The Issue Whether the Respondent violated Section 468.365(1)(p), (u), and (w), Florida Statutes, as alleged in the Administrative Complaint and, if so, what disciplinary action should be taken against Respondent's license to practice respiratory therapy.
Findings Of Fact Respondent, Dena Wadzinski (Respondent), was at all times material hereto licensed as a certified respiratory therapist in the State of Florida, having been issued license number TT 0005509. She has been licensed to practice as a respiratory therapist since November 1990. Respondent was employed as a respiratory therapist by University Community Hospital (UCH) as a respiratory therapist in November 1993, working three twelve (12) hour shifts per week. Respondent worked continuously at UCH until January 6, 1995, when she went on maternity leave for eight weeks. On March 3, 1995, Respondent returned to her position as respiratory therapist at UCH. Respondent reported to work at approximately 6:25 a.m., and proceeded to the conference room where respiratory therapists receive their work assignments. Steve Horne, supervisor of respiratory therapist at UCH, assigned Respondent to the progressive care unit at UCH designated 3 North. Respondent was scheduled to work a twelve hour shift, from 7:00 a.m. to 7:00 p.m. At the time Mr. Horne gave Respondent the assignment, he apologized for having to assign her to 3 North on her first day back from maternity leave. 3 North, sometimes referred to as the "hell floor," is a very busy unit. This progressive care unit has ventilator patients and those classified as DNR (do not resuscitate). While the patients on 3 North do not meet the criteria for admission to an intensive care unit, they are too ill to be on a regular floor. Due to their conditions, these patients often require more attention from the respiratory therapists than patients on regular floors. After receiving her floor assignment, Respondent remained in the conference room and waited for Lisa McClure, the respiratory therapist assigned to 3 North on the preceding shift. At UCH, the normal procedure was for a respiratory therapist completing a shift to meet with the respiratory therapist who was relieving her to give a report regarding the patients on the assigned floor. Typically, the meeting between the respiratory therapists would take place at the time one shift began and the other shift ended. In light of this, given the assigned shifts of Respondent and Ms. McClure, the meeting should have occurred around 7:00 a. m. on March 3, 1995. However, Ms. McClure did not arrive at the conference room to give Respondent the report until approximately 7:35 or 7:40 a. m. After receiving a brief generalized report from Ms. McClure, Respondent reported to 3 North. Although Respondent was excited about returning to work, she was anxious about her first day back on the job. As to her mental state, Respondent was "overwhelmed," felt pressured to complete all her assigned job responsibilities, and "just wasn't in sync." Except for the maternity leave, since becoming a respiratory therapist, Respondent had never been away from the job for such an extended period of time. Also, this was the first time Respondent had been away from her baby since he was released from the hospital. Upon arriving at 3 North, Respondent went to the nurse's station, where she picked up her first chart and read an order for Patient F.P. Respondent admitted that she did not read the entire chart, nor did she look at any other charts at the nurse's station. Respondent reviewed the physician's March 3, 1995, order for Patient F.P. The order, written by Dr. Ashok Modh, indicated that Patient F.P. was to be placed on a trach collar with 40 percent oxygen from 8:00 a.m. to 8:00 p.m., as tolerated by the patient. Patient F.P. was on an intermittent mechanical ventilator rate (IMV) of 6 and PS of 10 from 8:00 p.m. to 8:00 a.m., the evening before. The IMV indicates the amount of breaths a ventilator gives the patient and the PS indicates the patient's own breaths. The ventilator actually counts all the breaths a patient takes regardless of how those breaths are achieved. The order Respondent reviewed on March 3, 1995, is consistent with Patient F.P. having been off the ventilator on previous days. The ventilator order for Patient F.P. indicated that the patient's ventilator settings should be as follows: tidal volume of 700, respiratory rate of 6 breaths per minute, and an inspired oxygen concentration of 40 percent. After reviewing Dr. Modh's order and leaving the nurse's station, Respondent turned left instead of right, and entered the room of Patient L.A. rather than the room of Patient F.P. Respondent believed she was in Patient F.P.'s room. Patient L.A. was seriously ill upon re-admission to UCH on December 6, 1994. Patient L.A. had a history of an abdominal aortio aneurysm, chronic obstructive pulmonary disease, and possible congestive heart failure and cerebrovascular disease. Patient L.A. was expected to live only a few weeks to a few months. Due to the Patient L.A.'s condition and prognosis, at the family's request, the patient was in a DNR (do not resuscitate) status. Patient L.A. was ventilator dependent without prospect of weaning. During the entire time he was at UCH, except for the brief time periods when the hospital staff attempted to wean him, Patient L.A. was on a ventilator. All attempts to wean Patient L.A. were unsuccessful. On the morning of March 3, 1995, Patient L.A.'s condition prevented him from being able to breathe without the assistance of a ventilator. On March 3, 1995, the physician's orders for Patient L.A. included the following ventilator settings: tidal volume of 750, respiratory rate of 22 breaths, and an inspired oxygen concentration of 50 percent. Patient L.A. was one of the patients on 3 North whom Respondent was assigned to care for on March 3, 1995. This was the first time that the Respondent had cared for Patient L.A. When Respondent entered Patient L.A.'s room, Nurse Glade was in the room near the medicine cabinet located in the patient's room. The two engaged in small talk, including some conversation about Respondent's baby. Respondent and Nurse Glade did not engage in any formal discussion regarding Patient L.A. or his condition. Respondent looked at Patient L.A. (thinking he was F.P.) and introduced herself. Patient L.A. did not acknowledge Respondent's presence, but just looked around the room. Respondent indicated to Nurse Glade that she was going to begin weaning the patient, although it is unclear whether Nurse Glade heard Respondent. After the statement by Respondent, Nurse Glade indicated that she would get the patient something to relax him because "he gets this way". Nurse Glade was referring to Patient L.A.'s apparent restlessness. However, in her conversation with Respondent, Nurse Glade did not specify the medication she intended to administer to Patient L.A. On the morning of March 3, 1995, Nurse Glade administered a shot of morphine to Patient L.A. sometime prior to Respondent removing the patient from the ventilator. However, the Respondent neither observed Nurse Glade administering the medication to Patient L.A. nor was Respondent aware of the type of medication Nurse Glade intended to or actually administered to the patient. Respondent left the Patient L.A.'s room for less than a minute to obtain trach collar, tubing, and oxygen from the supply closet down the hall. Respondent returned to Patient L.A.'s room and spoke to him briefly. Because Respondent noticed no secretions, she did not suction the patient. Respondent listened to the patient's breath sounds. The breath sounds were wheezy, but this was not unusual in a patient with chronic pulmonary disease. Still believing she was treating Patient F.P., Respondent looked at the ventilator and noticed a rate of 22. Based upon the fact Respondent knew F.P. was on an IMV of 6 per Dr. Modh's order, she concluded that the Patient L.A. was breathing 18 breaths on his own and thus was doing well. Considering all these factors, Respondent had no reason to believe that the Patient L. A. was not a proper candidate to wean from the ventilator. After assessing the patient, Respondent removed Patient L.A. from the ventilator and placed the trach collar on his neck. Respondent then hooked the tubing on the collar and then to the oxygen from the wall which was placed on 40 percent per Dr. Modh's order. Respondent observed the patient for approximately one minute after the ventilator was removed. Respondent then asked Nurse Glade who was in the room, whether she would be in the room for a few minutes, because Respondent wanted to go across the hall to begin work on another patient. After Nurse Glade indicated that she would be in the room, Respondent proceeded to the patient's room across the hall. Respondent did not anticipate a problem with leaving the patient because she believed that he had been previously weaned from the ventilator. Assuming that Respondent was carrying out the order on the correct patient, there is no specific time for which a respiratory therapist must remain with a patient after performing a procedure. About five minutes after leaving Patient L.A.'s room, Respondent heard someone call for respiratory. Having determined that the call was coming from Patient L.A.'s room, Respondent immediately went to the room where she found several nurses, one of whom was ambuing him. Respondent took over the ambuing from the nurse and proceeded to give Patient L.A. 100 percent oxygen. Dr. Modh, Patient L.A's pulmonary consultant, later arrived to assess the situation. At that time Respondent told Dr. Modh that she was weaning the patient, and "He didn't handle it". Dr. Modh responded, "Doing treatment?" Respondent then repeated, "No, I was weaning him". It was only at this point that Respondent learned that she had been treating Patient L.A., and not Patient F.P. When Dr. Modh entered Patient L.A.'s room, the patient was in agional cardiac rhythm, a cardiac rhythm which indicates the heart is dying. Dr. Modh ordered Epinephrine for Patient L.A., but when that was not successful, further efforts to resuscitate the patient were discontinued due to Patient L.A.'s DNR status. Patient L.A. was pronounced dead at 8:32 a.m. on March 3, 1995. Respondent went to speak with her supervisor and the risk manager, who instructed her to fill out an incident report. Several attempts were made by Respondent to complete an incident report, but her initial incident forms were too lengthy. Respondent was instructed to be short and to the point. Respondent was also directed to complete her charting before she left for the day. Respiratory therapists at UCH must use a computer to do their charting. Respondent sought assistance from Mr. Suggs, of UCH's Risk Management office. In order for a respiratory therapist to chart patient information, a therapy procedure must first be coded into the computer. Because Patient L.A. was to have received an aerosol treatment, Respondent entered an aerosol treatment for Patient L.A. The comment section of the form is limited to three lines. Respondent did not use all the available space, but believed that what she wrote adequately described the treatment she provided Patient L.A. The entry made by Respondent read as follows: "PLACED ON TRACH COLLAR AT 40 percent PT DID NOT TOL MORE THAN 5 MIN, PT AMBUED DR, NOTIFIED" At the time Respondent completed the incident report and charted the information on Patient L.A., she was extremely upset. Prior to March 3, 1995, Respondent had never been involved in a situation that required an incident report. Petitioner contends that the medical record prepared by Respondent concerning the events that transpired following the removal of Patient L.A. from the ventilator were inadequate. Specifically, Petitioner contends that Respondent should have included whether Respondent was in the room when Patient L.A. began to experience respiratory distress and a more detailed description of the patient's condition when Respondent was in the room. Further, it was asserted that Respondent's medical records do not indicate why the Respondent removed Patient L.A. from the ventilator. On March 3, 1995, UCH had established protocols for mechanical ventilation which included criteria for weaning a patient from mechanical ventilation. The document entitled "Mechanical Ventilation (General Consideration)" provide in part the following: Among the criteria for weaning from mechanical ventilation are: Therapist confirms order with RN before weaning process. Therapist checks room number and patient's wrists band before weaning. The patient's pathophysiological (clinical) condition which was responsible for his being placed on the ventilator has either resolved or is resolving. The patient while on the ventilator should have an inspired oxygen concentration of less than 40 percent (with good blood gases), should have an inspiratory effect greater than -20 centimeters water pressure, and lungs should be relatively clear. The protocols are "general guidelines and are not meant to be rigid and apply to every case." Some of the guidelines listed in the protocols related to weaning are variable and are not used as strict criteria for electing to start or discontinue mechanical ventilation of a patient. For example, the protocol calls for a patient to have an inspired oxygen concentration of not less that 40 percent. However, an oxygen concentration of 50 would not necessarily disqualify a patient from being removed from a ventilator. There are three criterion which must be followed when disconnecting a patient from a ventilator. The respiratory therapist must look at the order in the chart, properly identify the patient, and assess the patient's status. Prior to removing Patient L.A. from the ventilator, Respondent reviewed the order for Patient F.P. However, Respondent admitted that she did not check the patient's room number and bracelet as required by the UCH protocol for weaning or removing a patient from the ventilator. Respondent assumed that she was in the room of Patient F.P., when she was actually in the room of Patient L.A. She observed no significant secretions which warranted suctioning, and Patient L.A. did not appear to be in any breathing distress. Respondent listened to Patient L.A.'s breath sounds which seemed consistent with the documented lung disease. Based upon Respondent's assessment and observations, Patient L.A. appeared to be a standard ventilator patient and a suitable candidate for weaning. In the instant case, given her observations and assessment, Respondent had no reason to question the physician's orders in regard to moving the patient from the ventilator. Therefore, Respondent removed Patient L.A. from the ventilator. Respondent did not follow established hospital protocol when she removed Patient L.A. from the ventilator. Specifically, Respondent failed to check the room number and the patient's wristband before weaning him from the ventilator. Respondent has not worked as a respiratory therapist since March 3, 1995. Although, UCH has never officially terminated Respondent, she has not been allowed to return to work. As a result, Respondent and her family have suffered financial hardship. Before this case, Respondent had practiced respiratory therapy for over four years with no history of any disciplinary action being taken against her license. Furthermore, Respondent has never been disciplined or admonished by a hospital. Respondent enjoys a reputation as an excellent respiratory therapist among health care professionals, including physicians, administrators, and other respiratory therapists. As a licensed respiratory therapist, Respondent was an exemplary employee with excellent skills and knowledge of respiratory care services.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that a Final Order be entered suspending the license of Respondent, Dena Wadzinski, for a period of eighteen (18) months, to be followed by a one year period of probation, under such terms and conditions as prescribed by the Board of Medicine. RECOMMENDED in Tallahassee, Leon County, Florida, this 14th day of December, 1995. CARLOYN S. HOLIFIELD 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 14th day of December, 1995. APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 95-3555 The following rulings are made on the parties' proposed findings of fact: Petitioner's Proposed Findings of Fact. Accepted and incorporated. - 7. Subordinate or unnecessary to result reached. 8. - 11. Accepted and incorporated. Rejected as not supported by clear and convincing evidence. - 18. Subordinate to result reached. 19. - 27. Accepted and incorporated to extent subordinate and unnecessary. Rejected as not supported by clear and convincing evidence. Rejected as not supported by competent and substantial evidence. - 31. Accepted and incorporated. 32. - 33. Accepted as to Respondent's failure to check room number and patient wristband; remainder rejected as not supported by competent and substantial evidence or clear and convincing evidence. 34. - 38. Accepted and incorporated. Accepted. Accepted as to statement that Respondent required to listen to breath sounds; remainder rejected as not supported by clear and convincing evidence. Rejected as not supported by competent and substantial evidence. Rejected as not supported by competent and substantial evidence or clear and convincing evidence. Accepted. Respondent's Proposed Findings of Fact. 1. - 20. Accepted and incorporated to the extent not subordinate or necessary. 21. - 23. Accepted and incorporated. 24. Subordinate to the result reached. 25-29. Accepted and incorporated. 30. - 31. Accepted. 32. - 33. Accepted and incorporated. 34. Subordinate to result reached. COPIES FURNISHED: Grover C. Freeman, Esquire Freeman, Hunter & Malloy Suite 1950 201 East Kennedy Boulevard Tampa, Florida 33602 Monica Felder, Esquire Kevin W. Crews, Esquire Agency for Health Care Administration Northwood Centre, Suite 60 1940 North Monroe Street Tallahassee, Florida 32399-0792 Jerome W. Hoffman, General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32309 Dr. Marm Harris, Executive Director Board of Medicine 1940 North Monroe Street Tallahassee, Florida 32399-0770
Findings Of Fact Sobel has applied for a license under the provisions of the Florida Clinical Laboratory Law, Chapter 483, Florida Statutes, as a Laboratory personnel supervisor in the speciality of Chemistry, Respiratory Therapy. On August 23, 1977, Sobel was notified by HRS that his application was denied because he lacked a degree in Respiratory Therapy or in the alternative that he lacked seven years experience in Chemistry (special). On September 2, 1977, Sobel requested an administrative hearing. Sobel has been given credit by HRS for six years experience in Chemistry (special). Long Island University, Sobel's alma mater, conducts a respiratory therapist program of at least two years duration. This program is accredited by the Council on Medical Education of the American Medical Association. In addition to his Bachelor of Science degree in Physical Education and his Master of Science degree in Health, Science and Physical Education, Mr. Sobel successfully completed the requirements of training in Respiratory Therapy given by Long Island University. In addition, Sobel is a registered Respiratory Therapist with the National Board of Respiratory Therapy, Inc., and has successfully completed the written registry examination for self assessment administered by the National Board for Respiratory Therapy. HRS recognizes that fourteen hours of Sobel's curriculum as reflected in his transcript of grades qualifies under the suggested basic units of instruction for a two year respiratory therapist program contained in the Allied Medical Directory. These general areas of study form the basis, in part, of accreditation by the Council on Medical Education of the American Medical Association.
The Issue The issue for determination is whether Respondent, a licensed physician, committed violations of Chapter 458, Florida Statutes, sufficient to justify the imposition of disciplinarysanctions against her license. The resolution of this issue rests upon a determination of whether Respondent intubated the esophagus of a patient, as opposed to the patient's trachea, in the course of rendering anesthesia care; and whether Respondent then failed to provide a record justifying such a course of medical treatment.
Findings Of Fact Respondent is Saroja L. Ranpura, a licensed physician at all times pertinent to these proceedings, holding medical license number ME 0039872. Respondent was licensed in the State of Florida on April 27, 1982. She currently practices medicine in Ohio. Petitioner is the Department of Professional Regulation, Board of Medicine, the state agency charged with the regulation of physicians in the State of Florida. On August 29, 1985, Frank Snydle, M.D., performed a laparoscopy on patient C.P. at Heart of Florida Hospital in Haines City, Florida. This medical procedure was performed on an outpatient basis. As a result, C.P. came into the hospital on the day the surgery was to be performed. She met Respondent, who later provided anesthesia care to her in the course of the laparoscopy. Respondent examined C.P. at that time, prior to the surgery, and noted that C.P. had a small mouth. Later, C.P. was brought into the operating room on a stretcher and moved herself over onto the operating table. Present in the operating room at that time were Jean Allen, L.P.N., Norma Masters, R.N., and Respondent. Respondent proceeded to do an unusual procedure known as a "blind nasal intubation." The procedure requires the placement of an tube in the patient's throat through the nose, as opposed to the mouth, in order to maintain an open airway during later anesthesia administration in the process of surgery. C.P. was sedated, but awake, during this process and was intubated with a minor degree of difficulty. Prior to placement of the endotracheal tube, Respondent had the patient breath pure oxygen through a mask covering the mouth and nose. The preoxygenation process, according to Respondent, provided extra oxygen "as a reservoir and as astorage" to C.P.'s body tissues. By letting a patient breath 100 percent oxygen for three to four minutes, the resultant saturation permits a margin of four to six minutes for such an intubation to be safely completed without risk of the patient becoming hypoxic. Jean Allen, with almost 25 years of nursing experience in a surgical assistance career where she assists in 400 to 600 operations per year, observed Respondent during the entire intubation process, inclusive of the preoxygenation phase. Accepted medical practice after such an intubation requires that the person placing the tube then listen for breath sounds over each lung and over the area of the stomach. Respondent maintains that she did listen for those breath sounds with the aid of a stethoscope. The anesthesia record completed by Respondent has a notation "BEBS" for bilateral and equal breath sounds which Respondent testified that she heard with the stethoscope prior to administering additional sodium pentothal to the patient and inflating the cuff of the endotracheal tube. This testimony of Respondent is not credited in view of the testimony of Ms. Allen that she observed Respondent during this entire time and that Respondent did not listen for the breath sounds with a stethoscope prior to administering the additional sodium pentothal to the patient. Allen's testimony is also afforded the greater credibility due to her opportunity as a neutral witness to observe the events which transpired and her testimony that although she didn't observe Respondent closely after the additional sodium pentothal was administered, she maintained that she would have recalled Respondent's use of the stethoscope prior to that point. Notably, it is at that point prior to the administration of the additional sodium pentothal and inflation of the cuff of the endotracheal tube where Respondent maintains she listened for the breath sounds. Respondent, after completion of the placement of the endotracheal tube, administered additional sodium pentothal to the patient without listening for breath sounds; connected the tube to the anesthesia machine; and remarked that "it must be in place, the bag is moving" in reference to the bag on the anesthesia machine which generally inflates as the lungs of the patient deflate. While inflation or deflation of a breath bag on an anesthesia machine is one part of the procedure for checking placement of an endotracheal tube, the expert testimony of John Kruse, M.D., and David Alan Cross, M.D., establishes that this procedure alone is not a reliable method of determining proper tube placement. Frank Snydle, M.D., who had entered the operating room by this time in the sequence of events, did a manual vaginal examination of the patient, left the room, scrubbed his hands and returned. He then donned surgical gloves and gown, moved to the left side of the patient and prepared to proceed with the operation. Ms. Allen took her position at the foot of the table, between the patient's legs with an unobstructed view of Respondent. Dr. Snydle proceeded to make a small incision in the patient's abdomen through which he inserted a hollow, "Verres" needle. Carbon dioxide was then introduced to C.P.'s abdominalcavity to push the abdominal wall away from the internal organs. Next, a device known as a "trocar" and a "trocar sleeve" was inserted through the incision into the abdomen. The trocar was then withdrawn and a laparoscope was inserted into the sleeve. Built somewhat like a telescope with a built-in light source, the laparoscope permits the surgeon to look inside the abdomen and visually observe the patient's internal organs. During this procedure, Nurse Allen commented that she heard a sound like a fog horn or frogs croaking when she touched the patient's abdomen. Allen's remark is corroborated by Norma Masters and Dr. Snydle. The proof establishes, as corroborated by expert testimony of Dr. Kruse, that such sounds were associated with air, captured in C.P.'s stomach as the result of esophageal intubation, escaping from the stomach when pressure was applied. When Dr. Snydle made his first incision in the patient's abdomen, Allen observed that the blood was dark and Dr. Snydle agreed. Respondent inquired whether it could be venous blood. Snydle indicated he didn't think this was the case. Notably, the dark blood was observed, according to Respondent's medical records at 10:27 a.m. Further, Petitioner's experts, Dr. Kruse and Dr. Cross, based on their review of C.P.'s medical records, determined that the patient was initially intubated at approximately 10:15 a.m. Thus, approximately 12 minutes transpired from the beginning of the intubation process and conclusion of preoxygenation of the patient until the observation of dark bloodat the time of incision. After her inquiry regarding whether the blood could be venous, Respondent further responded that she was giving the patient 50 percent oxygen. She testified that she then increased the oxygen level to 100 percent. While the anesthesia record indicates administration of 100 percent oxygen, there is no time notation when this occurred. Blood again welled up from the incision and Nurse Allen commented that the blood appeared black. The less oxygenated blood becomes, the darker it appears. By this time, Dr. Snydle had inserted the laparoscope in C.P.'s abdomen. He observed that the internal organs were a "blueish color" ; an observation consistent with a decreasing level of oxygen in the patient's blood and an indication that the patient was hypoxic. When the patient's internal organs were discerned to be blue, Respondent asked Dr. Snydle to wait a moment and requested the assistance of Norma Masters, the circulating nurse. Masters came to the head of the operating table and was handed another endotracheal tube by Respondent. Respondent then began the process of intubating the patient with that tube through the mouth. The original nasal tube was left in place during the insertion of the second tube; an unheard of possibility, according to expert testimony, unless one tube was in the patient's esophagus and the other in the trachea. Nurse Allen's testimony establishes that the second tube, inserted via the patient's mouth, became foggy after insertion. The observation by Allen is consistent with experttestimony and establishes the fog was created by warm moist air from the patient's lungs flowing through the second tube. Respondent's testimony that she placed the second tube at the conclusion of the surgical procedure is not credited in view of the very clear, contradictory testimony of Masters and Allen that the endotracheal tube was replaced contemporaneously with the notation that the blood was dark and the patient's organs "blueish". After removal of the nasal tube and connection of the second tube to the anesthesia machine, Respondent manually squeezed the anesthesia bag to ventilate the patient. Dr. Snydle observed that the organs were turning pink again, and continued the procedure without further incident. After finishing the procedure, Snydle went out of the operating room, sat at a desk across the hall and began to write his orders. Following the procedure, the patient was wheeled to the recovery room, a short distance away. Nurses Allen and Masters did not see C.P. open her eyes during this process. Respondent's assertion that the patient opened her eyes and was responsive to commands is corroborated only by Dr. Snydle. However, while he noted in his operative report and his deposition that C.P. was awake following the operation, Snydle's observation is not credited in view of other proof establishing that his back was to the patient as she was wheeled past and that he assumed an awake state in the patient because Respondent was speaking to C.P. In view of the foregoing, Respondent's testimony that the patient was awake or responsive to commands following the surgery is not credited. After the patient was removed approximately 15 feet away to the recovery room, Respondent maintains that she informed Margaret Bloom, R.N., who was on duty there, that the patient's endotracheal tube was not to be removed, although she omitted telling Bloom about the dark blood incident. Bloom, who is also a certified registered nurse anesthetist, maintains that Respondent told her nothing about C.P.'s condition; instead, she went rapidly to the rest room in the lounge area. Bloom, left in the recovery room with the patient, then proceeded to hook up appropriate monitors and oxygen to the patient's endotracheal tube and began the process of monitoring C.P.'s vital signs. Bloom places the time of C.P.'s arrival time in the recovery room at approximately 11:05 a.m. The patient was not responsive to Bloom's spoken commands when brought to the recovery room. The patient appeared well oxygenated to Bloom; a judgement she made based on her observation of the color of C.P.'s lips and fingernails, since C.P. is a black female. Bloom rated C.P.'s circulation at twenty to fifty percent of preanesthetic pressure and determined the patient to be totally unconscious. Respondent returned to the recovery room at this time, told Bloom that she had done an "awake intubation" on the patient and that the tube should remain in place until Bloom determined that the patient was ready for it to be removed. Respondent then left the recovery room. As the result of blood tinged mucus filling the patient's endotracheal tube, Bloom removed the tube after thepatient registered breathing difficulties and attempts by Bloom to suction the mucus failed. She replaced that tube with a device known as an oral pharyngeal airway which goes in the patient's mouth and curves down the throat, holding the tongue forward. The device does not reach to the lungs. Shortly thereafter the patient began making glutteral noises and Bloom placed a venturi mask on the patient. The mask controlled the percentage of oxygen going to the patient, estimated by Bloom to be sixty to one hundred percent oxygen. The patient's breathing improved. Bloom completed replacement of the endotracheal tube with the airway device and mask shortly before Respondent again returned to the recovery room. Respondent, upset at Bloom's action in removing the endotracheal tube, proceeded to replace the oral airway device with a nasal tube. At 11:20 a.m., Bloom noted in her records that the patient's state of consciousness was unchanged. Later the patient made moaning sounds and was responsive to pain stimulation at approximately 12:20 p.m. Respondent concedes that C.P. suffered an hypoxic event at some point which resulted in damaged brain function. It is Respondent's position that such event occurred in the recovery room as the result of laryngospasm, occasioned by Bloom's removal of the endotracheal tube. Allen and Masters working in the operating room a short distance away testified that the sounds they heard emanating from the area of the recovery room were not the type of noise they associated with laryngospasm. Bloom, trained to recognize laryngospasm, testified that C.P. did not have sucha spasm. The expert testimony of David Cross, M.D., based on a study of arterial blood gases of C.P. following the surgery, establishes that the patient suffered an hypoxic episode too severe and too protracted to have been the result of a possible laryngospasm in the recovery room and that, in his expert opinion, she did not have a recovery room laryngospasm. Respondent's defense that C.P.'s survival of such a lengthy esophageal intubation in the operating room is an impossibility, is not persuasive. The opinion of Respondent's expert, Dr. Gilbert Stone, that no esophageal intubation occurred in the operating room is predicated on his belief that the tube was not changed during the surgery. Dr. Stone conceded that replacement of the tube during surgery at the time the dark blood was noticed with resultant improvement in the patient's condition permits a conclusion that esophageal intubation was the cause of the hypoxia. Testimony of Petitioner's experts, Dr. Cross and Dr. Kruse, are consistent in their conclusions that C.P. was esophageally intubated by Respondent, although they differ in their reasons for C.P.'s survival of the event. The opinion of these experts, coupled with the eye witness testimony of Allen and Masters, further support a finding of Respondent's esophageal intubation of the patient in the operating room and that she failed to recognize such intubation in a timely manner as a reasonable and prudent physician should have. The expert opinion testimony of Dr. Cross establishes that C.P. was intubated in her esophagus and survivedas a result of oxygen, going into her stomach under pressure, being forced back up her esophagus into the pharynx and then drawn by negative pressure into the lungs. This resulted in a effect similar to, but not as efficient as, the technique known as apneic oxygenation. The technique, once used to provide marginally adequate oxygen levels to maintain a patient's neurological and cardiac status, has fell into disfavor since patients suffered from respiratory acidosis due to the buildup of carbon dioxide in the lungs. Cross also pointed out that the heart can function for a much longer period of time without adequate oxygen than is possible for the brain. Cross's testimony provides an explanation for C.P.'s neurological damage without similar cardiac impairment. Cross also noted that the preoxygenation process which C.P. initially underwent after entering the operating room added to the time she was able to undergo oxygen deprivation before the onset of tissue damage. Respondent notes the discovery of a tumor in C.P.'s throat some months later as a possible contributor to the patient's hypoxic event during surgery. Another of Respondent's experts, Dr. Deane Briggs, an otolaryngologist specializing in diseases of the ears, nose and throat, treated C.P. in October of 1985, following the August, 1985 surgery. He discovered the existence of a sub-glottic tumor in the patient's throat. However, the existence of the tumor at the time of the initial surgery is not established. Testimony of anesthesiologist experts, including Respondent's own expert, Dr. Stone, do not support a finding that the tumor, if itexisted, had any effect during the operation. Further, Dr. Briggs' opinion that Respondent probably intubated the patient's right stem bronchus, as opposed to the esophagus, and that neurological damage therefore occurred in the recovery room is not credited in view of the conflict of this testimony with that of other witnesses and expert opinions. A finding that C.P.'s neurological impairment following surgery may have been exacerbated by a possible laryngospasm in the recovery room is relevant only with regard to mitigation of the severity of penalty to be imposed for Respondent's misconduct. Respondent's esophageal intubation of the patient in the operating room, and the resultant hypoxic event are established by clear and convincing evidence. The fact that C.P. suffered brain damage is undisputed by the parties. The proof clearly and convincingly establishes that the severe and protracted hypoxic episode sustained by the patient resulted not from a possible mild recovery room laryngospasm, but from Respondent's esophageal intubation of that patient in the operating room. It is concluded with respect to treatment of C.P., Respondent failed 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. Respondent failed to keep medical records which justified her course of treatment of the patient, C.P. This finding is based upon the testimony of Dr. Cross that Respondent'smedical records did not justify her course of treatment, as well as the testimony of Respondent's expert, Dr. Stone. While testifying that he did not believe Respondent had intubated the patient's esophagus, Stone also acknowledged that Respondent's records would be inadequate if such had indeed occurred.
Recommendation Based on the foregoing, it is hereby RECOMMENDED that a Final Order be entered for Respondent's violation of Section 458.331(1)(t), Florida Statutes, placing Respondent's license on probation for a period of three years upon terms and conditions to be determined by the Board of Medicine, including, but not limited to, a condition requiring Respondent's participation in appropriate continuing medical education courses; and imposing an administrative fine of $2,000. IT IS FURTHER RECOMMENDED that such Final Order impose a penalty for Respondent's violation of Section 458.331(1)(m), Florida Statutes, of an administrative fine of $500 and a letter of reprimand. DONE AND ENTERED this 28th day of August, 1989, in Tallahassee, Leon County, Florida. DON W.DAVIS 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 28th day of August, 1989. APPENDIX The following constitutes my specific rulings, in accordance with Section 120.59, Florida Statutes, on findings of fact submitted by the parties. Petitioner's Proposed Findings. 1.-28. Accepted. 29. Unnecessary to result. 30.-31. Accepted. 32.-34. Adopted by reference. 35.-61. Adopted in substance. 62. Unnecessary to result. 63.-68. Adopted in substance. 69.-87. Adopted by reference. Respondent's Proposed Findings. 1.-3. Rejected, not supported by the evidence. 4.-5. Rejected, not supported by the evidence, Further, proposed findings that records were adequate constitute legal conclusions. 6. Rejected, not supported by the evidence. COPIES FURNISHED: David G. Pius, Esq. Department of Professional Regulation The Northwood Centre, Suite 60 1940 N. Monroe St. Tallahassee, FL 32399-0750 Sidney L. Matthew, Esq. Suite 100 135 South Monroe St. Tallahassee, FL 32302 Kenneth Easley, Esq. General Counsel Department of Professional Regulation The Northwood Centre, Suite 60 1940 N. Monroe St. Tallahassee, FL 32399-0750 Dorothy Faircloth Executive Director Board of Medicine Department of Professional Regulation The Northwood Centre 1940 N. Monroe St. Tallahassee, FL 32399-0750
The Issue The issue presented is whether Respondent is guilty of the allegations contained in the Administrative Complaint filed against her and, if so, what disciplinary action should be taken against her, if any.
Findings Of Fact Respondent is a licensed respiratory care practitioner, having been issued license number TT 0006767 by the State of Florida. The National Board for Respiratory Care (hereinafter "NBRC") is a voluntary certification board for respiratory therapists and pulmonary technologists. The NBRC administers examinations including the Certified Respiratory Therapy Technician (hereinafter "CRTT") Examination. The CRTT is an entry-level examination for respiratory care practitioners. Obtaining a passing score on that examination and receiving a CRTT certificate is a requirement for licensure in many states. On July 19, 1992, Respondent took the CRTT examination. She obtained a passing score and received a CRTT certificate from the NBRC in July, 1992. Based upon Respondent's obtaining her CRTT certificate, Respondent was licensed as a respiratory therapist in the State of New Jersey. Subsequent to the July 19, 1992, CRTT examination, the NBRC received information that persons sitting for that examination possessed a copy of the examination in advance of the test date along with a purported "answer key." Based upon an investigation and on statistical analyses performed on the examination answers of every candidate sitting for that examination, the NBRC determined that Respondent was one of the individuals who had received a copy of the examination in advance of the test date. On November 24, 1992, the NBRC wrote to Respondent advising her of its investigation and determination. The letter specifically advised Respondent that the NBRC had invalidated the results of her CRTT examination and had so informed the State of New Jersey. That letter specifically instructed Respondent to return her CRTT certificate immediately and that the NBRC no longer recognized her as a Certified Respiratory Therapy Technician. The letter further notified Respondent that the NBRC's Judicial and Ethics Committee would be conducting a parallel investigation. The letter was sent to Respondent by certified mail, and she received it on December 8, 1992. On June 26, 1993, the Judicial and Ethics Committee of the NBRC held a hearing regarding the action to be taken against Respondent. By letter dated October 14, 1993, that Committee advised Respondent, by certified mail, that she was suspended from admission to all NBRC credentialing examinations for an indefinite period of time and that that decision would be reconsidered only if she returned her CRTT certificate as had been repeatedly requested of her by the NBRC. That letter further advised her that if requested by the State of New Jersey, the NBRC would re-test her for licensure purposes only but that under no circumstances would she be re-tested for national certification unless she returned her CRTT certificate to which she was not entitled and the Committee reconsidered her case. Respondent refused to return her invalidated certificate to the NBRC. She continues to refuse to return her invalid certificate, thereby precluding herself from any opportunity to retake the CRTT examination for national certification purposes. On July 28, 1993, the New Jersey State Board of Respiratory Care filed an administrative complaint against Respondent and others, seeking revocation of Respondent's New Jersey license to practice respiratory care for her failure to successfully complete the NBRC examination due to the invalidation of her examination results by the NBRC. By Order Granting Partial Summary Judgment entered December 22, 1993, the New Jersey State Board of Respiratory Care determined that Respondent lacked valid test scores from the NBRC, a prerequisite to licensure in the State of New Jersey. In a Supplemental Order entered on February 1, 1994, the New Jersey State Board of Respiratory Care determined that although Respondent's license to practice respiratory care in New Jersey was revoked, Respondent would be permitted to sit for the CRTT examination to be administered in July 1994, in order to meet licensure requirements in New Jersey. Pursuant to New Jersey's request, the NBRC scheduled Respondent to retake the July 1994 CRTT examination. Respondent failed to appear. Respondent has never retaken that examination. On February 24, 1993, Respondent submitted to the Florida Board of Medicine a licensure application seeking licensure by endorsement. In her licensure application, Respondent represented that she was certified as a respiratory care practitioner by the NBRC and that she was certified on July 19, 1992. As part of her application, Respondent submitted a copy of her CRTT certificate. She did not disclose that her CRTT certificate had been invalidated. Question numbered 5 of that application asked Respondent if she had ever been notified to appear before any licensing authority for a hearing on a complaint of any nature. Respondent answered that she had not. Although Respondent had been notified in September or October 1992 that the State of New Jersey was proceeding against her license, she did not disclose that fact on her licensure application. Respondent's answers to the questions contained in her February 1993 Florida licensure application were made under oath and bear her notarized signature, attesting that her answers are true, correct, and complete. On July 26, 1993, Respondent was licensed by the State of Florida as a respiratory care practitioner based, in part, on her invalidated CRTT certificate. Honesty is an important trait for a practicing respiratory care practitioner, and dishonesty in the practice of respiratory care is potentially dangerous to patients. Respondent was previously licensed by the State of Florida as a respiratory therapist, non-critical care status. That license was revoked on February 6, 1990, due to Respondent's submission of fraudulent information in her application for licensure. Specifically, when Respondent applied for that license, she did not possess either a high school diploma or a graduate equivalency diploma, a requirement for licensure. Respondent, therefore, submitted a copy of her husband's graduate equivalency diploma, which she had xeroxed and altered to reflect her name instead.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered finding Respondent guilty of the allegations contained in the Administrative Complaint filed against her and revoking her respiratory care practitioner license number TT 0006767. DONE and ENTERED this 30th day of January, 1996, at Tallahassee, Leon County, Florida. LINDA M. RIGOT, 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 30th day of January, 1996. APPENDIX TO RECOMMENDED ORDER DOAH CASE NO. 94-5183 Petitioner's proposed findings of fact numbered 2-21 have been adopted either verbatim or in substance in this Recommended Order. Petitioner's proposed finding of fact numbered 1 has been rejected as not constituting a finding of fact but rather as constituting a conclusion of law. Respondent's proposed findings of fact numbered 3-5, 7, 9-11, and 13 have been adopted either verbatim or in substance in this Recommended Order. Respondent's proposed finding of fact numbered 1 has been rejected as not constituting a finding of fact but rather as constituting a recitation of the charges against her. Respondent's proposed findings of fact numbered 2 and 15 have been rejected as being irrelevant to the issues herein. Respondent's proposed findings of fact numbered 6 and 8 have been rejected as being subordinate to the issues herein. Respondent's proposed findings of fact numbered 12 and 14 have been rejected as not being supported by the weight of the credible, competent evidence in this cause. COPIES FURNISHED: Dr. Marm Harris Executive Director Board of Medicine Agency for Health Care Administration 1940 North Monroe Street Tallahassee, Florida 32399-0792 Hugh R. Brown, Esquire Agency for Health Care Administration 1940 North Monroe Street Tallahassee, Florida 32399-0792 Herbert B. Dell, P.A. 4801 South University Drive Fort Lauderdale, Florida 33328
