surgery on his arm five years ago, resulting in a screw being placed in his arm. Bordonaro stated that he had no other medical problems. He denied smoking, but indicated he did drink alcohol. When Coker asked Bordonaro what was the purpose of the visit, Bordonaro said that he wanted some Vicodin, which he had taken when he had hurt his arm. According to Bordonaro, it was "some good stuff." Coker's computer medical notes for Bordonaro's visit indicate that Bordonaro was currently taking pain medication; however, Bordonaro did not indicate that he was currently taking any pain medications. Coker took Bordonaro's blood pressure and listened to his lungs. Coker told Bordonaro that his blood pressure was high. Bordonaro told Coker that the last time that he had gone to his doctor in Pensacola, his blood pressure was 112/80. Coker told Bordonaro that they would keep an eye on his blood pressure. When Coker asked Bordonaro what he did that caused pain in his arm, Bordonaro replied, "Like all in, all in here." Coker had him lift his wrist up and down, spread his fingers apart and push them together, and touch his thumb and little finger. Coker wrote Bordonaro a prescription for 50 Vicodin with one refill. Vicodin contains Hydrocodone, which is a Schedule III controlled substance. Coker told Bordonaro to avoid doing anything that would exacerbate the pain and not to drink, drive, or operate any machinery while taking the medication. The prescriptions that Coker wrote for Grow and Bordonaro on September 27, 2001, were written on prescription forms which were pre-signed on the physician's signature line. Dr. Cannata was not present during the office visit, and Coker did not leave the room or make any telephone calls during the visit. Coker charged Bordonaro $100 for his and Grow's visit. On November 15, 2001, Grow returned to see Coker and took along undercover officer Donald Bowling.6 Both officers carried electronic devices that allowed the conversations during the visit to be recorded. Grow indicated that she was there because she wanted refills on her Lortab prescription. Coker asked her how she was feeling, to which she replied, "Oh, pretty good." When asked about her neck, Grow told Coker that it was about the same. Coker asked if ever got any better, and she told him it did, but that sometimes she slept funny. Coker took Grow's blood pressure, listened to her heart, and felt her neck. He asked Grow her weight and height. Coker indicated that she could get her medications from him, rather than getting prescriptions and having them filled at a pharmacy. He gave her a bottle of 100 Hydrocodone and a bottle of 180 one-milligram tablets of Alprazolam, the generic name for Xanax. He told her to take two of the Xanax instead of one because the dosage was smaller. When Coker asked Bowling the reason for his visit, Bowling told him that he had injured his knee in high school and that the knee would get really sore every now and then. He said that when he bent his knee he could feel something, but he did not know how to describe it. Bowling said that someone wanted to do a "scope thing" on his knee and that he had refused. Coker took Bowling's blood pressure and listened to his heart. Coker had Bowling lie down on the examination table. While Coker felt around Bowling's knee, he asked where the pain was. Bowling said that he could feel the pain when he was moving in a certain way. Coker had him tighten his muscle and lift his leg. Coker advised Bowling that his condition was early wear and tear on the knee, which was common. The condition, Coker said, would come and go. Coker told Bowling that in addition to taking the pain medication, he should take over-the-counter, anti-inflammatory medications such as Ibuprofen and Aleve. He told Bowling to put ice on the knee and to avoid actions that would tend to make the knee worse, such as squatting on the knee. Coker asked Bowling his height and weight. When asked by Coker, Bowling said that he had not had any major surgery and was not allergic to any medication. He told Coker that his father had recently been diagnosed with colon cancer. Bowling said that he smoked tobacco and drank alcohol. During the visit Grow told Coker that Bowling wanted some Zees. After examining Bowling, Coker asked, "You said you wanted Xanax also?" to which Bowling replied "Yes. Please." There was no other mention of a reason for giving Bowling Xanax. In Bowling's medical records, Coker indicated that Bowling had "Anxiety syndrome (tense or nervous)"; however, Bowling never said that he had anxiety or was tense or nervous. Coker gave Bowling a bottle of Alprazolam and a bottle containing 100 Hydrocodone tablets. Bowling paid Coker $310 for his and Grow's visit and medications. Dr. Cannata was not present during the visit of Grow and Bowling on November 15, 2001. Coker did not leave the room or contact Dr. Cannata during the visit. On December 13, 2001, Bordonaro went to see Coker to get a refill of his pain medication. Bordonaro carried an electronic device which allowed their conversation to be recorded. Even though Coker had told Bordonaro during their last visit that Bordonaro's blood pressure was high, Coker did not examine Bordonaro or take his blood pressure. Coker asked Bordonaro how he was doing, and Bordonaro replied, "Good. Good." After explaining the difference between Vicodin ES and Hydrocodone, Coker gave Bordonaro a bottle of 100 Hydrocodone tablets, and charged Bordonaro $115 for the visit and medication. On January 11, 2002, Bordonaro visited Coker at an adult club to get more medication. Again, Bordonaro wore a device which allowed the conversation to be recorded. He told Coker that he was having to take more of the Vicodin and asked if he could get something stronger. Bordonaro also asked if he could get some Xanax. At first, Coker told him no, but then gave him a form and told him to place a checkmark by everything that applied to him. Bordonaro checked the first three items on the form and gave it back to Coker. Coker did not discuss with Bordonaro any symptoms of anxiety that Bordonaro checked on the form or any plan of treatment for anxiety. Coker did not perform an examination of Bordonaro. Although Coker's computer-generated medical records for Bordonaro's January 11 visit indicate that Bordonaro's blood pressure was taken, it was not. Coker gave Bordonaro a bottle of 100 tablets of Hydrocodone/Acetaminophen, and a bottle of 90 Alprazolam bars for anxiety. Coker did not contact Dr. Cannata during the visit. The total charge for the visit and medications was $155. On February 12, 2002, Bordonaro returned to see Coker to get refills of his pain medication. The undercover officer wore an electronic device which allowed the conversation to be recorded. Bordonaro told Coker that the pain pills he had gotten at the last visit were not working and asked if he could get something stronger. Coker told him that he could write a prescription for Percocet, but that Bordonaro would have to get it filled at a pharmacy. Coker suggested that he get the prescription filled at Wal-Mart or Target because those pharmacies are not computer interconnected as Eckerds and Walgreens are. Coker gave Bordonaro a prescription for 100 Percocet with no refills. Percocet contains Oxycodone, which is a Schedule II controlled substance. Coker wrote the prescription on a prescription form which was pre-signed on the physician's signature line. Coker did not examine Bordonaro during the visit. Although Bordonaro complained that the pain medication that he had been given on his last visit was not working, Coker put in Bordonaro's medical records that Bordonaro was "[d]oing well with current medication and treatment plan." Coker asked Bordonaro if he wanted the Xanax medication refilled, and Bordonaro replied that his girl was out of town so he did not need the Xanax. Bordonaro paid Coker $75 for the visit. On April 25, 2002, Bordonaro again visited Coker for the purpose of getting refills of his medications. Again, Bordonaro wore a device which allowed the conversation to be recorded. Coker gave Bordonaro 120 tablets of Hydrocodone, the generic for Lortab, and 90 bars of two-milligram Alprazolam for anxiety. Bordonaro asked if he could double up on his medication, and the following conversation took place: Coker: No. Bordonaro: No? Coker: That's what I have to tell you. Bordonaro: Okay. Coker: Remember with these don't drink, drive, operate any machinery while you're taking it. Don't mix with other medicines or share them with anyone else. When Coker told Bordonaro that he could not double up on the medication, Coker winked at Bordonaro. Bordonaro was not examined on the April 25 visit. Coker charged Bordonaro $165 for the visit and medications. John Barsa, M.D., a board certified physician in pain medicine, testified as an expert witness on Coker's behalf. Dr. Barsa practices in the Tampa area. Approximately nine or ten years ago, Dr. Barsa employed a physician assistant for about six months to one year. He currently employs three nurse practitioners. Dr. Barsa gave his opinions on the care that Coker provided to the undercover officers. However, his opinions were based in part on the medical records made by Coker. Much of those medical records do not accurately reflect what occurred during the visits of the undercover officers. Herly Ramos, P.A.-C., is a physician assistant and has passed the national board certification examination for general medicine. He is presently employed as a surgical assistant. Previously he practiced for nine years with the Orlando Orthopedic Center, which is primarily an orthopedic practice. While with the Orlando Orthopedic Center, Mr. Ramos routinely took medical histories, performed physical examinations, made assessments, developed treatment plans, did discharge evaluations, and wrote progress reports. A large component of the orthopedic practice involves evaluating patients for complaints of pain. Common orthopedic ailments include back or neck pain, extremity pain from strains, sprains, or fractures. The first line of treatment for such ailments includes nonsteroidal, anti-inflammatory drugs, muscle relaxers, and physical therapy. Patients with fresh fractures or other conditions involving severe pain often require narcotic analgesics or controlled substances. Mr. Ramos credibly opined on the standard of care for a physician assistant in evaluating a patient on the initial visit and follow-up visits. It is his opinion that when performing an initial evaluation of a patient complaining of pain, a detailed medical history should be taken, and a thorough physical examination should be conducted. The medical history should include a personal medical history, social history, family medical history, allergies, surgical history, name of current physician, current medications, review of systems, and any diagnoses. According to Mr. Ramos, the initial physical examination for a patient complaining of pain should include taking the patient's vital signs (blood pressure, pulse, respiration, and temperature), heart and lung examination, assessment for any obvious abnormalities, examination of the abdomen, and a detailed examination of the portion of the body about which the patient is complaining. During the physical examination, the physician assistant should be looking for anything that might indicate a cause for the patient's complaint. A limited examination is a less detailed examination, and it is Mr. Ramos' opinion that a limited examination is indicated when the physician assistant is treating the patient for a recurring complaint and wants to determine if there was any interval change. Dr. Barsa and Mr. Ramos agree that a physician assistant could recommend to the supervising physician that controlled substances be prescribed for a patient, but that a physician assistant could not prescribe controlled substances for a patient. It is the opinion of Dr. Barsa that a physician assistant who prescribes controlled substances is practicing beyond the scope permitted by law for a physician assistant. According to Dr. Barsa, the prescribing of controlled substances should be based upon a clear documentation of unrelieved pain that is unmanageable with simple Tylenol or aspirin. For example, it would be a violation of the standard of care to prescribe a controlled substance for neck pain when the patient has no complaints of neck pain. Mr. Ramos credibly opined that Coker's treatment of the undercover officers fell below the level of care, skill, and treatment which is recognized by a reasonably prudent physician assistant as being acceptable under the conditions and circumstances.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered finding James Coker guilty of violating Subsections 458.331(1)(t), 458.331(1)(q), 459.331(1)(nn), and 456.072(1)(o) and Florida Administrative Code Rule 64B8-30.008, and revoking his license as a physician assistant. DONE AND ENTERED this 31st day of October, 2003, in Tallahassee, Leon County, Florida. S SUSAN B. KIRKLAND Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 31st day of October, 2003.
Findings Of Fact At all times relevant hereto, Respondent, Jaime Benavides, held medical doctor License No. 10189 issued by Petitioner, Department of Professional Regulation, Board of Medical Examiners. He currently resides at 1201 South Main Street, Belle Glade, Florida. Respondent is a graduate of the University of Pennsylvania Medical School and entered the U.S. Navy in 1949. He retired from the Navy in 1966 1/. His last duty assignment was as chief of orthopedics at the Navy hospital in Key West. He was board certified as an orthopedic surgeon in 1961 and is a Fellow of the American Academy of Orthopedic Surgeons. He has also received the Physician's Recognition Award every three years for continuing education studies and was president of the Florida Orthopedic Society for several years. Since June, 1980, he has been practicing in Belle Glade, where he is vice-chief of staff at Glades Hospital. In 1973, Robert Greene was initially treated at Respondent's clinic in Marathon, Florida. Respondent's office was in Key West, but he provided medical services at a clinic in Marathon on Tuesday of each week. Greene had suffered a wrist injury while in the service and reinjured it while employed at a grocery store in Marathon. Greene was initially treated by Respondent's associate, Dr. Schaubel, and eventually had a bone graft placed in his wrist in January, 1974, by both physicians. Schaubel prescribed Demerol for Greene and in June, 1974, Respondent began prescribing Dilaudid for pain. Between January 1, 1976, and October 4, 1976, Respondent wrote prescriptions for 3,041 Dilaudid tablets of 4- milligram strength and 518 Dilaudid tablets having 2-milligram strength. The maximum amount of Dilaudid consumed by Greene during any period of time was 10 tablets per day, with each having 4-milligram strength. During this same period of time, Greene had three additional operations on the same wrist. The second operation involved a silicone implant, the third a replacement of the implant, and the fourth replaced a bone in his wrist and realigned the implant to its proper place. A scheduled fifth operation never took place. After the third operation, Greene told Respondent he believed he was becoming addicted to the drug. Respondent "detoxed" Greene prior to the fourth operation, but Greene later requested more drugs because of the intense pain in his wrist and his inability to work as a fisherman, which required that he lift lobster traps weighing more than 125 pounds. Respondent attempted on a number of occasions to cut back the dosage, but Greene could not stand the pain and always requested that the medication be continued. Although Respondent prescribed a large number of tablets in the first 10 months of 1976, Greene did not actually ingest all the tablets since his prescriptions were lost or stolen on "numerous" occasions, thereby necessitating the obtaining of a new prescription from Respondent on each occasion. This was confirmed by testimony from the patient. Some of the prescriptions were obtained by Greene when Benavides was on rounds at the hospital or at his home and did not have his medical records present. Respondent conceded the amount of dosage was high, but said the patient had a low threshold for pain and could not support his family unless he was able to work as a fisherman. Based on the seriousness of the injury, he concluded that only Dilaudid was effective in taking care of the pain, particularly since in 1976 there were no other oral medications that were equally satisfactory. According to the 1982 Physician's Desk Reference (PDR), the following instructions appear relative to the use of Dilaudid: The oral route of administration is effective for the treatment of moderate to severe pain. The usual oral dose is two milligrams every four to six hours as necessary. The dose must be individually adjusted according to severity of pain, patient response, and patient size. More severe pain may require three to four milli- grams every four to six hours. If the pain increases in severity or relief is not ade- quate or a tolerance occurs, a gradual in- crease in dosage may be required. (p.1009) The prescriptions given by Respondent, excluding those that were lost or stolen, were consistent with this PDR instruction. An expert retained by the Department, Dr. John R. Mahoney, a board certified orthopedic surgeon, characterized the amount of Dilaudid prescribed for Greene as an "enormous amount" and "far in excess" of what his condition indicated. However, he did not take into account the fact that large amounts were never ingested by the patient since they were lost or stolen. He considered the maximum accepted daily dosage to be 12 to 16 milligrams per day for short periods of time. He conceded that larger amounts could be taken under certain circumstances. It was his opinion that Respondent's conduct in treating Green deviated from the standard of care expected from an orthopedic surgeon. Mahoney did not dispute the recommendations of the PDR on prescribing Dilaudid. He also agreed that preventing addiction by a patient is a great problem and one that is "not manageable on an individual physician's part." Michael Aulting was injured in a motorcycle accident in 1974 and suffered a fractured dislocation of his left hip. He subsequently developed a traumatic arthritis. It is unclear when Respondent began treating Aulting, but Respondent eventually performed a total hip replacement on Aulting. This was followed by the removal and replacement of a new prosthesis due to an infection and a similar procedure some two years thereafter. The exact dates of surgery were not disclosed. During the period October 2, 1975, through February 16, 1979, Benavides prescribed the following drugs for Aulting: 10/2/75 20 Dilaudid 2 mg. 11/3/75 28 Dilaudid 2 mg. 11/10/75 20 Dilaudid 2 mg. 1/10/76 45 Dilaudid 4 mg. 1/12/76 28 Dilaudid 4 mg. 5/14/76 28 Dilaudid 2 mg. 5/23/76 56 Dilaudid 2 mg. 5/30/76 46 Dilaudid 4 mg. 6/14/76 21 Dilaudid 4 mg. 6/16/76 21 Dilaudid 4 mg. 7/25/76 24 Dilaudid 4 mg. 9/16/76 30 Tuinal 100 (?) 9/17/76 30 Parest 400 (?) 9/26/76 45 Parest 400 (?) 10/11/76 21 Parest 400 (?) 10/14/77 50 Percodan (strength unknown) 11/15/76 50 Percodan (strength unknown) 11/26/76 50 Percodan (strength unknown) 12/11/78 40 Percodan (strength unknown) 12/19/78 50 Percodan (strength unknown) 12/29/78 50 Percodan (strength unknown) 1/15/79 50 Percodan (strength unknown) 1/22/79 50 Percodan (strength unknown) 1/26/79 40 Percodan (strength unknown) 2/12/79 30 Percodan (strength unknown) 2/16/79 50 Percodan (strength unknown) Aulting claimed he lost his prescriptions on several occasions. Whether any of the above were duplicate or backup prescriptions was not disclosed. Benavides described Aulting as having a low pain threshold and a fairly high tolerance to medication. Given this and the severe hip injury and associated operations, he felt the medications for Aulting were reasonable. He also believed that Aulting may have been "feigning" pain at times, and on these occasions, he would turn down his requests for more drugs. After his treatment of Aulting had ceased, he learned that Aulting may have stolen blank prescription pads from his office and forged his signature to obtain drugs. The expert retained by the Department considered the amount and level of drugs given to Aulting to be unacceptable and below the standard of care expected of an orthopedic surgeon in treating a patient with Aulting's condition. In reaching this conclusion, he relied principally upon the prescriptions written on June 14 and 16, 1976, and January 22 and 26, 1979. However, the strength of the drugs prescribed on the latter two dates was not disclosed. Dilaudid is a Schedule II narcotic pain killer and has addictive qualities. Percodan has similar characteristics. Tuinal is a nonnarcotic barbiturate with habituating qualities. The characteristics of the drug Parest were never disclosed. The Department began its investigation of Benavides in 1976 when it investigated Benavides' treatment of Aulting. In early September, 1977, the Department again sent investigators to Key West to draw a profile of Respondent in treating Greene. A report as to Greene was prepared on September 16 for the Board of Medical Examiners. No action was taken by the Department until April, 1982, when the administrative complaint was issued. No explanation was given as to why it took almost five years to formalize the charges and file a complaint.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that all charges against Respondent be DISMISSED. DONE and ENTERED THIS 18th day of November, 1983, in Tallahassee, Florida. DONALD R. ALEXANDER Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings 18th day of November, 1983.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is recommended that the Board of Medical Examiners enter a final order dismissing the charges against Dr. Santos on the merits and with prejudice. DONE and ENTERED this 30th day of March 1984, in Tallahassee, Leon County, Florida. J. LAWRENCE JOHNSTON Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 FILED with the Clerk of the Division of Administrative Hearings this 30th day of March 1984.
