The Issue The issue is whether the Respondent violated Subsections 458.331(1)(1), (n), (q), and (t), Florida Statutes, as alleged in the administrative complaint.
Findings Of Fact A. BACKGROUND Dr. Song is a licensed physician in the State of Florida, having been issued license number ME 0033410, and was so licensed at all times material to this proceeding. Dr. Song is a Board certified member of obstetrics and gynecology. Dr. Song is of Korean origin and was naturalized as an American citizen in 1978. He was graduated from Seoul Catholic Medical College in Seoul, South Korea, on February 16, 1963. From 1963 to 1967, he served in the South Korean Army as a medical officer. He interned at Howard University Medical School, Washington, D.C. for one year. He was a surgical resident at St. Peters General Hospital, New Brunswick, New Jersey. He changed his specialty from general surgery, to a residency in obstetrics and gynecology at Allentown Hospital from 1969 to 1972. He worked as an emergency room physician at Holy Redeemer Hospital, Jenkintown, Pennsylvania from October 1972 until August, 1974. He joined the U.S. Navy on September 1, 1974. He was transferred to Naval Regional Medical Center, Orlando, Florida, where he served from August 1976 until September, 1981, and received an honorable discharge from the United States Navy in 1981. He then began a solo private practice in Orlando, Florida. He was on the staff of Florida Hospital in Orlando from at least 1982 until 1985 and was on staff there for all times material to this proceeding. Dr. Song was the primary physician who treated the seven patients in question during their pregnancy, labor and delivery. Respondent at all times material to this proceeding has been licensed in the State of Florida. (Pet. No. 21) Patient 178793 Patient 178793, a 27 year old white female, was admitted at approximately 12 o'clock midnight to Florida Hospital in active labor for her first delivery on February 7, 1983 (Pet. No. 20, p.6; T.37-38). Respondent was the admitting physician (Pet. No. 4). The patient was fully effaced in a vertex presentation and dilated to 9 cm. at 8:30 a.m. and was fully dilated by 9:45 p.m. The patient was transferred to the delivery room at 10:10 p.m. where the attending nurses and Dr. Song encouraged her to push; however, the baby only progressed .5 to 1 cm. from 8:30 to 10:30 a.m. (Pet. No. 22, p.11). Respondent delivered the patient by mid- forceps at 10:53 p.m. (Pet. No. 20, p.7,9). At the time she was delivered she had been in labor from 1.5 to 2.5 hours. According to the nursing notes, Petitioner's Exhibit 4, at 7:40 a.m. the internal fetal heart monitor failed to work. No explanation is given in the nurse's notes about what was done to correct the problem. At 9:00 a.m. the IV which had been hung at 8:15 a.m. began to infiltrate (move into the tissue surrounding the site at which the needle is inserted) and as a result, the IV was discontinued. The patient was given oxygen between 9:00 and 9:30 a.m., at which the fetal heartbeat had decelerated to between 90 and 100. The normal range for a fetal heartbeat is between 110 and 180 (T. 51). Concurrently, the internal heart monitor was reported to have failed again and could not be made to work although the electrode was changed three times. The external monitor was reapplied. At 9:45 a.m. the fetal heart rate is indicated to have decreased during a contraction. Also at 9:45 a.m. the IV was restarted in the left arm. The spontaneous delivery of the patient halted between 9:30 and 10:00 a.m. This resulted in fetal stress as indicated in the decrease in heart rate. The problem was most probably caused by the baby's shoulder becoming hung on the mother's pelvis. A primary indicator of fetal stress, the fetal heart monitor, was not working and there were problems with maintaining the mother's IV, an important matter if an emergency cesarian section were necessary. See Fetterman Deposition, Page 55, et seq. Under these circumstances, the ,Respondent decided to intervene by delivering the baby using mid-forceps. "Low and mid" modifying forceps reference the position of the top of the baby's head as it is coming through the birth canal. The definition involves a measurement of the distance in centimeters from a location in the birth canal. The definition involves a measurement of the distance in centimeters from a location in the birth canal referred to as the Ischial Spine. High-forceps situations are outside the accepted standard of care in modern obstetrics. The generally accepted standard of care allows forceps deliveries with the use of low-forceps and mid-forceps. Mid-forceps are permissible from positions 0 to plus 2. Mid-forceps are only indicated where there is maternal or fetal distress or where the patient has a protracted second stage of labor in excess of two hours. (Pet. No. 22, p.14-15). The baby had forcep marks on the cheek near the orbit of the right eye. The left earlobe and left neck were injured. The neck injury was described as a shearing injury by Dr. Stone in his report. (Pet. No. 4; 5; 6; 20, p.11). In addition, the baby's left arm was weak and it had a large caput succedaneum of the head due to molding of the head from a long, forceful labor. Fetterman Deposition, Page 97, line 18 et seq. The forcep marks on the face indicated a less than optimal application of the forceps; however, forcep marks are to be expected in a delivery and or by no means unusual or reflect poor practice. The injury to the left neck could not have been made by the forceps. Fetterman Deposition, Page 44, line 14. The mark on the neck and the weakness resulted from the traction needed to deliver the shoulder. Fetterman Deposition, Page 98 and 99. This together with the caput succedaneum indicates that the spontaneous delivery had arrested and justifies the Respondent's decision, particularly in the absence of a heart monitor strip due to equipment failure, to use mid-forceps to deliver the patient who had had a difficult labor of approximately two hours duration. Apgar scores are a means by which newborn babies are rated as to their overall health. Apgar scores are given at one minute after birth and five minutes after birth. The range is from 1 to 10, with 10 being the best. Patient 178793's baby had Apgar scores of 8 at one minute and 10 at 5 minutes. Patient 145489 Patient 145489 was admitted by Dr. Henry Bruce, a psychiatrist, to Florida Hospital between February 1, 1983 and March 10, 1983 for a diagnosed personality disorder and substance abuse (Pet. No. 19, p.8). Respondent had been patient 145489's physician since 1982 (T. 129). Patient 145489 was in her second pregnancy during the time she was treated by Dr. Song. Patient 145489 was in Florida Hospital from April 17, 1984 until April 18, 1984 under Dr. Song's care for possible overdose of drugs. The April 17, 1984 admission was by her husband, with whom she was having marital difficulties, who reported that she had taken a drug overdose. The clinical findings and observations reported in the records do not support the claim of an overdose. The husband brought to the hospital many medications, only part of which had been prescribed by Dr. Song. The patient was admitted on April 24, 1984 for labor and delivery of her second child. (T. 140). She was discharged on April 27, 1984. The Respondent is charged with over prescribing controlled substances without sufficient medical justification to the patient during this pregnancy. The Respondent's records reflect regular prenatal examinations, and various treatment for the patient's sundry complaints over her pregnancy. Patient 145489 was prescribed 80 tablets of Parafon Forte, a muscle relaxant for back pain, on January 4, 1984 by Dr. Song. Patient 145489 was prescribed 100 mg. Seconal #15 on January 17, 1984, for aid in sleeping, by Dr. Song. Additional prescriptions' of 100 mg. Seconal #15 were made by Dr. Song on February 1, 1984 and 100 mg. Seconal #12 on March 26, 1984 for aid in sleeping. Patient 145489 was prescribed .05 mg. Valium #15 on January 17, 1984, by Dr. Song. Valium is recognized both as a muscle relaxant and tranquilizer. Both uses were appropriate if the patient was a pregnant addict. Drs. Yelverton and Adler criticized Dr. Song's failure to refer this patient to an orthopedic specialist for consultation on the cause of her low back pain. Dr. Song was concerned about the propensity for his patient to abuse drugs and in 1984 referred patient 145489 to another psychiatrist, Dr. Michael Gutman, a Board certified psychiatrist and head of the psychiatry unit at Florida Hospital at that time. Patient 145489 was generally an uncooperative and difficult-to-manage patient. Dr. Song did not send patient 145489 to an orthopedic specialist because an orthopedic specialist would not have been able to ascertain any better diagnosis of the patient than Dr. Song without the use of x-rays which were contraindicated at her stage of pregnancy. The utility of seeking a consult with an orthopedic specialist was disputed by Dr. Fetterman, who stated that low back pain is a common complaint with pregnant woman. Dr. Fetterman's expert testimony was that there was no deviation in the standard of care with regard to Dr. Song's treatment of patient 145489. The amounts of medication prescribed and the intervals between their prescription indicates that Dr. Song was aware of the woman's drug abuse problem, was providing her appropriate medications in appropriate amounts based upon her complaints which were medically reasonable. Dr. Song did not prescribe excessive amounts of controlled substances to the patient or prescribe any controlled substances to her without sound medical indications. Dr. Song properly examined, diagnosed and treated patient 145489. Dr. Song did keep records with regard to prescription of drugs in her case and gave medical indications for the prescription of these drugs. Patient 276960 Patient 276960 was a 23 year old white female in her third pregnancy without having given birth, the prior two pregnancies having been terminated by abortion. She saw Dr. Song initially on November 3, 1983, and was seen regularly by him until March 9, 1984. Her records do not reflect she was seen by him again prior to her admission by Dr. Song to the hospital on May 10, 1984 for a Non Stress Test. The records of this admission and Dr. Song's office records are at the back of Petitioner's Exhibit 3. In Petitioner's Exhibit 3, "The History and Physical," Dr. Song notes in the patient's history dictated on June 9, 1984 after her delivery by caesarian section on June 5, 1984, that "A twin pregnancy was accidentally found out last month, which is out(sic) the middle of May because of a large abdomen and supposedly she is overdue and came in for partial induction. The twin pregnancy was found out at the time, and sonography done, biparietal diameter, with one at 35 weeks, and the other one at 37 weeks. It was decided not to do any more induction, and weight(sic), and she came in for active labor. She was followed up and taken care of in early pregnancy, and no remarkable obvious problems were noticed during pregnancy." (Emphasis supplied.) Dr. Song testified that he had trouble being understood by medical transcribers. Problems with transcription of his dictation, as well as Dr. Song's use of English, are evident in the quoted section. Dr. Song indicated that his pronunciation of "possible" was frequently transcribed as "partial." The Department's experts concluded after examination of the hospital records that Dr. Song had attempted to induce labor in this patient without ascertaining at what point she was in her pregnancy are based upon this document. They also concluded that Dr. Song should have determined that the patient was pregnant with twins, and that failing in this and attempting to induce labor was not professionally acceptable practice. The nurse's notes reflect that the patient was admitted at 1:00 p.m. on May 24, 1984 for a "NON STRESS TEST." The hospital record includes a release executed on May 24, 1984 from the patient to conduct a "NON STRESS TEST." The nurse's notes reflect that the non stress test (NST) was conducted in connection with ultrasound examination. See Petitioner's Exhibit 3. The Nurse's notes regarding these procedures state in part, "Fetus active-hard to get Ext. tracing but by constant observation & holding fetal ultrasounded-fetus reactive-3 movement in 15 m lasting 15 sec. acceleration 5 bpm-Dr. Song notified and pt sent home[.]" See Petitioner's Exhibit 3. There is no reference in the nurse's notes to administration of any drugs during the May admission. See Petitioner's Exhibit 3. The discharge record for the May admission reflects Dr. Song had discovered a twin pregnancy and discharged the patient at approximately 1:15 p.m. See Petitioner's Exhibit 3. There is nothing contained in the May notes and records which would indicate that the purpose of the May admission was to induce labor. See Petitioner's Exhibit 3. Dr. Song's patient history written in June led to speculation that Dr. Song had admitted the patient in May to induce labor and had stopped when he accidentally discovered the twins. The facts do not support this speculation. Petitioner's proposed findings, paragraph 27, reference administration of 10 units of Pitocin. All records for the May admission contained in Petitioner's Exhibit 3 were searched and none of these records reflected the administration of Pitocin. The purpose of Pitocin is to induce contractions. Nurse's notes for the May admission make no reference to contractions. No drugs were administered to the patient during the May admission. The patient was not in labor in May for several hours before induced labor was stopped. She was examined and discharged in approximately 15 minutes. It was not unprofessional for Dr. Song to have missed finding the twin pregnancy by March 9, 1984, the patient's last visit to Dr. Song prior to the non stress test. Many twin pregnancies are not discovered until sonograms are performed, as in this case. See Fetterman Deposition, Respondent's Exhibit 3. The patient was admitted on June 5, 1984 in active labor and was delivered by caesarian section of twins, one boy and one girl, without incident. Patient 199111 Patient 199111 was admitted on November 13, 1982. Respondent was the admitting physician (Pet. No. 12). She arrived in labor and was 7 to 8 centimeters vertex presentation at 0 station. At 4:45 a.m. she was in active labor (Pet. No. 20, p.46). Patient was fully dilated at 5:00 a.m. and Respondent delivered by use of low forceps at 5:25 a.m. (Pet. No. 20, p.47, 50; Res. No. 3, p.60). Though the use of low-forceps is considered a safe modality when medically indicated and properly used, low-forceps should still be used only when there is a medical need (Pet. No. 22, p.51). The principal criticism of the care rendered to patient 199111 by Dr. Song is that he performed a forceps delivery, allegedly without any medical necessity. The patient record does reflect the existence of a thick green meconium amniotic fluid which is indicative that there was fetal distress either at the time noted or in the past (Pet. No. 20, p.48). Other than this, the record reflects that the patient was progressing normally and the monitor was normal (Pet. No. 20, p.48-49). The pea soup meconium was an indication that the fetus had had or was having a difficulty and that under this circumstance this patient had to be delivered with the utmost speed. The option to have a cesarean would take to long, even if all preparations had been made. Deposition of Dr. Fetterman, Respondent's Exhibit 3. DPR's own witness, Dr. Stone, noticed the same pea soup meconium and stated: " I can understand the obstetrician getting rather nervous and possibly doing a low forceps." Dr. Song testified to having been aware of this pea soup meconium and that it was an indication that the baby was in acute distress and that a low forceps delivery was in fact indicated. The condition requiring a medical necessity was present in this case and justified the Respondent's actions which were within accepted medical practice. Patient 274312 Patient 274312, a 19 year old female as admitted to the hospital on April 8, 1984 for labor and delivery (T. 222). Respondent was the admitting physician (Pet. No. 15). The principal complaint against the Respondent in the case of patient 274312 was that Dr. Song allegedly attempted to deliver a footling breech vaginally, was not prepared to deliver the baby by C-section and that this is a violation of the standard care. Respondent states in his Clinical Resume dated April 12, 1984 that "an x-ray was taken to rule out small pelvis or abnormal position of breech presentation. It turned out one leg extended frank breech and the other leg was a complete position." (Pet. 15, p.104: Clinical Resume dated 4-12-84). Dr. Song's notes for April 11, 1984 make the same comment about the position of the legs of the fetus. A complete breech presentation is where the bottom of the fetus is down and the feet are around the buttocks (T. 226). A footling breech is where the baby presents feet first (Pet. No. 22, p.59). Patient was admitted at 12:05 a.m., an x-ray taken at 12:25 a.m., and a mini-prep was done prior to 1:00 a.m. An IV was started just after 1:00 a.m. and an abdominal preparation done at 1:15 a.m. Dr. Song directed preparations for a C-section and the patient was fully prepared for a possible C-section at 1:15 a.m. According to the nurses notes, the patient did not reach full dilation prior to Dr. Song's decision to deliver her by C-section at approximately 4:20 a.m. when the patient had dilated to nine centimeters. See Pet 15, nurses notes, pages 115,116. (Pet. No. 22, p.62). Respondent was trying to permit the patient to deliver vaginally, however because of fetal distress he delivered the patient by cesarean section. Mother and baby progress normally and were discharged on April 12, 1984. (Pet. No. 19, p.57; Pet. No. 22, p.59). All the testimony indicates that footling breech presentations are too dangerous to attempt vaginal delivery unless there is rapid, spontaneous descent of the fetus. It is within acceptable standards of care in obstetrics to attempt vaginal delivery of frank breech or partial footling breech provided there is no fetal distress. (Fetterman Deposition: Page 90, line 6-23.) Dr. Marley's opinion was similar to that of Dr. Fetterman. She opined that a complete breech can be delivered vaginally provided you have adequate cervical dilation. Dr. Yelverton, who indicated his preference for a cesarean-section when confronted with a complete breech, indicated that in the case of complete and incomplete breech presentations there was controversy within the obstetrical community about proper method of delivery. There is no evidence in this case that the fetus was in other than a partial footling, partial complete breech. Dr. Song was the only witness who actually was present at the delivery in question and saw patient and the x-rays showing the presentation of the fetus. His descriptions of his findings dictated prior to the complained of conduct reflect a partial footling, partial complete breech. The x-ray report, referred to by Dr. Song, in his summary was not made available by the Department of the Navy, which was the custodian of the medical records of this patient who was a Navy dependent. Asked to articulate an opinion as to whether or not Dr. Song departed from the standard of care in doing this particular cesarean section, Dr. Stone replied that his personal choice would have been to perform a cesarean section sooner; however, he indicated that there were minorities of opinion which might differ with his. Dr. Stone believed that adequate preparation for an emergency had been made by Dr. Song. The evidence in this case indicates that the presentation of the fetus in question was a combination of footling and complete. Attempted vaginal delivery of a partial footling, partial complete or frank breech presentation is appropriate unless there is fetal distress. Caesarian section is indicated if there is fetal distress. Dr. Song did not attempt to deliver a footling breech vaginally, was prepared to deliver the baby by caesarian section, delivered the baby by caesarian section when fetal distress was noted, and did not violate the standard of care in treating this patient. Patient 196663 Patient 196663 was admitted to the hospital at 7:15 a.m. on November 10, 1982. in early labor with ruptured membranes. (Pet. No. 20, p.53; T. 238). The patient was transferred from the Navy Base Hospital on that date and had not been previously seen by the Respondent. (Pet. No. 13, T. 238; Pet. No. 20, p.53). The first page of Petitioner's Exhibit 13 indicates that the patient had a uterine pregnancy, 37 weeks; premature rupture membrane and labor; and postpartum bleeding. The same exhibit reflects delivery by low forceps. The records of the patient's treatment at the naval hospital reflect that the patient was VDRL reactive which means the patient had syphilis antibodies. On 4-8-82 the husband reported that she had been treated. On 7-20- 82 the patient was given penicillin for VD and a retest of VDRL was planned. On 7-23-82 a second RPR (VDRL) was conducted and FTA was ordered. On 8-3-82 penicillin (2,400,000 units x 3 was ordered. These records were attached to the patient's records when she was transferred to Dr. Song's care. See Petitioner's Exhibit 13, page 8. The Dr. Song's patient record indicates that on November 4, 1982 Respondent ordered a confirming test (RPR) upon the patient's next visit. Instead the patient entered the hospital in labor on November 10, 1982. At 8:00 p.m. on November 10, 1982 the Respondent ordered an FTS-ABS for the following morning. (T. 244; Pet. No. 13). Upon the baby's birth, mother and baby were released from the hospital and Respondent's care. Based upon the fact that the patient was transferred from the navy hospital and the patient's medical records were obtained from the Navy, presumably, the patient received after care from the naval medical facility which had made the original determination that the patient had a positive VDRL. Respondent recalled, at hearing, that the test came back negative and, therefore, no penicillin was given to the baby (T. 242, 244). Although the patient records are void of any notation that indicates that Respondent in formed the pediatrician of the FTA-ABS test results (T. 246), it would have been meaningless for Dr. Song to have advised the naval doctors of information which they knew prior to Dr. Song seeing the patient. The principal criticism of the care rendered to patient 663 by Dr. Song is that he performed a low forceps delivery, as reflected in Exhibit 13, without obstetrical indications or documentation which justified such a delivery, and the alleged failure to keep records. The records are clear that the patient had come into labor after premature rupture of the amniotic membrane, that the patient had a difficult labor, and that Pitocin was administered at 3:45 p.m. to eliminate an irregular labor pattern. Pitocin administration was continued until birth. At 5:10 the nurse and Dr. Song did a vaginal examination and noted swollen rim. Dr. Song instructed the patient not to push for awhile. Petitioner's Exhibit 13. Dr. Song used low forcep, an accepted procedure If there is any fetal distress. The notes reflect that the mother had been In labor for 10 hours, that she had remained dilated at 8-9 cm. since 4:30 p.m. The baby's respiration at birth was delayed a half minute and oxygen was administered. Petitioner's Exhibit 13. Regarding postpartum hemorrhage, Dr. Stone speculates that it may have indicated a hard forceps delivery; however, Dr. Stone admits it could also have been due to other things. Dr. Fetterman testified that it was "obvious" that the postpartum bleeding occurred from the uterus because of pieces of placental material which were not sloughed off and was not the result of the use of forceps. Dr. Fetterman testified that the baby in this case had excellent Apgar scores of 9 and 9, and that Dr. Song did not deviate from the standard of care in delivering the child of patient 196663. Drs. Fetterman and Song described how the premature ruptured membranes was an indication of potential infection or a problem for the fetus. Therefore, a low forceps delivery was indicated. There is less than a preponderance of evidence in this case to suggest that Dr. Song departed from the standard of care with regard to the examination, diagnosis and treatment of patient 196663. Patient 244254 Patient 244254 was a 26 year old Puerto Rican who was admitted to the hospital on September 26, 1984 in her forty-second week of her third pregnancy and who previously had delivered two children. The forty-second week of pregnancy is critical, being considered a maximum term. Respondent was brought in to induce pregnancy in this patient. The nursing notes for the period 8:30 p.m. until 12:40 a.m. are missing in the record. The last nursing note at 8:30 p.m. was that the patient was completely dilated and was being taken to the delivery room. It does not record any position for the baby. Other records show that the Respondent performed a caesarian section and delivery the baby at 11:19 p.m. and the mother was resting after surgery at 12:40 a.m. The Respondent's testimony is the only eyewitness account of what occurred during the intervening period. Expert testimony stated that a caesarian section under optimum conditions takes 15 minutes to perform. Approximately an hour before performing the caesarian section, at around 10:00 p.m., the Respondent's requested Dr. Hoover to examine the patient. Dr. Hoover recommended letting the woman remain in labor another hour unless fetal distress occurred. It was while waiting this hour, that fetal distress occurred, and Dr. Song performed the caesarian section and delivered a baby girl whose Apgar scores were 7 and 9. These Apgar scores indicate the baby was initially in some distress which was relieved by administration of oxygen. Just prior to asking Dr. Hoover to examine the patient, Dr. Song had attempted to rotate and deliver the baby because the baby stopped in the transverse position with its shoulders caught on the mother's pelvic ridges. In this position, the baby's head is at the zero or mid-forcep position. Dr. Adler's principal criticism of this case arose as a result of his hearing that Dr. Song had attempted a high forceps delivery. There is no evidence to support this supposition. Alternatively, Dr. Alterman complains that Dr. Song had departed from the standard of care by failing to make adequate notations in the record to justify any use of forceps in this case. It is true that there is a gap in the record; however, it appears that this was not the result of the failure to make notes, but the loss of notes. In Dr. Fetterman's opinion, Dr. Song had two options, one being an immediate cesarean section, the other being an attempt at rotating the head with forceps. Dr. Fetterman emphasized that it was his belief that the only use of forceps in this case involved a mid-forceps procedure to facilitate delivery of the fetus out of the transverse arrest position so that it might proceed down the birth canal. Dr. Fetterman testified that a mid-forceps rotation was an accepted obstetrical procedure. Dr. Fetterman testified that his reading of the charts in this case indicated that fetal heart sounds had dropped and that this was "certainly a reason for concern." This was the fetal distress which resulted in the caesarian section. DPR's witnesses regarded to utilization of forceps in this case improper based upon a belief that Dr. Song was attempting mid-forceps delivery of this patient while on "probation." Dr. Song was using mid-forceps to rotate the baby out the transverse position which was for the purpose of delivering the baby. This use of forceps for rotation out of transverse arrest is an acceptable obstetrical maneuver, although, as in this case, the forceps generally leave marks on the baby's face. On February 22, 1983, the Respondent resigned from his position at the Apopka Clinic by letter. See Exhibit 10.
Recommendation Based upon the foregoing findings of fact and conclusions of law, it is recommended that the Board of Medical Examiners dismiss its complaint against the Respondent. DONE and RECOMMENDED this 25th day of May, 1989, in Tallahassee, Florida. STEPHEN F. DEAN 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 25th day of May, 1989. APPENDIX A Rulings on Respondent's Objections presented in Petitioner's Appendix A: Sustain the objection. Sustain the objection. Overrule the objection. Sustain the objection. Overrule the objection. Sustain the objection. Sustain the objection. Rulings on Respondent's Objections to Petitioner's Exhibits: Exhibit 2: Overruled. Note, however, the facts presented at the hearing reveal that half of the medication mentioned had not been prescribed by the Respondent. There was nothing unusual or inappropriate in the medications prescribed by Respondent. The Exhibit reflects an attitude of the hospital staff of suspicion concerning the Respondent which is not supported in the medical records. The Respondent's records for the patient reflect the basis for the prescriptions which, in the opinion of a medical expert, were appropriate in terms of the quantity of medications prescribed and the time frame in which they were prescribed. The suggestion by Dr. Adler that the pregnant patient be sent to an orthopedic specialist for low back pain in order to support the treatment was clearly a means of avoiding responsibility for the course of treatment. Dr. Song was willing to accept that responsibility and the records support the propriety of his decision. Exhibit 5: Sustained. This purports to be a statement of a medical examination conducted contemporaneously with the giving of the statement; however, a check of the dates reveals that it could not have been made on January 11, 1983 because Patient 178793 did not give birth until February 7, 1983. Because of this inconsistency, Respondent's objection is sustained. Exhibit 6, 7, 8, 10, 11: Petitioner seems to assert that Exhibits 6, 7, 8, and 10 relate to peer discipline and that as such they should be admissible. However, the only evidence of possible peer discipline is Exhibit 11, and it merely references an interview concerning possible corrective action. Part of the basis of this interview are cases discussed by Dr. Stone and the Respondent on December 1, 1982 and February 3, 1983 (Exhibit 11, second paragraph); however, Exhibits 6, 7, 8, and 10 relate to an event on February 7, 1983 which could not have been addressed in either of these conversations. It is conjectural whether any disciplinary action was taken and whether the event of February 7, 1983 was the basis for action, if any action was taken. The objection is sustained regarding Exhibits 6 and 7. Exhibits 8 and 10 will be considered to the extent that they state the findings of physical examinations about the baby whose treatment is the subject of a portion of the Board's administrative complaint. Objection of Petitioner to Respondent's Exhibit 3, Deposition of Henry H. Fetterman, M.D. Counsel for Petitioner presented a continuing objection to questions calling for an opinion on the standards of care in Florida on the basis that the witness was not licensed in Florida. The standard of practice for obstetrics is not so parochial that a recognized out-of-state expert cannot offer an opinion concerning the standards of care of obstetric practice. This objection is overruled and the testimony of Dr. Fetterman will be received. APPENDIX B Findings on Proposed Findings The findings contained in the following paragraphs of Petitioner's Proposed Findings were adopted substantially: 1, 2, 3, 4, 5, 6 - that forcep marks occur, 8, 15, 16, 17 - patient complained, 18-1 and 2*, 20 - only prescriptions written are in chart, 22, 26 - dates of admissions, 33, 38, 46, 47, 54, 56, 58, 69, 33, 35, 37 - use of low forceps safe, 38, 39, 46, 48 - indications for forcep delivery, 53, 54, 56, 58, 59, 60 - claim to rotate baby, 64 - head was at minus 1 on admission and 0 to plus 1 when rotation was attempted, 66 - standard to conduct vaginal exam and reflect chart, and 69. The findings contained in the following paragraphs of Petitioner's Proposed Findings were rejected because they were contrary to facts which were found to be more credible: 6 - that forcep marks occur when the doctor is rushed, 7, 9, 10, 11, 12, 17 - no indication of examination, 21, 26 - premature labor, 27 - see special finding, 28,29, 30 31, 32, 34, 36, 39 - concerning type of breech, 40, 44, 45, 47, 50, 51, 52, 57, 60 - all after first sentence is hearsay, 61, 64 - what prudent ob-gyn would do, 66 - Respondent's violating standard, and 70. The findings contained in the following paragraphs of Petitioner's Proposed Findings were rejected as irrelevant to the issues in light of other findings: 13, 14, 19, 20 - all after first sentence, 23, 24, 25, 41, 42, 43, 55, 62, 63, 65 - hearsay about restriction on forceps and inability of a hospital to restrict practice of physician in a manner contrary to patient's interest and contrary to full grant of practice by state licensing' agency, and 67. The findings contained in the following paragraphs of the Respondent's Proposed Findings were adopted substantially: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 29, 21, 22, 23, 25, 26, 27, 28, 29, 30, 31, and 32. The findings contained in the paragraph 24 of the Respondent's Proposed Findings were rejected as irrelevant in light of other findings. *Petitioner's Proposed Findings of Fact had two paragraphs 18. COPIES FURNISHED: Robert D. Newell, Esquire Newell & Stahl, P. A. 817 North Gadsden Street Tallahassee, Florida 32303 John D. Buchanan, Jr. Esquire Henry, Buchanan, Mick & English, P.A. Post Office Drawer 1049" Tallahassee, Florida 32302 Dorothy Faircloth, Executive Director Board of Medicine Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, FL 32399-0729 Kenneth Easley, Esquire General Counsel Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, FL 32399-0729
The Issue Whether Respondent's license to practice medicine should be disciplined for the alleged violations as set forth in Petitioner's Administrative Complaint.
Findings Of Fact Based on the testimony and documentary evidence presented at final hearing, and the entire record of this proceeding, the following findings of fact are determined. Petitioner: Department of Health Petitioner is the state agency charged with regulating the practice of medicine pursuant to Section 20.43, and Chapters 456 and 458, Florida Statutes. Respondent: Dr. Mahesh Allam Respondent, Dr. Mahesh Gandi Allam, is and has been at all times material to the allegations in the Administrative Complaint a licensed physician in the State of Florida, having been issued License No. ME 64990 on September 7, 1993. Respondent earned his medical degree at the medical school of the University of the West Indies located at the University of London. He was employed for one year as the Medical Director at the University Hospital of West Indies in Kingston, Jamaica, followed by a three-year internal medicine residency at Howard University Hospital in Washington, D.C. Thereafter, he completed a two-year program fellowship at the same hospital. After completing his formal education and training, Respondent began practicing medicine as a sole practitioner in Polk County, Florida, in 1993. On August 6, 1996, when he provided care and treatment to Patient W.B., Respondent was a sole practitioner. Currently, Respondent works with a group of four doctors employed by a professional corporation and practices medicine in Lake Wales, Haines City and Winter Haven, Florida. Respondent has had staff privileges and has treated Intensive Care Unit (ICU) patients at various hospitals including Heart of Florida, Lake Wales, and Winter Haven Hospitals since 1993. Respondent has provided specialist consultations to area physicians on internal medicine and pulmonary medicine. He is board-certified in Internal Medicine. Chronology of Events at Lake Wales Medical Center on August 6, 1996 According to Lake Wales Medical Center records, Patient W.B., a 42-year-old male, presented himself to the emergency room on August 6, 1996, at 6:45 a.m., with complaints of chills, fever, and an inability to take deep breaths. He indicated that his flu-like symptoms had begun four days earlier causing aching on both sides of his spine and cramping in his leg. He had experienced some diarrhea, no vomiting, no coughing, generalized muscle pain, leg pain, and was drinking fluids well. He provided a medical history to the emergency room personnel of a past appendectomy and stated that he smoked two and one-half packs of cigarettes a day, drank two beers a day and had a family history of hypertension. The initial physical exam by emergency room staff at 6:55 a.m. revealed the following: blood pressure of 100/56, pulse of 112-114/minute, respiration rate of 28-32/minute, temperature of 97.7 degrees, oxygen saturation of 99 percent, tachycardia (increase in heart rate above normal), tympany over the left lower lung fields and left upper quadrant, muscle tenderness bilaterally and good distal perfusion. A chest X-ray and an electrocardiogram (EKG) were ordered, and blood and urine samples were collected for laboratory analysis. After a review of the lab results and other clinical data, the attending emergency room physician formed initial impressions consisting of dehydration, pancreatitis, R/O prerenal (renal failure), R/O Hepatitis, R/O UTI and thrombocy topenia. At approximately 8:00 a.m., Respondent was called to the emergency room to attend to Patient W.B. Respondent had no previous knowledge of Patient W.B., but was selected from a hospital physician roster by the Emergency Room physician. Respondent arrived at the Emergency Room at approximately 8:30 a.m., examined Patient W.B., reviewed his lab tests and advised the Emergency Room physician to admit him to the ICU. Shortly thereafter, Respondent returned to the ICU, reassessed Patient W.B. and performed a thorough physical examination and evaluation. Respondent recorded Patient W.B.'s chief complaint, current illness, past medical history, medications ingested, allergies, family history, and social history. Under social history, Respondent noted that Patient W.B. had a history of drinking one six-pack of beer each day but had stopped since the onset of the symptoms. Respondent indicated that Patient W.B. looked slightly ill with acute cardiopulmonary distress. Respondent recorded the following vital signs: temperature 97.7 degrees, pulse 124, respiratory rate 32, blood pressure 109/51. Patient W.B's chest trachea was central, with "good air entry bilaterally with no wheezes or rhonci audible." His heart sounds were normal and jugular venous pressure was not elevated. Under "peripheries," Respondent noted that there was no edema, with good pulses. The abdomen was soft and non- tender, with minimum epigastric and periumbilical tenderness and no guarding or rebound. His bowel sounds were normal. Under "neurological," Respondent noted that "Patient is slightly weak but alert and oriented to time, place and person," with no obvious cranial nerve, motor or sensory deficits. Respondent, in his evaluation, identified his patient's significant lab results including: WBG 6.9; hemoglobin 14.4; platelets 73,000; and bands 13 percent. Chemistry lab results showed a BUN of 56, creatinine of 3.3, bicarbonate of 19, total bilirubin of 2.7, creatinine kinase of 1810, GGT of 139, AST 136, and amylase of 235. The urinalysis was positive for blood and nitrates with a trace of leukocytes and bacteria. The Radiographic Report indicated that the chest X-ray and abdomen, supine and upright, were normal or unremarkable. It was later determined that the lab results collected earlier at 7:10 a.m. showed no growth in the patient's urine culture, and no growth in his blood cultures after 48 hours. The sputum from the lung showed 3+ growth of normal oropharyngeal flora after 48 hours. The hepatitis profile for A, B and C were non-reactive. Respondent's history and physical examination of Patient W.B., and his evaluation of the lab results produced four initial impressions with four diagnoses: Urinary tract infection with possible urosepsis; Dehydration with prerenal azotemia; Rhabdomyolysis; and Pancreatitis. Respondent's first diagnosis, urosepsis, was based on the patient's urinary tract infection which may lead to an infection in the blood. The second diagnosis was based on evidence that the patient was severely dehydrated, causing renal failure, i.e. prerenal azotemia. The third diagnosis, rhabdomyolysis, is indicative of massive muscle skeletal breakdown which leads to elevated creatine kinase as found in Patient's lab that morning. The fourth diagnosis, Pancreatitis, relates to inflammation of the pancreas, as evidenced by Patient's abnormal amylase level and possible abnormal liver enzymes. Respondent initiated the following plan of treatment to address the tentative diagnoses: Patient will be admitted to Intensive Care Unit; He will be started on aggressive hydration with IV fluids; Clear liquids only to control Pancreatitis; Septic screen followed by antibiotics for urinary tract infection. Patient most likely has a benign prostatic hypertrophy which will be investigated once patient's acute medical condition has resolved. Further therapy will be dictated on patient's clinical response. Respondent's initial plan of care required the ICU registered nurses to monitor Patient W.B.'s vital signs, including temperature, pulse, respiratory, blood pressure and oxygen saturation rates, and stabilize him according to his orders. Initial Orders by Respondent At approximately 8:40 a.m., Respondent provided detailed orders to the nurses which included the following: intravenous fluid hydration at 200 cc per hour for three liters, to correct the hydration; monitor intake and output (I & O); collect two sets of blood and send for cultures to identify any abnormalities in the blood system and liver; obtain urine sample for culture and sensitivity; obtain (by respiratory therapy) sputum for culture and sensitivity and gram stain; obtain stool sample for gram stain, culture and sensitivity to look for infectious sites; obtain abdominal x-ray, flat plate and upright, to ensure no complicating factors in abdomen which may lead to Pancreatitis; test for serum lipase which is an enzyme elevated in Pancreatitis; provide oral diet of clear fluids as tolerated, because a patient with Pancreatitis may not tolerate solid food; and obtain a PT, PTT, hepatitis profile. At approximately 10:00 a.m., Respondent ordered Bactrim, an antibiotic, to combat any sepsis. He ordered clear liquids and continuous IV fluids. At approximately 11:00 a.m., Patient W.B. complained of shortness of breath. The ICU nurses and Respondent examined his lungs with a stethoscope which were unremarkable. Patient W.B's oxygen saturation was normal at 98 percent and his temperature was within normal range at 100 degrees. Respondent Returns to Office Practice At approximately 11:10 a.m., Respondent departed the hospital and headed for his office practice which was approximately 25-30 minutes from the Lake Wales Medical Center. He intended to manage Patient W.B. by phone until he returned to the ICU later that evening for his re-evaluation. Respondent testified that he normally re-evaluated all of his hospital patients at the end of the day and completed his rounds at approximately 9:00 p.m. each night. Phone management of patients at Lakes Wales Medical Center, a small-town hospital, was a common and necessary practice. While the hospital's ICU did not have a physician present at all times, Respondent testified that it was not practical for a doctor to remain in the ICU all day and all night. Petitioner's expert, Dr. Jack Giddings, agreed and stated, "The alternative to that would be for the physician to live in the hospital. How can you possibly object to it?" The Lake Wales Medical Center contained six ICU patient beds, with one nurse to every two patients. Vanessa McIntosh, a registered nurse, attended to Patient W.B. during the 7:00 a.m. to 3:00 p.m. shift, while Nurse S. Long attended to him during the 3:00 p.m. to 11:00 p.m. shift. Attending nurses in the ICU carefully monitor and record each patient's condition in their Nurse's Progress Notes. They regularly record patient vital signs including temperature, blood pressure, respirations, oxygen saturation and pulse. In addition, communications with the attending physician, including phone orders, and nurse actions are recorded. Clinical Course of Patient W.B. Through 10:00 a.m., while Respondent was present at the hospital, Patient W.B.'s vital signs were reasonably consistent. His heart rate was 114/minute, his respirations were 24/minute, his blood pressure was 90/66 and his oxygen saturation rate was 93 percent. Over the next several hours, Patient W.B.'s mental and physical status deteriorated. He became extremely anxious and agitated, required additional sedation and restraint, and his vital signs increasingly fluctuated in the abnormal range. At approximately 12:55 p.m., Patient W.B.'s heart rate had risen to 143/minute, his respirations had nearly doubled to 39/minute, his blood pressure had increased to 108/96, and his oxygen saturation was at or slightly above 90 percent. In addition, the patient became increasingly anxious and was hyperventilating. At approximately 1:00 p.m., Nurse McIntosh, the attending registered ICU nurse, was concerned and paged the Respondent at his office practice. Nurse McIntosh testified that the ICU nurses had a policy of contacting the attending physician to convey concerns about their patient, alert a change in their patient's condition, receive medication directives, provide patient status reports and lab results and to ask questions. She indicated that if the attending physician was needed immediately, the doctor was paged using the code "stat." By 1:15 p.m., the Respondent had not returned her page so Nurse McIntosh, again, paged Respondent to alert him of Patient W.B's change in status. At 1:30 p.m., Nurse McIntosh paged the Respondent for the third time. Patient W.B.'s vital signs were increasingly abnormal; he remained extremely anxious and was hyperventilating. Nurse McIntosh did not, however, page Respondent "stat" because she believed that Patient W.B.'s condition was not "seriously deteriorating." At approximately 1:35 p.m., Respondent returned Nurse McIntosh's third page, received his patient's change in status over the telephone, and ordered sedatives ("Ativan" 2 mg IV push, and "Librium" 10 mg) to settle him. Respondent also ordered the lab to immediately draw arterial blood gases (ABGs) to determine his metabolic condition, e.g., whether there was a severe metabolic acidosis, metabolic alkalosis, or other abnormalities in his pH, and whether he was receiving adequate oxygen and the extent of oxygen saturation. Respondent indicated that the results were important to determine whether Patient W.B. required intubation and a ventilator, and whether he required bicarbonate supplementation to correct the metabolic acidosis. At approximately 1:40 p.m., ABGs were drawn and at 2:00 p.m., the results were relayed to Respondent. Patient W.B.'s oxygen saturation rate was borderline normal and his pH was in the normal range. Although he had difficulty breathing, he was maintaining his own oxygenation without the need for immediate intubation and a ventilator. Respondent believed that Patient W.B. was tending toward mild metabolic acidosis and that his condition was common with renal failure and rhabdomyolysis. Respondent indicated that, thereafter, he developed a working diagnosis of delirium tremens (DTs), a sudden, severe deterioration of a patient's neurological function, causing the patient to become disoriented, confused and agitated. Potentially lethal, DT's occurs in a small percentage of patients who are undergoing alcohol withdrawal. Although the symptoms are often delayed until days after the withdrawal, they include fever, excessive sweating, tachycardia, hypertension or hypotension, hallucinations, agitation, confusion, fluctuating mental status, seizures, and combativeness. Proper treatment for a patient afflicted with DT's includes supportive sedation, sufficient fluids, adequate oxygenation, maintenance of respiratory status, and close monitoring. While Patient W.B. did not exhibit all of the symptoms of DTs, the overwhelming weight of the testimonial evidence suggested that the diagnosis was not unreasonable nor inconsistent with the patient's lab results, vital signs, and behavior. In fact, Petitioner's expert Dr. Schmidt, when asked at hearing to describe the symptoms of a patient suffering from DTs, responded: Those that this patient showed, including agitation, perhaps delirium, loose associations in terms of conversations, rapid heart beat, rapid respirations, more and more agitations, combativeness. In addition, Respondent's expert, Dr. William E. Manry, who is Board-certified in Family Practice and has practiced in Lake Wales for over 50 years, reviewed Patient W.B.'s medical chart and opined: I think the evidence is substantive that it just about had to be that. Part of the answer is based on the fact that he admitted, I think, a six-pack of beer a day. Now if an alcoholic admits to a six-pack of beer a day, the actual total is somewhere around three times as much. Dr. Vincente S. Verzosa, a Board-certified Internist who has practiced medicine in the Lake Wales area for 30 years, agreed. "From the time the patient was admitted, he gradually deteriorated, or he developed delirium -- delirium tremens -- most probably. I think it had something to do with his demise later that day." Following the nurse's 2:00 p.m. patient status update, Respondent ordered an additional sedative for Patient W.B. to control his heightened agitation. Respondent also instructed the nurses to page him if physical restraints were needed to control the patient. At 3:00 p.m., Nurse Long, R.N., began her shift and tended to Patient W.B. At 3:30 p.m., she recorded that his vital signs had improved since the earlier episode, his oxygen saturation was 94 percent, and his respiration rate was 36/minute. She noted that Patient W.B., again complained that it was difficult for him to breathe. Patient W.B.'s vital signs recorded between 3:45 p.m., 4:00 p.m., and 4:35 p.m. reflected a mild increase in heart rate (134 to 139), respirations steady at 36, oxygen saturation steady at 93 percent, and fluctuating blood pressure. At approximately 5:05 p.m., Patient W.B.'s condition again deteriorated and Nurse Long paged the Respondent. She recorded that Patient W.B.'s oxygen saturation rate was varying between 85-96 percent, his respirations were labored and he needed respiratory treatment. His respirations had increased to 44 per minute, his heart rate escalated to 150 per minute, and he was hyperventilating. At approximately 5:40 p.m., Respondent called Nurse Long and she alerted him of Patient W.B.'s status. Respondent ordered a restraint vest, Valium, 10 mg IVP, and maintenance of oxygen saturation at or above 90 percent. Shortly thereafter, at approximately 5:45 p.m., Patient W.B.'s status worsened and Nurse Long again paged Respondent. She recorded in her notes that the Valium had been given for his restlessness, he had twice climbed out of bed, pulled at his IV lines, and twice removed his EKG leads and blood pressure cuff. Moreover, the orderly was called twice to place the Patient back into bed and install the restraint. According to Nurse Long, Patient W.B. was "getting combative." At approximately 6:30 p.m., Patient W.B. remained agitated and combative. Although Respondent had not returned Nurse Long's 5:45 p.m. page, she called Respiratory Services, located within the hospital, to assist and increase his oxygen saturation rate. However, when personnel attempted to place an oxygen mask on him, the patient resisted. At approximately 6:35 p.m., Patient W.B.'s pulse had climbed to 163 per minute, his respirations increased to 48 and his oxygen saturation rate was critically low at 73 percent. At approximately 6:55 p.m., Respondent was again paged, twice. Hospital staff placed an external re-breather on Patient W.B. and provided him with 100 percent oxygen. At approximately 7:25 p.m., Respondent contacted Nurse Long and was advised of Patient W.B.'s severely deteriorating condition. Respondent ordered 20 mg Valium IV to combat his extreme agitation. Shortly thereafter, Respondent departed his office for the hospital in preparation for possible intubation. At approximately 7:55 p.m., Patient W.B. stopped breathing and the "code" was called. The emergency room physician and other health care personnel immediately assisted and attempted to intubate the patient. At approximately 8:10 p.m., Respondent arrived on the scene and assisted the health care professionals. At approximately 8:30 p.m., on August 6, 1996, Patient W.B. expired. Autopsy On August 9, 1996, the Medical Examiner performed an autopsy on Patient W.B. The examiner stated in his Autopsy Report that Patient W.B. had "a number of bacteria in his system at the time of his death," and determined that bacterial sepsis was the cause of his death. However, as the Medical Examiner indicated in his Autopsy Report, the death of Patient W.B. "is somewhat problematic." In fact, much of the expert testimonial evidence questioned the accuracy of the examiner's determination that bacterial sepsis was the cause of Patient W.B.'s death. Specifically, they opined that his determination was inconsistent with the fact that Patient W.B.'s blood cultures, collected shortly before his death, showed no bacterial growth five days after his demise. Respondent suggests that it is likely that Patient W.B. suffered a respiratory arrest at that time, not a cardiac arrest, and that he was, in fact, undergoing a seizure which led to his cardiac arrest. Alleged Violations Count I: Deviations From The General Standard of Care Failure to Physically Reevaluate the Patient Earlier Petitioner's experts, Drs. Schmidt and Giddings, testified that in their opinion the acceptable standard of care, under the circumstances, required Respondent to physically reevaluate Patient W.B. sooner. Their opinions are credible and persuasive. Subsequent to 11:55 a.m., Patient W.B.'s vital signs fluctuated significantly in the abnormal range. In fact, on at least eight separate occasions in approximately six hours, an ICU nurse paged Respondent to alert him of his patient's deteriorating status, yet Respondent chose to manage him solely by telephone. While Respondent's working diagnosis of delirium tremens was not shown to be unreasonable or inappropriate, nor was Respondent ever paged "stat" by the ICU nurses, the evidence is clear and convincing that a reasonably prudent physician would have physically reassessed his ICU patient's dramatically fluctuating condition earlier than 8:10 p.m. Considering Patient W.B.'s increasingly erratic vital signs and abnormal behavior, the severity of his condition, the potential and recognized lethality of Respondent's working diagnosis, the repeated pages he received, and the credible and persuasive expert testimonial evidence, Respondent failed to practice medicine with the level of care, skill and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances. It is concluded that Petitioner proved Count I of the Administrative Complaint, by clear and convincing evidence. The acceptable standard of care required Respondent to physically reevaluate Patient W.B. earlier than 8:10 p.m., approximately 20 minutes before his death. Failure to Obtain Consultations With Specialists Both Dr. Schmidt, who practices in Miami, and Dr. Giddings, who practices in Jacksonville, admitted that they were unfamiliar with the medical specialists available in Polk County and the surrounding area. Respondent expressed his feeling that there was no indication of a need to obtain a consultation from a cardiologist or other specialist because the Patient did not exhibit any signs of a cardiac condition. It is concluded that Petitioner failed to establish by clear and convincing evidence that the acceptable standard of care required Respondent to seek a consultation when such specialists were either not available in the area or not indicated by his patient's condition. Failure to Order Follow-up Tests Dr. Schmidt testified that, in his opinion, Dr. Allam fell below the acceptable standard of care by not ordering follow-up tests for potassium and platelets, and not ordering a brain CT and an abdominal ultrasound or CT scan which "might have provided useful information." Respondent and Drs. Manry and Verzosa gave detailed opinions in opposition to Dr. Schmidt's and their opinions are credible and persuasive on this issue. It is concluded that Petitioner failed to establish by clear and convincing evidence that the acceptable standard of care required Respondent, on that day, to order the follow-up tests suggested by Dr. Schmidt. Count II: Failure to Keep Appropriate Medical Records It is concluded that Petitioner failed to establish by clear and convincing evidence that Respondent failed to document and keep appropriate medical records justifying the patient's course of treatment. Count III: Failure to Appropriately Prescribe Medications It is concluded that Petitioner failed to establish by clear and convincing evidence that Respondent failed to appropriately prescribe medications to Patient W.B.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Petitioner enter a final order finding that: (1) Respondent DID NOT violate Subsections 458.331(1)(m)and(q), Florida Statutes, as alleged in the Administrative Complaint; and (2) Respondent DID violate Subsection 458.331(1)(t), Florida Statutes, as alleged in the Administrative Complaint and imposing the following sanctions: an administrative fine of $5,000; the performance of ten hours in continuing medical education in care of critical patients; and issuance of a letter of concern. DONE AND ENTERED this 20th day of February, 2002, in Tallahassee, Leon County, Florida. WILLIAM R. PFEIFFER 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 20th day of February, 2002. COPIES FURNISHED: R. L. Caleen, Jr., Esquire Watkins & Caleen, P.A. Post Office Box 15828 Tallahassee, Florida 32317-5828 Ephraim D. Livingston, Esquire Agency for Health Care Administration Post Office Box 14229 Tallahassee, Florida 32317-4229 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Tanya Williams, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
Findings Of Fact Petitioner is the state agency charged with regulating the practice of medicine pursuant to Section 20.30 and Chapters 455 and 458, Florida Statutes. Respondent is a licensed physician in the State of Florida and holds license number ME 0043566. Respondent has never been the subject of a previous complaint from the Department of Professional Regulation (now the Department of Business and Professional Regulation). No patient involved in this proceeding incurred injury as a result of any procedure performed by Respondent or as a result of any medical record kept by Respondent, nor did any patient claim injury or make a complaint against Respondent. Respondent derived no financial gain from any act or omission alleged in the administrative complaint. All events pertaining to this proceeding occurred in 1987 or 1988. Prior to February 8, 1988, the effective date of Chapter 88-1, Laws of Florida, Section 458.331(1), Florida Statutes provided, in pertinent part, as follows: The following acts shall constitute grounds for which the disciplinary action specified in subsection (2) may be taken. * * * (m) Failing to keep written medical records justifying the course of treatment of the patient, including, but not limited to, patient histories, examination results, and test results. * * * (t) Gross or repeated malpractice or the failure to practice medicine with that level of care, skill, and treatment which is acceptable under similar conditions and circumstances. The board shall give great weight to the provisions of s. 768.45 when enforcing this paragraph. As used in this paragraph, "repeated malpractice" includes, but is not limited to, three or more claims for medical malpractice within the previous 5-year period resulting in judgment or settlement and which incidents involved negligent conduct by the physician. 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 to require more than one instance, event, or act. Section 25 of Chapter 88-1, Florida Statutes, became effective February 8, 1988, and amended the pertinent provisions of Section 458.311(1), Florida Statutes, to read as follows: The following acts shall constitute grounds for which the disciplinary action specified in subsection (2) may be taken. * * * (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 acceptable under similar conditions and circumstances. The board shall give great weight to the provisions of s. 768.45 when enforcing this paragraph. As used in this paragraph, "repeated malpractice" includes, but is not limited to, three or more claims for medical malpractice within the previous 5-year period resulting in judgment or settlement and which incidents involved negligent conduct by the physician. 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 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 be disciplined pursuant to this paragraph. At the times pertinent to this proceeding, Petitioner had adopted no rules pertaining to the keeping of records by a licensed physician. Imperial Point Medical Center (Imperial Point) is a hospital located in Broward County, Florida. Unless otherwise indicated, all hospital records referred to in this matter are from Imperial Point. PATIENT #1 (C.S.) On August 8, 1988, Respondent performed an upper endoscopy on Patient #1, a male, who was 44 years old at the time of the procedure. This procedure was performed at Imperial Point on an outpatient basis. An upper endoscopy is the viewing of the mouth, the pharynx, the esophagus, the stomach and portions of the duodenum with a fiber optic instrument that allows direct visualization of the lining of these structures and allows therapeutic maneuvers. The records kept of this procedure performed on Patient #1 on August 8, 1988, include an outpatient hospital record entitled "Operative Report". The description of the procedure portion of this report includes the following: ". . . The gastric portion was infiltrated with 1:1,000 adrenaline . . ." Adrenaline, also known as epinephrine, is a vasoconstrictor that can be used to control minor bleeding and oozing. It is used regularly in gastroenterology to treat actively bleeding lesions or ulcers with evidence of recent bleeding prior to performing a more permanent type of hemostasis. Dr. Goldberg testified that epinephrine was usually injected into these areas by a needle. Dr. Goldberg was of the opinion that epinephrine should not be used in cases of trivial bleeding or oozing or after routine biopsies unless there is an imminent danger of a significant arterial bleed. The testimony of Dr. Cerda and Dr. Singh established that spraying epinephrine over an area that is subject to bleeding is a precautionary technique some gastroenterologists follow. Dr. Singh and Dr. Cerda have both either used this technique, or have observed its use by other physicians. The expert witnesses agreed that the injection by needle of epinephrine into the gastric wall would be a procedure that falls below an established standard of care. There was a dispute among the expert witnesses as to how the term "infiltrated" should be interpreted. Petitioner contends that the term "infiltrated" is synonymous with the term "injected", and that the medical records should be construed to mean that Respondent injected the gastric wall with a needle, and therefore practiced below the standard of care. This contention is consistent with the testimony of Dr. Goldberg. Respondent asserts that the medical record should be construed to mean that Respondent sprayed the gastric wall as a precautionary measure. This contention is consistent with the testimony of the expert witnesses who testified on behalf of the Respondent. This dispute is resolved by finding that the term "infiltrated" does not have the same meaning as the term "injected" and does not prove that Respondent injected Patient #1's gastric wall with a needle. This conclusion is based, in part, on the definition of the term "infiltrate" and on the context in which epinephrine is sometimes administered by gastroenterologists during this type procedure. According to The American Heritage Dictionary of the English Language, the term "infiltrate" means to pass a liquid or a gas into something through its interstices or to permeate with a liquid or gas passed through interstices. Dorland's Illustrated Medical Dictionary, Twenty Sixth Edition (Dorland) has a similar definition of the term "infiltrate". According to Dorland, an "interstice" is small interval, space, or gap in a tissue or structure. According to Dorland, the term permeate means to penetrate or pass through, as through a filter. Also according to Dorland, the term inject means the act of forcing a liquid into a part, as into the subcutaneous, the vascular tree, or an organ. Based on these definitions, it is found that the use of the term "infiltrate" is more consistent with the practice of spraying epinephrine onto the gastric wall, and that the use of the term "infiltrate" does not prove that Respondent injected the epinephrine into the gastric wall with a needle. It is found that Petitioner failed to prove that the use of epinephrine was improper or that the manner in which Respondent used the epinephrine during the subject procedure was improper. Since Petitioner failed to prove that Respondent injected Patient #1 with epinephrine, its charge that Respondent failed to document his reasons for doing so must also fail. A pathology report dated August 8, 1988 contained in the medical file provided a pathological diagnosis as follows: "esophageal brushings: no evidence of malignancy." Brushings are the result of passing a small brush through the biopsy channel of an endoscope, rubbing it over an area of concern that might have either a malignancy or a fungal infection, taking the brush out of the scope, wiping it on a microscopic slide, and sending the slide to the pathologist for cytological examination. The reference to the "esophageal brushings" in the pathology report was error. The brushings taken from Patient #1 during the procedure on August 8, 1988, came from the stomach, a fact obvious to all of the expert witnesses in light of the operative report and operative drawing made by Respondent. Because Petitioner failed to prove that Respondent took esophageal brushings from Patient #1, its charge that he failed to properly document his reasons for doing so must also fail. 1/ Petitioner proved that Respondent's medical records, including his office notes as to Patient #1 failed to contain an adequate medical history for Patient #1 and failed to reflect the findings of any physical examination of Patient #1 by Respondent. Petitioner further proved that such failures fall below an established standard of care as alleged in Count Two of the Amended Administrative Complaint. PATIENT #2 (R.B.) Patient #2 was a 70 year old male seen by Respondent for a consultation because of the patient's history of hematemesis, which is the vomiting of blood. Respondent prepared a formal consultation note dated September 25, 1988. The consultation note contains a description of the patient's condition, references a rectal exam, which was positive for blood, and indicates that a physical examination of the patient was made. Respondent again saw the patient on September 27, 1988 and performed an upper endoscopy. Dr. Goldberg was critical of the medical records kept by Respondent as to this procedure and was of the opinion that the medical records were inadequate. Other, equally credible expert witnesses were of the opinion that the medical records provided sufficient information to document the procedure. While it may be concluded that Respondent's medical records could be improved, it is found that Petitioner failed to prove that the medical records pertaining to this patient were inadequate. It is further found that Petitioner failed to prove the standard by which the adequacy of medical records are to be judged, other than the pertinent statutory standards set forth above. The records kept of this procedure reflect that Respondent "infiltrated" Patient #2 with epinephrine. This is the identical dispute over the meaning of the term "infiltrated" that pertained to Patient #1 as discussed above. For the reasons given in resolving the dispute as it pertains to Patient #1, it is found that the term "infiltrated" does not have the same meaning as the term "injected" and that the use of the term does not prove that Respondent administered the epinephrine by injecting Patient #2 with a needle. It is found that Petitioner failed to prove that the use of epinephrine was improper or that the manner in which Respondent used the epinephrine during the subject procedure was improper. Since Petitioner failed to prove that Respondent injected Patient #2 with epinephrine, its charge that Respondent failed to document his reasons for doing so must also fail. PATIENT #3 (B.B.) Patient #3, a 65 year old female was admitted to Imperial Point with chest pains by her physician, a Dr. Fanfan. Patient #3 had a history of cancer which included the prior surgical removal of a tumor. On October 3, 1988, Respondent performed a colonoscopy of Patient #3. A colonoscopy is an examination of the colon from the anus to the ileocecal valve using a fiber optic instrument. A colonoscopy is indicated to evaluate abnormal X-rays, changes in bowel habits, evidence of bleeding, suspicions of inflammation, tumors, or polyps. Respondent adequately performed the procedure on Patient #3. The colonoscopy detected that Patient #3 had polyps. Subsequent laboratory results established that these were hyperplastic polyps that required no follow-up. Had the polyp been an adenomatous polyp, which is a true neoplasm with malignant potential, a follow-up for recolonoscopy would have been appropriate in one year. Prior to receiving the pathology reports, on the polyp, Respondent recommended a six month follow-up for the patient. This follow-up recommendation was appropriate at the time it was made. Petitioner failed to prove that the recommendation that a follow-up be performed was below an established standard of care. Petitioner failed to prove that the recommendation that the follow-up for this patient with a history of cancer be in six months as opposed to one year fell below an established standard of care. The barium enema for this patient was originally scheduled by the attending physician, Dr. Fanfan. Dr. Fanfan clearly wrote a note on the same day following Respondent's report of the colonoscopy that the barium enema was pending, yet the attending physician did not cancel the barium enema. There is no disagreement among the experts that the barium enema was unnecessary in light of the findings of the colonoscopy. It is medically unnecessary and inappropriate for both tests to be performed on the same day. Dr. Goldberg was of the opinion that Respondent was responsible for the patient once he began his consultation and that Respondent should have canceled the barium enema. Dr. Cerda, Dr. Eberly and Dr. Singh were of the opinion that the attending physician was responsible for scheduling the barium enema and that the attending physician or the radiologist should have canceled the barium enema. Dr. Eberly testified that as the primary care physician, the admitting physician is the "captain of the ship" and has the responsibility to make final determinations with respect to tests of this nature. Because of the conflicting testimony from equally credible expert witnesses, it is found that Petitioner failed to prove that Respondent violated an established standard of care by not cancelling Patient #3's enema. Dr. Goldberg was of the opinion that Respondent's medical records pertaining to Patient #3 were inadequate. He had several criticisms of the records. Dr. Goldberg opined that there should have been a formal consultation note on Patient #3's chart that included past history, present illness, review of systems, allergies, pertinent laboratories, a thorough organ specific or system examination, an impression, an adequate discussion of the consultant's impression and the consultant's plans. He opined that the indications for Patient #3's procedure were inadequately dictated on the procedure notes and that Respondent's history pertaining to Patient #3 was inadequate because there was no pertinent review of systems or past history, no mention of the previous tumor, no mention of allergies, and an extremely scant examination. Other, equally credible expert witnesses were of the opinion that the medical records were adequate. It is found that Petitioner failed to prove the standard by which the adequacy of this patient's medical records are to be judged, other than the pertinent statutory standards set forth above. While it may be concluded that Respondent's medical records could be improved, it is found that Petitioner failed to prove that the medical records fell below an established standard of acceptability. PATIENT #4 (E.K.) On October 4, 1988, Patient #4, a 92 year-old female, was admitted to the hospital with an acute onset of vomiting, dehydration, and abdominal pain. Respondent was asked by Patient #4's attending physician to evaluate Patient #4 for a potential small bowel obstruction following an X-ray that was consistent with a small bowel obstruction. Respondent performed an upper endoscopy on Patient #4 on October 7, 1988. An obstruction of the intestines is a blockage in the large or small intestine. The bowel behind the blockage may become inflated with fluid or air and may be seen on X-ray. The obstruction may result from a variety of abnormalities. Dr. Goldberg was of the opinion that the upper endoscopy was contra- indicated and potentially dangerous to the patient because of the X-ray indicating a complete bowel obstruction. Dr. Goldberg was also of the opinion that an upper endoscopy should be used only under compelling circumstances if there is a partial bowel obstruction. Dr. Goldberg was of the opinion that Respondent did the right tests on Patient #4, but in the wrong order since he did not first rule out an obstruction. Prior to performing the upper endoscopy Respondent monitored the patient for several days. During that time period, examinations indicated that the patient was having bowel movements. Both the attending physician's notes, Respondent's notes, and the nurse's notes indicate positive bowel signs on October 5 and 6, indicating that there was not a complete bowel obstruction. Respondent ordered a Golytely preparation administered to the patient, which usually consists of one or two liters of non-absorbable solution that basically washes the bowel out. That preparation would have been improper with a complete bowel obstruction. Dr. Goldberg was of the opinion that the use of a Golytely prep in this patient was a gross judgment error. Dr. Singh was of the opinion that there was no contra-indication for using the preparation in this situation. Petitioner failed to prove that Patient #4 had a complete bowel obstruction or that the procedure, including the use of the Golytely preparation, violated an established standard of care. It is found that Respondent was acting within the scope of his discretion as the consulting physician to order the administration of the Golytely preparation and to perform the upper endoscopy. On October 11, 1988, Respondent performed a colonoscopy on Patient #4. Respondent stated on the operative report that the colonoscopy was indicated because of diverticulitis. Diverticulitis was not mentioned in any of Respondent's notes concerning Patient #4, and there was no notation as to the reasons Respondent thought the patient had diverticulitis. Although Respondent failed to document why he felt that diverticulitis was an appropriate indication for the colonoscope, there is no dispute that a colonoscope was, in fact, indicated. Further, the colonoscope established that the pretest diagnosis of possible diverticulitis was not incorrect. The colonoscopy revealed areas of colitis, and the pathology report noted an ulcer with acute and chronic inflammation. Respondent's experts testified that they were of the opinion that Respondent violated no established standard by listing diverticulitis as an indication for the colonoscopy. It is found that Petitioner failed to prove that Respondent practiced below an established level in listing diverticulitis as an indication for the colonoscope. During the colonoscopy, Respondent found several mildly bleeding areas and infiltrated Patient #4 with epinephrine. For the reasons discussed pertaining to Patient #4, it is found that Petitioner failed to prove that Respondent violated an established standard of care in administering epinephrine to Patient #4. Dr. Goldberg was of the opinion that Respondent's handwritten consultation report was inadequate. Dr. Goldberg bases his conclusion on the following observations. The report was difficult to read and failed to include any significant historical events concerning Patient #4. In his consultation report, the Respondent failed to note anything about having done a rectal examination on this patient, whether or not the abdomen was distended, and whether there were active or inactive bowel sounds. Dr. Goldberg was of the opinion that these findings would help to distinguish between an obstruction and an ileus or paralysis of the bowel. Dr. Goldberg was also of the opinion that the patient's records of the upper endoscopy performed October 7, 1998, fail to reveal any significant findings. Other, equally credible expert witnesses were of the opinion that the medical records were adequate. It is found that Petitioner failed to prove the standard by which the adequacy of medical records are to be judged, other than the pertinent statutory standards set forth above. While it may be concluded that Respondent's medical records could be improved, Petitioner failed to prove that the medical records fell below an established standard of acceptability. PATIENT #5 (J.T.) Patient #5, an 89 year-old male, was admitted to Imperial Point with a history of peptic ulcer disease and arthritis. This patient was seen by Respondent on a consulting basis. The patient was vomiting blood and Respondent was asked to see the patient to determine the source of the bleeding. Respondent performed an upper endoscopy on October 13, 1988, and found a significant outlet obstruction. On October 17, 1988, a G.I. series was performed and a repeat upper endoscopy and pyloric dilatation was performed. The procedures performed by Respondent were properly indicated and had a beneficial result to the patient. Back-to-back pyloric dilatations were appropriate and clinical judgment was properly exercised. Dr. Goldberg was of the opinion that Respondent failed to keep adequate written medical records pertaining to the upper endoscopy of October 13, 1988, in that Respondent's operative report failed to document Respondent's findings in detail. Dr. Goldberg testified that an essential endoscopy report that physicians are trained to do should include the following: indications for the procedure, medication used to sedate the patient, identification of instrument used, description of the anatomical landmarks and their condition as visualized by the physician passing the endoscope, the removal of the scope, the physician's impressions and what the physician plans to do about those impressions, how the patient tolerated the procedure and what the patient's condition was after the procedure, and that the patient was sent to the recovery area. Dr. Goldberg was of the opinion that Respondent failed to keep adequate written medical records pertaining to the procedures performed on this patient on October 17, 1988, in that Respondent's operative report did not document Respondent's findings in detail and did not indicate if the scope was passed through Patient #5's dilated pylorus into the duodenum. In Respondent's impressions on the second endoscopy, he noted pyloric stenosis and duodenal ulcer. In his procedure note Respondent does not mention whether he passed the scope into the duodenum or how he knew there was a duodenal ulcer. Dr. Goldberg was of the opinion that Respondent did not properly document what he did. On October 18, 1988, Respondent performed a repeat pyloric dilation on Patient #5. Dr. Goldberg was of the opinion that Respondent failed to record the reasons for the second procedure and to document his findings. Dr. Goldberg was of the opinion that the third endoscopy note did not adequately detail the examinations of the esophagus and stomach. Dr. Goldberg was of the opinion that every procedure note stands alone, and that if a physician does an endoscopy on day one and repeats it on day two, the physician still must make that report complete because it is not always going to be part of a document. Dr. Goldberg was of the opinion that Respondent's records did not stand alone. Dr. Goldberg was of the opinion that Respondent's handwritten consultation note was sketchy and should have contained a history of allergies because of the need to give the patient medications for sedation. Dr. Goldberg's criticisms of Respondent's medical records do not prove that the medical records kept by Respondent were inadequate as measured by an established standard. Other, equally credible expert witnesses were of the opinion that the medical records provided sufficient information to document the procedures and that the records were adequate. While it may be concluded that Respondent's medical records could be improved, it is found that Petitioner failed to prove that the medical records were inadequate. It is further found that Petitioner failed to prove the standard by which the adequacy of medical records are to be judged, other than the pertinent statutory standards set forth above. PATIENT #6 (D.Y.) From October 19, 1988, until October 22, 1988, Respondent was consulting physician to Patient #6, a 72 year-old male, who was admitted to Imperial Point with rectal bleeding. Dr. Goldberg was of the opinion that Respondent failed to keep adequate written medical records pertaining to Patient #6 because a formal consultation note was lacking. The medical records which were reviewed by Dr. Goldberg were incomplete when reviewed by him. A specific reference is made to a consultation note that is not contained in the hospital records. Respondent established that other medical records were missing from the hospital records. In light of the specific reference to the consultation note, it is found that the absence of this consultation note from the hospital records is insufficient to prove that there existed no consultation note. On October 20, 1988, Respondent performed an colonoscopy on this patient and a biopsy was taken in the segmental descending colon area. The colonoscopy could not be completed because the colonoscopy could not pass to the patient's cecum. The following recommendation was made by Respondent (the original is in all capital letters): IN VIEW OF NOT REACHING TO THE CECUM, THE PATIENT WOULD NEED BE (this is an abbreviation for barium enema) AND ALSO IF EVERYTHING IS NEGATIVE, RECOLONOSCOPY IN ONE YEAR AND IF THERE ARE ANY CHANGES IN THE BIOPSY OF THE POLYP, THEN ACCORDINGLY WILL PLAN. On October 21, 1988, the follow-up barium enema was performed by Dr. Nicholas M. Arfaras, a radiologist. The radiology report reflected the following finding: "Also in the sigmoid there is an approximately 1 cm. rounded filling defect identified near the junction with the descending colon. This is felt to be secondary to a polyp." The possible polyp detected by the barium enema should have been followed up. However, it was not established that Respondent was consulted by the attending physician about the results of the barium enema. Dr. Lipton, as the attending physician, would have had the responsibility for following up the recommendations made by Respondent and for bringing Respondent or another gastroenterologist in for further consultations following the barium enema if Dr. Lipton had believed it necessary to do so. This patient was discharged from Imperial Point by Dr. Lipton on October 22, 1988. The final page of the discharge summary for this patient reflected the following notation: "Condition was improved. The patient is to have a follow up in one week in the office with Dr. Lipton and with Dr. Gupta in two weeks." The evidence presented in this proceeding, including Respondent's office notes, does not reflect that Respondent had any involvement with this patient after October 21, 1988, until 1990, when he performed on the patient at North Broward Medical Center a procedure described as a "multiple colonoscopy with multiple biopsies and cauterization." This procedure in 1990 revealed multiple polyps. The polyp removed on colonoscopy in 1988 was an adenomatous polyp, a polyp with significant malignant potential. This patient needed a follow-up colonoscopy in one year. Respondent was the consulting physician and recommended reevaluation of the patient in one year. Follow-up care was not the responsibility of Respondent, but of the treating physician. Dr. Goldberg was of the opinion that Respondent failed to keep adequate written medical records in that Respondent failed to adequately document the indications for the colonoscopy performed on Patient #6 and why the colonoscope could not be passed to Patient #6's cecum. Dr. Goldberg opined that a physician doing a colonoscopy needs to tell why he did not get to the cecum so that the next physician colonoscoping this patient can take appropriate precautions. Other, equally credible expert witnesses were of the opinion that the medical records were adequate and provided sufficient information to document the procedures that were performed. Petitioner failed to prove that the medical records were inadequate. Petitioner failed to prove the standard by which the adequacy of medical records are to be judged, other than the pertinent statutory standards set forth above. PATIENT #7 (C.R.) Respondent was a consulting physician to Patient #7, a 64 year old male who was hospitalized with rectal bleeding. Respondent saw this patient because of a possible colonic fistula, which is a connection with any piece of the intestine and some other structure. Respondent recommended a barium small bowel X-ray and a barium enema, both appropriate clinical recommendations. On November 11, 1987, Respondent performed a colonoscopy on Patient #7. Petitioner contends that Respondent failed to keep adequate written medical records pertaining to the aforementioned procedure in that Respondent failed to document an adequate history as an indication of Patient #7's colonoscopy. This contention is rejected based on the testimony of Dr. Singh. The medical records provide adequate justification for the procedure. Dr. Goldberg was critical of Respondent's records pertaining to this patient and considered the records inadequate. He was of the opinion that the records should have better detailed his findings and should have recorded any follow-up plans for a repeat colonoscopy on the patient. Other, equally credible expert witnesses were of the opinion that the medical records were adequate and provided sufficient information to document the procedures that were performed. Petitioner failed to prove that the medical records were inadequate. Petitioner failed to prove the standard by which the adequacy of medical records are to be judged, other than the pertinent statutory standards set forth above.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Petitioner enter a final order which finds that Respondent violated the provisions of Section 458.331(1)(m), Florida Statutes, by failing to provide a history or physical examination for Patient #1 as alleged in Count Two, which reprimands Respondent for that violation, and which imposes an administrative fine in the amount of $250.00 against the Respondent for that violation. It is further recommended that all other charges against Respondent contained in the Amended Administrative Complaint be dismissed. DONE AND ENTERED this 12th day of October, 1993, in Tallahassee, Leon County, Florida. CLAUDE B. ARRINGTON Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 12th day of October, 1993.
The Issue Whether disciplinary action should be taken against Respondent's license to practice medicine based on allegations that Respondent violated the provisions of Subsections 458.331(1)(m) and (t), Florida Statutes, arising from his treatment and care of Patient R.E., as alleged in the Administrative Complaint in this proceeding.
Findings Of Fact Based on the oral and documentary evidence adduced at the final hearing, and the entire record in this proceeding, the following findings of fact are made: Petitioner is the state agency charged with regulating the practice of medicine pursuant to Section 20.43, Florida Statutes, and Chapters 456 and 458, Florida Statutes. Respondent is and has been at all times material hereto a licensed physician in the State of Florida, having been issued license number ME 0057927. Respondent practices primary care and internal medicine. He is board-certified in internal medicine, and has never had disciplinary action taken against his license. Patient R.E., a male who was 78 years old in January 2001, had a history of diabetes, hypertension, heavy smoking, high blood pressure, and circulatory problems. Respondent had first treated Patient R.E. on August 28, 2000, while covering for the physician with whom Respondent shared a practice. Patient R.E. had been a patient of the practice for several years. In August or September 2000, Respondent purchased the other physician's portion of the practice. The other physician remained as an employee of the practice until January 2001, when Respondent assumed the total care of Patient R.E. On January 16, 2001, Patient R.E. presented to Respondent with a complaint of redness and swelling in the right ankle that made walking difficult. Patient R.E. did not have a regularly scheduled office visit, but Respondent "squeezed him in" after Patient R.E. telephoned Respondent's office complaining of a great deal of pain. On January 16, 2001, the complete patient chart from the previous physician was available to Respondent and became part of Respondent's office chart for Patient R.E. Patient R.E.'s chart contained a "problem list" reflecting diagnoses made throughout his treatment at that office. A problem list assists the physician in tracking on- going problems with a patient. Patient R.E.'s problem list included a diagnosis of "PVD," or peripheral vascular disease. Peripheral vascular disease describes reduced blood flow to the extremities. It can be caused by a narrowing of large blood vessels, and exacerbated by diabetes-related small vessel disease. Prior to Respondent's involvement with his treatment, Patient R.E. had been evaluated for peripheral vascular disease, and was referred to a vascular specialist who recommended revascularization by way of bypass surgery. However, Patient R.E. declined the referral and elected to undergo chelation therapy instead. Mainstream physicians do not consider chelation an effective therapy for peripheral vascular disease, though Patient R.E. believed that it relieved his symptoms. After the November 11, 1999, physical exam, Patient R.E. was seen by the previous physician for three-month follow- ups on February 24, 2000, and June 5, 2000, with no particular complaints. As noted above, Respondent first saw Patient R.E. on August 28, 2000. This visit was for shortness of breath, diagnosed as bronchitis and treated with antibiotics and inhalants. Patient R.E. returned to see the previous physician on September 11, 2000, with chest congestion and coughing. This was his last office visit prior to January 16, 2001. The office visit of January 16, 2001, was a complaint- driven visit, meaning that Respondent's exam addressed Patient R.E.'s specific complaint. Such an exam is appropriate where the physician has a chart with a record of a complete history and physical exam. Respondent checked Patient R.E.'s blood pressure and listened to his heart and lungs, which were clear. Respondent then examined Patient R.E.'s right ankle, finding erythema (redness) and tenderness to palpation. Respondent did not perform an examination to address peripheral vascular disease, because he did not consider peripheral vascular disease as the presenting problem and was already aware that peripheral vascular disease was present in this patient. Respondent recorded a diagnosis of "? gout vs. cellulitis." Gout is an inflammation of the joints caused by deposition of uric acid crystals in the joint fluid. Cellulitis is a term given to an infection of the tissue, typically skin and underlying soft tissue. Gout and cellulitis are symptomatically similar conditions, in that both typically present with pain, stiffness, swelling, and redness of the affected area. Respondent prescribed Levaquin, an antibiotic, and Indocin, a medication for gout with some pain-relieving properties. Respondent told Patient R.E. to follow up in ten days, and gave Patient R.E. a quantity of medication for ten days' duration. Respondent's office chart did not clearly indicate instructions for the frequency or duration of the Levaquin prescription. The chart indicated that the Indocin was to be taken three times per day, but did not indicate a duration for taking the medication. On January 17, 2001, Patient R.E. telephoned Respondent's office to request a walker. On January 18, 2001, Respondent ordered a walker through a home health care provider and had it delivered to the patient's home. Respondent heard nothing from Patient R.E. on January 19, 2001. On Saturday, January 20, 2001, Respondent's office was closed. That evening, he received a telephone call from Patient R.E.'s wife, who told him that her husband was in a lot of pain. Respondent told the wife that Patient R.E. had not been on the prescribed medications long enough to cure his condition, and that if his pain became worse she should take him to the hospital emergency room. Shortly after 8:00 p.m., on January 20, 2001, Patient R.E. presented at the emergency room of Oak Hill Hospital complaining of pain and tenderness in his right ankle. There was an intact red blister over the ankle. The emergency room physician performed an examination, ordered blood tests, and confirmed the diagnosis of cellulitis. Patient R.E. was given injections of insulin and of Rocephin, an antibiotic. The emergency room physician instructed Patient R.E. to continue taking the Levaquin, and to stop taking the Indocin for the suspected gout. Respondent consulted with the emergency room physician by telephone. At Respondent's suggestion, the emergency room physician also prescribed Flagyl, another antibiotic, to ensure coverage against all potential anaerobes or aerobes that could cause cellulitis. The emergency room physician told Patient R.E. to follow up with Respondent on Monday, January 22, 2001. The emergency department of Oak Hill Hospital provided Patient R.E. with written discharge instructions for his cellulitis, including the following information: With antibiotic treatment, the size of the red area will gradually shrink in size until the skin returns to normal. This will take 7-10 days. The red area should never increase in size once the antibiotic medicine has been started. FOLLOW UP with your doctor or this facility as directed. If you were not given a specific follow-up appointment, look at the infected area in two days for the warning signs listed below. RETURN PROMPTLY or contact your doctor if any of the following occur: Increasing area of redness Increasing swelling, or pain Appearance of pus or drainage Fever over 100.5 orally Patient R.E.'s wife telephoned Respondent's office on Tuesday, January 23, 2001, to schedule a follow-up visit. The office visit was scheduled for January 26, 2001. On the scheduled date, Respondent examined Patient R.E. and found that his ankle had worsened and begun to develop necrosis. Respondent referred Patient R.E. to Dr. Malik Piduru, a vascular surgeon, for debridement, instructed him to continue taking the prescribed antibiotics, and to soak his foot in soapy water, which would help to debride the necrotic tissue in the interim. On February 1, 2001, Dr. Piduru examined Patient R.E. and noted a blue-black discoloration on the right lateral aspect of the lower right leg. The physical examination notes stated: "On the right lateral aspect of the leg approximately 6 x 4 cm necrotic, gangrenous patch of skin which appeared to be very fluctuant indicating underlying either abscess or hematoma of necrosis. The foot itself does not appear to be acutely ischemic and appears to be pink and viable." Dr. Piduru recommended hospitalization, excision of the necrotic area, and evaluation for further peripheral vascular disease correction. He also discussed the option of amputation if the leg did not heal. The surgeon noted that Patient R.E. understood the options presented to him, and the risks involved, but that Patient R.E. preferred to pursue another course of chelation therapy rather than undergo the recommended bypass surgery to correct the PVD. On February 5, 2001, Patient R.E. was admitted to the hospital for debridement of the right ankle. While in the hospital, Patient R.E. underwent an angiogram that revealed multiple occlusions of the blood vessels of the right leg. Dr. Piduru recommended bypass surgery, though he estimated the chances of success at around 30 percent. After discussion of all the options, Patient R.E. elected to have his right lower leg amputated. Dr. Piduru agreed that this was a reasonable decision in light of all the known factors. Patient R.E.'s right leg was amputated below the knee on February 12, 2001. In March 2001, Patient R.E. suffered an infection of the stump requiring additional hospitalization for debridement. His health continued to decline due to his multiple medical problems, including pain and peripheral vascular disease. On April 14, 2001, Patient R.E. was again admitted to Oak Hill Hospital with cellulitis of the left foot and the right stump. He declined any invasive procedures to restore circulation to his left leg. Patient R.E. was discharged to a hospice on April 20 and died on April 23, 2001. Dr. Patrick Hennessey, Petitioner's expert, testified that he reviewed all of the pertinent medical records concerning the treatment and care provided by Respondent to Patient R.E. and that based upon his review of these records and based upon his education, training, and experience, it was his opinion to within a reasonable degree of medical probability that Respondent deviated from the accepted standard of care in his treatment and care of Patient R.E., which constituted a violation of Subsection 458.331(1)(t), Florida Statutes. Dr. Hennessey also testified that in his opinion, Respondent violated Subsection 458.331(1)(m), Florida Statutes, in that he failed to compile appropriate medical records reflecting the treatment and care provided to Patient R.E. Dr. Hennessey's opinion as to the standard of care was based on several criticisms of the examination conducted on January 16, 2001. First, Dr. Hennessey opined that Respondent should have scheduled a follow-up appointment within three days to evaluate Patient R.E.'s clinical response to the prescribed medicines. The quick follow-up was indicated because of Patient R.E.'s advanced age, and because Patient R.E.'s diabetes and peripheral vascular disease could cause the cellulitis to progress rapidly. Dr. Hennessey also noted that peripheral vascular disease can reduce the effectiveness of antibiotics, further indication of the need for a prompt follow-up examination. Dr. Hennessey also believed that a three-day follow-up was necessary to definitively rule out the differential diagnosis of gout, if Respondent seriously believed gout was a possibility. Dr. Hennessey testified that Indocin should have provided relief from gout within three days, and that Levaquin should have stopped any increase in swelling, pain, or size of the affected area if Patient R.E. was suffering from cellulitis. In Dr. Hennessey's opinion, a three-day follow-up appointment would have allowed Respondent to determine whether Patient R.E. was obtaining relief and, if not, to try a different antibiotic regime or pursue other avenues of treatment. Dr. Hennessey also believed that Respondent should have tested Patient R.E.'s blood sugar level on January 16, 2001. Dr. Hennessey testified that diabetes has an impact on a person's ability to fight infection, and that the right antibiotic would be inadequate if the patient had uncontrolled diabetes. Thus, Respondent should have assessed Patient R.E.'s current and recent diabetic controls. Finally, Dr. Hennessey criticized Respondent for failing to give Patient R.E. adequate instructions for monitoring his own progress after the January 16, 2001, appointment. Dr. Hennessey testified that the instructions that the Oak Hill Hospital emergency room provided to Patient R.E. on January 20, 2001, set forth in full above, were precisely the kind of instructions Respondent should have given to Patient R.E. on January 16, 2001. Dr. Hennessey could not say whether the amputation of Patient R.E.'s right leg was inevitable, though he conceded it was likely to occur within a year or two even if his preferred course of treatment had been followed. He concluded that, on January 16, 2001, the correct alternative was to undertake an "aggressive evaluation" and to make the case to Patient R.E. that he should undergo surgical re-vascularization immediately, while the skin was still intact. Dr. Hennessey's "best guess" was that this course could have given Patient R.E. "probably fifty percent or better likelihood" of avoiding amputation, though he also conceded that "there's a lot of unknowns in there." Dr. Hennessey concluded that the time lost between January 16 and February 1, when Patient R.E. was seen by Dr. Piduru, the vascular surgeon, made a successful outcome much less likely. Respondent's expert, Dr. Kent Corral, testified that he reviewed all of the pertinent medical records concerning the treatment and care provided by Respondent to Patient R.E. and that based upon his review of these records and based upon his education, training, and experience, it was his opinion to within a reasonable degree of medical probability that Respondent did not deviate from the accepted standard of care in his treatment and care of Patient R.E. Dr. Corral also testified that in his opinion, Respondent did not violate Subsection 458.331(1)(m), Florida Statutes, by failing to compile appropriate medical records reflecting the treatment and care provided to Patient R.E. Dr. Corral testified that Respondent's examination of Patient R.E. was within the standard of care. The examination was complaint-driven, directed at the immediate presenting problem, a common and acceptable method employed by nearly all physicians in office practice. Dr. Corral testified that gout versus cellulitis is a very common differential diagnosis, especially in a patient with diabetes. Because there was inflammation of the ankle, peripheral vascular disease would fall very low on the list of possible diagnoses. Had Patient R.E. presented with a cold, necrotic foot, then peripheral vascular disease would have been more likely to be the presenting problem. Respondent knew that Patient R.E. had peripheral vascular disease, and it was apparent from the presenting symptoms that peripheral vascular disease was not the acute problem on January 16, 2001. Dr. Corral agreed that setting a three-day follow-up appointment would have met the standard of care. However, Dr. Corral disagreed that it was necessary to do so. He believed that Respondent reasonably elected not to schedule a three-day follow-up, but to follow up in ten days. Based on the information available on January 16, 2001, it was not unreasonable for Respondent to test the ten-day course of the prescribed antibiotics before scheduling a follow-up appointment. Dr. Corral testified that no laboratory tests were necessary to arrive at the differential diagnosis of gout versus cellulitis. He agreed that there was "potentially" some benefit to be derived from testing Patient R.E.'s blood sugar, but did not agree that Respondent's failure to do so amounted to practice below the standard of care. When Patient R.E.'s blood sugar level was checked in the emergency room on January 20, 2001, it was only slightly elevated. Dr. Corral also disagreed that Respondent failed to meet the standard of care in not giving Patient R.E. instructions on monitoring his own progress. Dr. Corral concluded that instructions would have made no difference. In his opinion, the antibiotic therapy was the only essential treatment to pursue on January 16, 2001. Dr. Corral believed that anything beyond the antibiotics would amount to "a hope and a prayer." In summary, Dr. Corral found the examination adequate and the diagnosis correct. He believed that the criticism of Respondent was due entirely to the poor outcome for Patient R.E., and that the poor outcome was not caused by anything Respondent did or did not do on January 16, 2001. In his own defense, Respondent testified that, prior to the January 16, 2001, appointment, he knew he was dealing with a very difficult patient who had a history of declining surgical intervention to resolve his circulatory problems. Respondent testified that his "first and foremost belief" was that Patient R.E. had cellulitis, and that the only other option, given the presenting symptoms, was an acute attack of gout. The potential for gout led him to prescribe Indocin as well as the antibiotics, because the Indocin would control the pain. Respondent noted that the emergency room physician confirmed his diagnosis of cellulitis on January 20, 2001. Respondent did not chart peripheral vascular disease on January 16, 2001, because that was not the presenting problem. Further, Respondent testified that Patient R.E.'s cellulitis was not necessarily related to peripheral vascular disease. Patient R.E. had several other problems, such as his heavy smoking and his diabetes, that could have generated cellulitis independently of peripheral vascular disease. Respondent disagreed with Dr. Hennessey's suggestion that "aggressive evaluation" and immediate surgery might have saved Patient R.E.'s foot, because it would not be prudent to undertake surgery until the cellulitis infection was cleaned up. Immediate surgery would have the potential of infecting the bypass grafts. On January 16, 2001, Patient R.E.'s foot was not gangrenous, and Respondent believed it essential to give Patient R.E. a reasonable trial of antibiotic therapy before sending him for surgical evaluation. Respondent's opinion on this issue was supported by Dr. Malik Piduru, the vascular surgeon who performed the amputation on Patient R.E.'s right leg. Dr. Piduru testified that in a patient with peripheral vascular disease and a diagnosis of cellulitis with no acute gangrenous changes or acute pain, the standard of care is to treat the infection first, then perform the re-vascularization. The weight of the evidence does not support an ultimate finding that Respondent failed to practice medicine with an acceptable level of care in the treatment of Patient R.E. Dr. Hennessey's conclusion that a more "aggressive evaluation" might have improved the chances of saving Patient R.E.'s leg rests on the assumption that Patient R.E. would have agreed to the proposed surgery had it been recommended on January 16, 2001. Patient R.E. rejected bypass surgery on his left leg before he became Respondent's patient, rejected it again in February 2001, and rejected it a third time in April 2001 when his right leg was threatened by cellulitis. There is little reason to assume that his decision would have been different on January 16, 2001. In view of all the evidence, the expert testimony of Dr. Corral was at least as persuasive as that of Dr. Hennessey in regard to the standard of care and Respondent's actions in this matter. Dr. Hennessey believed that the standard of care required a more aggressive approach to Patient R.E.'s presentation from the outset. Dr. Corral agreed that Dr. Hennessey's approach to the case would have met the standard of care, but also concluded that Respondent's approach was unexceptionable. Further, Dr. Hennessey could state with no degree of confidence that his own approach would have changed the ultimate outcome for Patient R.E. Dr. Hennessey opined that Respondent should have taken a blood sugar level and have given Patient R.E. detailed instructions for self-monitoring similar to those he later received at Oak Hill Hospital. Dr. Corral agreed that a blood sugar level might have been helpful, but was not necessary to meet the standard of care given the presentation and differential diagnosis. Dr. Corral believed that the failure to provide instructions was de minimus at most. Given the facts presented, Dr. Corral's opinion on these issues was at least as persuasive as Dr. Hennessey's. The evidence did not support a finding that Respondent took lightly Patient R.E.'s condition, or failed to consider any of the many variables created by Patient R.E.'s complicated history in arriving at a therapeutic approach. Respondent correctly diagnosed Patient R.E.'s cellulitis, and reasonably decided to attempt a course of antibiotic treatment to heal the infection before pursuing surgical options. The evidence presented at the hearing failed to establish that Patient R.E.'s poor outcome could be fairly attributed to Respondent's treatment of Patient R.E. on January 16, 2001. The main evidence submitted in support of the contention that Respondent failed to keep adequate medical records was directly related to the standard of care claim. Dr. Hennessey conceded that Respondent's medical record was minimally sufficient to justify the treatment provided. His chief criticism of Respondent's records for the January 16, 2001, appointment focused on the lack of documentation to explain actions that Respondent did not take, i.e., set a three- day follow-up appointment, order laboratory tests, and provide detailed instructions to Patient R.E. Because it has been found that the standard of care did not require Respondent to take these actions, his medical records cannot be faulted for failure to explain why he did not take them. However, Dr. Hennessey rightly criticized the lack of examination detail noted in the records of the January 16, 2001, examination. It was established at the hearing that Respondent charted by exception, meaning that he noted only positive findings rather than every unremarkable detail of the examination. Dr. Hennessey noted that, while this method of charting is acceptable practice, it was not acceptable that Respondent provided no description of the size or location of the erythema or the extent of the swelling of the ankle. Such detail would be essential to a subsequent treating physician in determining whether Patient R.E.'s condition had worsened. Further, Respondent did not note the frequency or duration of the Levaquin prescription, or the duration of the Indocin prescription, though Respondent credibly testified that he gave Patient R.E. oral instructions as to both medications. Again, a subsequent treating physician would need to know the details of Patient R.E.'s current medications before undertaking treatment. Finally, Respondent's notes were in several places illegible. Petitioner did establish that Respondent's records failed to document the office notes in a completely legible manner. The detail in Respondent's records was sufficient to justify the course of treatment on January 16, 2001, but their illegibility and lack of detail made them of limited use to anyone other than Respondent in assessing Patient R.E. for subsequent treatment. Patient R.E. was not exposed to potential injury because Respondent was consistently available to consult with the other treating physicians, but this fact does not cure Respondent's failure to keep adequate, legible records.
Recommendation Based on all the evidence of record, it is RECOMMENDED that the Board of Medicine enter a final order holding that the evidence is not clear and convincing that Respondent has violated Subsections 458.331(1)(t), Florida Statutes, in his treatment of Patient R.E., and that the evidence is clear and convincing that Respondent has violated Section 458.331(1)(m), Florida Statutes, in his failure to keep appropriate written medical records regarding his treatment of Patient R.E. and that Respondent be reprimanded for that violation. DONE AND ENTERED this 17th day of July, 2003, in Tallahassee, Leon County, Florida. S LAWRENCE P. STEVENSON 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 17th day of July, 2003. COPIES FURNISHED: Bruce A. Campbell, Esquire Department of Health 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Christopher J. Schulte, Esquire Burton, Schulte, Weekley, Hoeler & Beytin, P.A. 100 South Ashley Drive, Suite 600 Tampa, Florida 33602 Larry McPherson, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 R.S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
The Issue The issues in this case are whether Respondent violated Subsections 458.331(1)(t) and 458.331(1)(m), Florida Statutes (1995), as alleged in the Administrative Complaint, and, if so, what is the appropriate discipline to impose.
Findings Of Fact The Parties Petitioner is the state agency charged with regulating the practice of medicine in Florida, pursuant to Section 20.43, Florida Statutes, and Chapters 456 and 458, Florida Statutes. Petitioner has contracted with the Agency for Health Care Administration to provide consumer complaint, investigative, and prosecutorial services required by the Division of Medical Quality Assurance pursuant to Section 20.43(3), Florida Statutes. Respondent is a licensed physician in the State of Florida, having been issued License No. ME0053370, and is board- certified in orthopedic surgery. Respondent's medical license has never previously been subject to discipline. The Injury and Treatment On March 3, 1995, Patient D.L., then aged 76, fell off a curb and injured her face and right wrist. She presented to the emergency room at Columbia Northside Medical Center in St. Petersburg, Florida, with severe contusions to her face and an aching wrist. Patient D.L. was evaluated by the emergency room physician, who documented the pertinent medical information, including the physical findings, results of diagnostic x-rays taken of Patient D.L.'s wrist, and the recommended treatment plan. She was diagnosed by the emergency room physician as having severe contusions to her face and a wrist fracture, commonly known as a Colles fracture. The physician applied an air splint to Patient D.L.'s arm, ordered a consult with an orthopedic physician to evaluate it, and admitted her into the hospital for observation. The admitting physician documented an admission note on March 3, 1995, noting a history and physical examination, findings, diagnosis, and treatment plan. At 2:00 on the following day, Respondent and his physician's assistant, Paul Russo, examined Patient D.L., pursuant to the consult order and diagnosed her as having a "comminuted, impacted, slightly shortened distal radius fracture with minimal angulation; will need a short arm cast." No further written report of Respondent's initial evaluation or diagnosis exists. On March 6, 1995, Patient D.L. purportedly was experiencing some hallucinations and exhibiting psychotic behaviors, and was ordered to remain admitted to the hospital for psychiatric evaluation. Respondent was not advised of her condition. Respondent admits that he currently has no specific recollection of Patient D.L. Respondent had a general policy of discussing his findings and diagnosis with his patient, as well as the various treatment options available; however, Patient D.L.'s chart does not reflect such a discussion. Notwithstanding Respondent's written diagnosis calling for a short-arm cast, Respondent placed her wrist in a long-arm cast. While Respondent explains that the long-arm cast was necessary to restrict and limit certain movements of Patient D.L.'s arm, there is no information within Patient D.L.'s chart noting the event or the modification rationale. Respondent explains that it is his policy to instruct each of his patients to follow-up with an appointment in his office within a week to ten days. However, it is clear that Patient D.L.'s chart does not reflect any communication or instructions. Respondent explained that he and his physician's assistant regularly documented various activities in the hospital chart's progress notes as a matter of policy, including the evaluation, findings, diagnosis, and disposition. It is clear, however, that Patient D.L.'s hospital chart contains no written notes made by Respondent relating to her history, physical examination, or disposition. On March 8, 1995, Patient D.L. was discharged to a nursing home with an order by the attending physician to follow- up with Respondent in two weeks. Two weeks later, on March 22, 1995, Patient D.L. presented to Respondent's office for a follow-up appointment. Upon arrival, Patient D.L. completed paperwork, including a Patient Medical Questionnaire, and was evaluated. Respondent's typed progress note indicates that Patient D.L. had extensive arthritis throughout her hand with very limited range of motion of her fingers. There is no patient history or physical in Respondent's note. On that same day, Respondent ordered and reviewed x-rays of Patient D.L.'s wrist which revealed that the fracture had remained in satisfactory position, with essentially neutral angulation of the lateral view and some shortening on the AP view. Respondent's note indicates that he removed Patient D.L.'s long-arm cast and placed her in a short-arm cast. The note indicates that Respondent instructed Patient D.L. to wear the cast for an additional three to four weeks; and thereafter, would likely require splinting and therapy. Respondent was advised that Patient D.L. was relocating to Fort Lauderdale, and Respondent instructed her to seek treatment there. Although Respondent explains that Patient D.L. would have likely been given the x-rays to take to the next orthopedic surgeon, the medical records do not indicate that Patient D.L. received them. On April 4, 1995, Patient D.L. presented to Lewis Eastlick, M.D., in Plantation, Florida. Dr. Eastlick noted that an abutment of the ulna was displaced which caused marked shortening of the radius and resulted in a permanent deformity of Patient D.L.'s wrist. Dr. Eastlick referred Patient D.L. to physical therapy. Petitioner established by clear and convincing evidence that Respondent's medical records for Patient D.L. were inadequate. Respondent did not sufficiently document, in writing, his evaluation, diagnosis, treatment, and patient communication. The testimony provided by Petitioner's experts, relating to documentation, was reasonable and credible. The testimony provided by Respondent's expert, Dr. Wasylik, relating to record keeping was less credible, given the available physical evidence. While Dr. Wasylik opined that Respondent's hospital progress note dated March 4, 1995, and the office record dated March 22, 1995, contain sufficient information regarding Patient D.L.'s condition and Respondent's evaluations and treatment plans, his conclusion was not supported by the evidence. Furthermore, Respondent's suggestion that Patient D.L.'s dictation notes may have been lost by the transcription service lacks credence. Although it is clear that Respondent deficiently memorialized certain information, Petitioner did not prove by clear and convincing evidence that Respondent's casting treatment of Patient D.L. fell below the applicable standard of care. In fact, one of Petitioner's own experts, Dr. Averbuch, agrees with Respondent's expert that casting Patient D.L.'s fractured wrist was more appropriate than utilizing more aggressive treatment via an external fixation or open reduction with internal fixation. The experts conclude that the fracture was non-displaced and impacted and in good position, making it more stable and more appropriate for casting. Respondent adhered to the standard of care in treating Patient D.L.'s fractured wrist by placing it in a cast. In addition, Petitioner did not demonstrate by clear and convincing evidence that Respondent's follow-up care fell below the applicable standard of care. Although it is established that Respondent did not see Patient D.L. until eighteen days after the initial setting of her fracture, the evidence is clear that Respondent regularly requested patients to follow up in his office within one week to ten days. Despite the fact that Petitioner's experts opine that Respondent should have seen Patient D.L. sooner, it is important to note that Patient D.L. was specifically instructed in writing by her attending physician, upon her discharge from the hospital on March 8, 1995, to follow up with Respondent in 14 days, which she did. There is no evidence that Respondent was made aware of Patient D.L.'s new psychiatric condition and extended hospitalization nor that he should have inquired. Patient D.L. was admitted on March 3, 1995, for observation only, treated by the Respondent on March 4, 1995, and formally admitted for mental examination on March 6, 1995. Patient D.L.'s mental status was not at issue until March 6, 1995, two days after Respondent placed her arm in a cast.
Recommendation Upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health, Board of Medicine, enter a Final Order finding that Respondent, Clinton Bertrand Davis, M.D.: DID violate Subsection 458.331(1)(m), Florida Statutes (1995), and is ordered to pay a $5,000.00 fine, to be paid within 30 days, and undergo ten hours of Continuing Medical Education related to medical records documentation within 90 days; and DID NOT violate Subsection 458.331(1)(t), Florida Statutes. DONE AND ENTERED this 8th day of August, 2003, in Tallahassee, Leon County, Florida. S WILLIAM R. PFEIFFER 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 8th day of August, 2003. COPIES FURNISHED: Daniel Lake, Esquire Department of Health Prosecutorial Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Christopher J. Schulte, Esquire Burton, Schulte, Weekley, Hoeler & Beytin, P.A. 100 South Ashley Drive, Suite 600 Tampa, Florida 33602 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Larry Mcpherson, Executive Director Board of Medicine Department Of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
The Issue The issues in this case for determination are whether Respondent James C. Dozier, M.D., committed the violations of Chapter 458, Florida Statutes (2003), as alleged in an Administrative Complaint filed by the Department of Health on October 3, 2006; and, if so, what disciplinary action should be taken against his license to practice medicine in Florida.
Findings Of Fact The Parties. Petitioner, the Department of Health (hereinafter referred to as the "Department"), is the agency of the State of Florida charged with the responsibility for the investigation and prosecution of complaints involving physicians licensed to practice medicine in Florida. § 20.43 and Chs. 456 and 458, Fla. Stat. Respondent, James C. Dozier, M.D., is, and was at the times material to this matter, a physician licensed to practice medicine in Florida, having been issued license number ME 47971. Dr. Dozier’s mailing address of record at all times relevant to this matter is Indian River Memorial Hospital Department of Emergency Medicine, 1000 36th Street, Vero Beach, Florida 32960. Dr. Dozier is board-certified in Emergency Medicine. Dr. Dozier has previously been subject to license discipline in Agency for Health Care Administration Case Number 93-20295. Patient D.C. On September 3, 2003, Patient D.C. was 49 years of age and obese. He was living a largely sedentary lifestyle, having suffered a work-related spinal injury several years before 2003. D.C. did not work. He was taking methadone, a powerful narcotic painkiller used for long-term, chronic pain relief, daily. As a result of his spinal injury, D.C. spent most of his time at home and did not engage in significant physical activity. On September 3, 2003, D.C. experienced an episode of hard coughing, during which he produced brown sputum. At approximately 9:15 a.m., September 4, 2003, D.C. awoke with sharp, left-sided chest and shoulder pain, and shortness of breath. The pain in his chest was excruciating and he had difficulty breathing. Consequently, his wife, S.C., telephoned 911 and requested emergency assistance at approximately 9:19 a.m. Transport of Patient D.C. to the Hospital. Emergency medical services personnel (hereinafter referred to as “EMS Personnel”), arrived at D.C.’s house at approximately 9:25 a.m., September 4, 2003. What transpired beginning with the arrival of EMS Personnel and their delivery of D.C. to Indian River Memorial Hospital (hereinafter referred to as “Memorial Hospital”), was documented in an Indian River County EMS report, Incident # 014509 (hereinafter referred to as the EMS Report). A copy of the EMS Report was admitted as Petitioner’s Exhibit 3. As alleged in the Administrative Complaint, the EMS Report indicates the following: D.C.’s lung sounds were decreased on the left side with wheezes in several fields bilaterally and during transport to the hospital there was no change in his pain, although there was a decrease in the wheezing; At 9:27 a.m. D.C.’s pulse rate was 110, respiratory rate was 24 and oxygen saturation level was 92 percent by pulse oximetry; At 9:39 a.m. D.C.’s pulse rate was 116, respiratory rate was 24, and oxygen saturation level was 97 percent after the administration of oxygen by nasal cannula. A copy of the EMS Report was not provided to Memorial Hospital until after the events relevant to this case. While the EMS Report notes that EMS Personnel “[t]ransferred care to ER nurse with report,” the nature of the “report” was not proved during the hearing of this matter. Dr. Dozier was not made aware of the contents of the EMS Report or the “report” purportedly made by EMS Personnel to the emergency room nurse. Nor did he make any effort to inquire about D.C.’s condition during the time he was in the care of EMS Personnel. While the evidence presented at hearing proved that Dr. Dozier should have made an effort to inquire about D.C.’s condition during the time he was in the care of EMS Personnel, the charges in this case are limited to Dr. Dozier’s actions after D.C.’s arrival at Memorial Hospital; there is no allegation in the Administrative Complaint relating to any failure on the part of Dr. Dozier to determine what data EMS Personnel were aware of or ultimately reported. Most importantly, while there are allegations of fact concerning what EMS Personnel determined about D.C.’s condition, the Administrative Complaint does not inform Dr. Dozier of how those facts related to his care of D.C. What was in the EMS Report is, therefore, ultimately not relevant in deciding whether the allegations of the Administrative Complaint have been proved. Counsel for the Department has accurately reported parts of the EMS Report in paragraphs 23 through 32 of Petitioner’s Proposed Recommended Order and counsel for Dr. Dozier have accurately summarized some of the information contained in the EMS Report in their proposed finding of fact 8. Those proposed findings of fact, although accurate, have not been included in this Recommended Order because they relate to information which Dr. Dozier never had at the times relevant to this case. Dr. Dozier’s Treatment of Patient D.C. EMS personnel delivered D.C. at Memorial Hospital at approximately 9:54 a.m., September 4, 2003. It was documented in the Emergency Room (hereinafter referred to as the “ER”), nurse’s notes, that D.C., upon arrival, reported that he had suffered a severe coughing spell the night before, experienced increased shortness of breath, coughed up dark brown sputum, and had felt sharp left-side chest pain. It was also documented that D.C.’s oxygen saturation was 94 percent on supplemental oxygen; he was experiencing the highest level of left-sided chest pain, pain that increased with deep breaths; he was awake, alert, and oriented; his complexion was normal in color; his pulse rate was 99 beats per minute; and his respiratory rate was 22 breaths per minute. An ER nurse noted that D.C. had a history of spinal surgery and was taking methadone. Another ER nurse saw D.C. at approximately 10:00 a.m. The nurse noted in the record that D.C. was suffering sharp pain on inspiration, his oxygen saturation had increased to 97 percent on two liters of supplemental oxygen, and that he had decreased breath sounds on the left side of his chest. One of the nurses who saw D.C. ordered blood tests, including a complete blood count, cardiac markers, a differential, and a complete metabolic panel. The blood tests were subsequently cancelled. The only documentation in D.C.’s medical records at Memorial Hospital indicates that the tests were cancelled at 10:15 a.m. with a notation “Cancelled Requested by Nurse/MD PER DR DOZIER,” although Dr. Dozier did not first see D.C. until approximately 10:15 a.m. Dr. Dozier testified at final hearing that the tests had been cancelled at D.C.’s request. There are no medical notes to substantiate this testimony. Dr. Dozier documented his care of D.C. in an “Any Complaint Template” form with a time stamp of 10:17:33 a.m. Dr. Dozier noted in the Any Complaint Template that D.C. was suffering from sharp, left-sided chest pain of several hours duration with splinting (stiffening of the body to avoid pain caused by movement) and decreased breath sounds on the left side. Dr. Dozier also documented that D.C.’s past medical history included chronic pain that was being treated by methadone. Dr. Dozier ordered a chest X-ray and an EKG. He also started D.C. on Toradol, a non-steroidal, anti-inflammatory drug used for pain relief, and Levaquin, an antibiotic. The chest X- ray and EKG were documented in the Any Complaint Template. The EKG performed on D.C. was normal. His chest X-ray was interpreted by the radiologist as normal, except that he was exhibiting poor inspiratory effort. Dr. Dozier, under “differential diagnosis,” listed pleurisy (an inflammation of the lining of the chest wall and lungs marked by chest pain that increases on inspiration) first and pneumonia (an infection of the lungs marked by a severe cough, chest pain, and fever) second. A “differential diagnosis” was explained by Dr. Murray: Differential diagnosis is when you have a patient that comes into the emergency room and he has this constellation of signs and symptoms and risk factors. You try to put it together, you make a list, here’s all the possible things that could be wrong with this guy. So that’s your differential diagnosis. What are the possibilities here with what I have to look at. So you list our differential diagnosis. Transcript, page 39, lines 22-25, and page 40, Lines 1-4. Based upon the information which Dr. Dozier had concerning D.C., while pleurisy and pneumonia were reasonably included in his differential diagnosis, he should have also considered myocardial infarction, bronchitis, and, most significantly, pulmonary embolus. Of significance in this case, is Dr. Dozier’s failure to include pulmonary embolus in his differential diagnosis. Pulmonary embolus is a condition whereby the arteries in the lungs are blocked by one or more blood clots. A pulmonary embolism usually occurs when blood clots that have formed in the veins of a person’s extremities dislodge and are transported by the blood stream to the lungs where they become trapped by smaller arteries. The formation of blood clots in the extremities is called deep vein thrombosis (hereinafter referred to as the “DVT”). When blood clots become lodged in the lungs, the lungs can be damaged or, if blood flow becomes too constricted, the person can die. Pulmonary embolisms are encountered in emergency rooms with some frequency. In determining whether a person is suffering from pulmonary embolus, the common risk factors must be considered. Those risk factors include a history of previous pulmonary embolus or DVT; immobilization (the person is confined to bed, sedentary, or has recently taken a long trip); smoking; obesity; hypercoagulablity (increased tendency of the blood to clot); and cancer. The most common signs of pulmonary embolus are chest pain, usually of sudden onset and which becomes worse with deep breathing or coughing; shortness of breath, again of a sudden nature; sweating; nausea; rapid breathing or tachypnea; increased heart rate or tachycardia; low oxygen saturation; and hemotysis or coughing up blood. Making it difficult to diagnose, a patient with a pulmonary embolism may present with various combinations of symptoms, and the symptoms are often similar to those of other ailments, such as heart attack, bronchitis, pleurisy, pneumothorax, acid reflux, dissecting thoracic anerurysm, and pneumonia. Tests which can assist a physician in the either confirming or ruling out a pulmonary embolism, include ventilation/perfusion scanning (hereinafter referred to as “V/Q Scanning”), d-dimer testing, spiral computerized axial tomography, pulmonary angiography, and Doppler ultrasound. While not all of these tests were available to Dr. Dozier, V/Q Scanning was. Pulmonary embolus should have been included in Dr. Dozier’s differential diagnosis of D.C. because D.C. arrived at the ER with a chief complaint of chest pain and, as explained by Dr. Murray because of the following: Now, what would even make [pulmonary embolus] more likely, and perhaps having to pursue a little bit more, is the type of pain that he had, which is important to tell the difference between a lot of those conditions. He had pleuritic pain. That’s the classic type of chest pain that somebody with a pulmonary embolus has as classically described as pleuritic sharp chest pain. That’s what this patient had. Then what was the onset? Was this gradual onset or sudden? P[ulmonary] E[mbolism]s are sudden onset. As far as I can tell, when it says in timing, it says symptoms for, now I can’t read that, how many that is, but he had circled hours. So I can just assume that he told Dr. Dozier that he was having these symptoms just for however many hours that stands for. So I was worried about the chest pain, the nature of the chest pain, the short duration of it, that I think it says brownish – or I’m not even – I would cough brownish sputum. I think that’s what it says, but I couldn’t say for sure under history of present illness, which would make me worry about that. Transcript, page 85, lines 3-23. D.C.’s history of acute onset shortness of breath and severe left-side pleuritic chest pain, his possible hemoptysis the night before his arrival at Memorial Hospital, and his elevated pulse and respiratory rates, all facts that were documented in the medical records for D.C. at Memorial Hospital, should have caused Dr. Dozier to include pulmonary embolus in his differential diagnosis. As a result of the fact that he did not consider pulmonary embolus as a possible ailment, Dr. Dozier failed to order tests which could have helped him to rule out pulmonary embolus or led him to conclude that D.C. was suffering from the ailment. In particular, he failed to order a V/Q scan. Ultimately, Dr. Dozier released D.C., listing as his final diagnoses pleurisy and bronchitis (inflammation of the bronchial tubes marked by painful cough and fever). Dr. Dozier prescribed Vioxx, a non-steroidal anti-inflammatory drug, Levaquin, and Flexeril (a central nervous system depressant, commonly referred to as a “muscle relaxer”). Cancellation of the Blood Tests. As noted in Findings of Fact 19, blood tests ordered for D.C. were ultimately cancelled. According to Dr. Dozier, they were cancelled because D.C. refused the tests, a suggestion that was not documented by Dr. Dozier in D.C.’s medical records, despite the seriousness of a patient refusing tests which a physician prescribes. Given the significance of the consequences of such a refusal, Dr. Dozier’s testimony on this point is questionable and rejected as not convincing. Other facts also raise concerns about the credibility of Dr. Dozier’s testimony concerning the cancellation of the blood tests. For example, S.C. saw D.C. approximately an hour after his arrival at the hospital and found him quiet, pale, and looking very ill. At no time did D.C. or Dr. Dozier, whom she had spoken with, inform S.C. that D.C. had refused blood tests. It is also noted that D.C. did not refuse other tests, including the chest X-ray and EKG ordered by Dr. Dozier. Ultimately, Dr. Dozier’s explanation concerning the cancellation of the blood tests was not convincing, based upon findings made in this Recommended Order and because of the troublesome aspects of his testimony as explained in paragraph 51 of Petitioner’s Proposed Recommended Order, which is incorporated by reference. Despite this conclusion, ultimately, it was the Department’s burden to prove why the blood tests were cancelled. This the Department simply did not do. Ultimately the evidence simply proved that the tests were ultimately cancelled. Regardless of why the blood tests were cancelled, Dr. Dozier violated the standard of care, as found, infra. Instructions on Discharge. On discharge, D.C. was given the following written instructions on a pre-printed form: The doctor thinks your symptoms may be due to: PLEURISY. Keep this in mind: DIAGNOSIS WITH 100% CERTAINTY IS NOT POSSIBLE in the Emergency Department. Therefore, if you find you are not getting better, another diagnosis is possible, and you must see your doctor or return here. After you leave, you must properly care for your problem and observe its progress. If you do not improve as expected, or are worse, do one of the following. Immediately: contact your doctor or follow up doctor or call here [the ER]. Contact your doctor, call, or return here if you experience any of the following: A) high fever or chills B) difficulty breathing C) difficulty; swallowing or drooling D) pain or tightness in chest or neck E) thick green or bloody sputum F) fast pulse (more than 100 a minute at rest) G) vomiting. Your symptoms should improve within 4-6 days and should not worsen. You should be able to breathe comfortably when sitting or lying down, and should not be struggling to breathe. You should be able to eat, drink, and swallow without pain or drooling. Rest, drink plenty of fluids, and eat regular well-balanced meals. Use Acteminophen (Tylenol, etc.) for pain or fever, and take any prescribed medications. A cool-mist vaporizer may help decrease cough and discomfort. DO NOT use a hot mist vaporizer of hot steam. DO NOT smoke during your illness; smoking will delay your recovery. The forgoing instructions were consistent with Dr. Dozier’s diagnosis of pleurisy or bronchitis. Having failed to consider pulmonary embolus, the instructions were inadequate in failing to address this possible condition. The Standard of Care. The Department's expert, John V. Murray, M.D., credibly opined that Dr. Dozier failed to practice medicine in accordance with the level of care, skill, and treatment recognized in general law related to health care licensure in violation of Section 458.331(1)(t), Florida Statutes (hereinafter referred to as the "Standard of Care"), in his treatment of D.C. In particular, it was Dr. Murray’s opinion that Dr. Dozier violated the Standard of Care by failing to recognize the possibility that D.C. was experiencing a pulmonary embolism and, as a consequence, by failing to include pulmonary embolus in his differential diagnosis; and by failing to order diagnostic tests, in particular V/Q Scanning, which may have either ruled out or confirmed the existence of a pulmonary embolism. Dr. Murray’s opinions are credited and accepted. The opinions to the contrary offered by Dr. Dozier and his expert witness are rejected as not convincing and as not addressing the issues precisely enough. Too much was made of facts which were not available to Dr. Dozier at the time he made his differential diagnosis and the consequences thereof, unlike Dr. Murray, who specifically testified, when asked whether he attempted “to put yourself in Dr. Dozier’s shoes on the day these events occurred,” as follows: A. Yes, sir. I think that’s necessary. If you’re going to make a finding that was the standard of care, I think the standard of care relates to what would the prudent physician in the same circumstances on the same day do. In order to do that, you put yourself in those shoes. Say if I was there what would I do and what would be the standard of care for that, the minimum. Transcript, page 33, lines 22-25, and page 34, lines 1-3. Dr. Murray went on to explain that, although he had learned from the documents presented to him, information that Dr. Dozier did not have available while caring for D.C., he was able to limit his opinions appropriately to the time of the actual events and the information which Dr. Dozier was presented with. The opinions offered on behalf of Dr. Dozier were not so precisely limited. Medical Records. Dr. Dozier failed to document in his medical records for D.C. whether D.C. was a smoker or had recently taken any long trips, both facts which are relevant bits of information when considering pulmonary embolus. Dr. Dozier’s medical records were, therefore, inadequate in this regard. Dr. Dozier also failed to give adequate follow-up instructions for pulmonary embolus upon discharge. Dr. Dozier’s actions, however, were the result, not of his failure to include pulmonary embolus in his differential diagnosis, but in the failure to accurately diagnosis D.C.’s condition, a failure for which Dr. Dozier has not been charged. I. D.C.’s Demise. On September 6, 2003, D.C. died in his sleep. A postmortem autopsy of D.C. revealed that he died of “massive pulmonary thromboembole due to phlebothromboses of lower extremities.” It was found that D.C. had an abdominal malignancy, a significant contributing factor in the death of D.C. What role, if any, that Dr. Dozier’s failures in his treatment of D.C. contributed to D.C.’s ultimate demise was not proved.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the a final order be entered by the Board of Medicine finding that James C. Dozier, M.D., has violated Section 458.331(1)(m) and (t), Florida Statutes, as described in this Recommended Order; issuing a reprimand; imposing a fine of $10,000.00; requiring that he complete the Florida Medical Association’s “quality Medical Record Keeping for health Care Professionals” course or a Board-approved equivalent; and requiring that he complete five hours of continuing medical education in diagnosis and treatment of pulmonary embolus. DONE AND ENTERED this 20th day of September, 2007, in Tallahassee, Leon County, Florida. S LARRY J. SARTIN 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 20th day of September, 2007. COPIES FURNISHED: Don Freeman, Esquire Assistant General Counsel Prosecution Services Unit Department of Health 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3250 Barry A. Postman, Esquire Lee Cohen, Esquire Cole, Scott & Kissane, P.A. 1645 Palm Beach Lakes Boulevard Second Floor West Palm Beach, Florida 33401 Larry McPherson, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701 Josefina M. Tamayo, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Dr. Ana M. Viamonte Ros, Secretary Department of Health 4052 Bald Cypress Way, Bin A00 Tallahassee, Florida 32399-1701 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
