The Issue The issues for determination in this case are whether Respondent's license to practice medicine should be revoked or otherwise disciplined for the reasons set forth in the Administrative Complaint, specifically for: 1) Respondent's failure to meet the acceptable standard of care for psychiatry in not immediately admitting patient J.R. to an intensive in-patient care facility; 2) Respondent's failure to justify his failure to admit patient J.R. to an intensive in-patient care facility; and 3) Respondent's failure to maintain records which state why patient J.R. was not admitted to an intensive in-patient care facility.
Findings Of Fact Petitioner, Department of Health, is the state agency vested with the statutory authority to enforce the disciplinary standards for the practice of medicine under Chapters 455 and 458, Florida Statutes. Respondent, Ashok M. Patel, M.D., is and at all material times was, a physician licensed to practice medicine in Florida, having been issued license number ME 0066214. Respondent practices psychiatry in Largo, Florida. Respondent is board certified in psychiatry. On July 31, 1996, Patient J.R. was referred for an appointment to Respondent by Professional Psychological Services (hereinafter PPS), a mental health care provider with which Respondent was contractually affiliated. At this time J.R. was a 44-year-old white male who was employed as a paramedic, and later as a firefighter for the City of Clearwater. J.R. had worked in this capacity for over 19 years. J.R. was happily married to P.R. for more than 11 years. The couple had no children. In the weeks preceding his appointment with Respondent, J.R. was experiencing severe depression. The primary basis of J.R.'s depression was chronic health problems. J.R. had a history of back problems which began in 1980. He had back surgery in 1989, and suffered from psoriatic arthritis in his back which adversely affected his ability to function effectively as a paramedic and later as a firefighter. In July of 1996, J.R. had the job of driver of the firetruck. In July of 1996, J.R. was under the care of his primary physician Dr. Mark Smitherman, as well as a rheumatolgist, Dr. Adam Rosen, who prescribed medicine for J.R.'s chronic pain. On July 22, 1996, during an appointment with Dr. Smitherman, J.R. expressed his feelings of depression. Dr. Smitherman suggested that J.R. contact PPS, the psychological services provider of J.R.’s employment insurance plan. An appointment with PPS was thereafter scheduled for July 31, 1996. J.R. also had previously expressed his feelings of depression to Dr. Rosen who had prescribed Serzone, an anti-depressant for J.R. J.R. went to work at the firehouse on Monday, July 29, 1996. At some time during the evening while the other firefighters were asleep, J.R. removed a defibrillator from the firetruck, went to a private room, and used the defibrillator on himself in an unsuccessful attempt to commit suicide. The following morning of Tuesday, July 30, 1996, J.R. returned home at approximately 8:00 a.m., and telephoned his wife, P.R., who was already at work. J.R. informed his wife of his suicide attempt. P.R. immediately went home and called PPS, explained the circumstances, and requested an earlier appointment. Arrangements were made with PPS to reschedule J.R. from his existing appointment on Wednesday, July 31, 1996, to an appointment July 30, 1996, at 7:00 p.m. Later that day, the appointment was moved up to 5:00 p.m. When J.R. and his wife arrived at PPS they met with Betti Pate, a licensed mental health counselor employed by PPS. During the course of her evaluation, Betti Pate noted that J.R. was severely depressed with a suicide attempt within the previous 24 hours. Ms. Pate in her care plan for J.R. identified three problems, depression, fear of being left alone, and suicidal ideation. Under intervention, she noted, "prevent suicide, daily observation." Betti Pate’s note to her supervisor stated that J.R. was fearful, very depressed and negative. She also noted that J.R. was "afraid he’ll try again if alone." After Betti Pate’s evaluation on July 30, 1996, her supervisors at PPS recommended that J.R. enter a Partial Hospitalization Program (PHP) at Charter Behavioral Health System of Medfield Hospital (Charter). The PHP at Charter was a mental health counseling program which was conducted during the day at the hospital. The primary focus of the Charter PHP was mental health therapy provided in group settings with licensed mental health counselors. The care plan for J.R. was to provide partial hospitalization at Charter during the day while his wife was at work. J.R. would then return home to his wife in the evening. Under this arrangement J.R. would not be alone for extended periods of time. Admission to the PHP at Charter required the concurrence of an admitting psychiatrist. Because the other psychiatrists employed by PPS were unavailable, an appointment was made for J.R. to be evaluated by Respondent who, although in private practice, had an affiliate agreement with PPS to render mental health services to referred patients. PPS made an appointment for J.R. to see Respondent on Wednesday, July 31, 1996, at 4:00 p.m. It was common and usual practice for PPS to refer patients to Respondent for evaluation prior to admission to PHP, as well as for evaluation of a patient’s medications. J.R. went alone to his appointment with Respondent. Prior to seeing Respondent, J.R. completed a patient information document. J.R. described his reason for visit as "mental health & coping problem." He circled the following problems which pertained to him: nervousness, anxiety, insomnia, stress, headaches, overwhelmed, obsessive thoughts, compulsive behavior, depression, loneliness, fears, suicidal thoughts, concentration, appetite changes, helpless/hopeless, low energy, sexual problems, impulsive behavior, medical problems, and physical pain. J.R. listed the medications he was taking as Serzone 150 mg (10 day), Lortab 7.5/500, Robaxin 750 mg. J.R. indicated that he had not received prior psychiatric treatment. After completion of the patient information document, J.R. was seen by Respondent. Respondent observed that J.R. was casually dressed and not dishelveled, was articulate, made eye contact, was appropriately aware of time and place, and able to communicate effectively. Respondent asked J.R. the nature of the problem that had brought J.R. to him. Respondent then conducted a medical history, a family history, and a history of the problems leading to the visit to Respondent. In the course of his evaluation of J.R., Respondent completed a clinical assessment form which included a DSMIV diagnosis. According to Respondent’s records J.R. stated as "chief complaint" that "I was referred by PPS." In history of present illness, Respondent notes that: "Patient is 44 year-old white male came in complaining of chronic back pain, decreased sleep agitation, irritability." Patient says he is feeling depressed, says he tried to kill himself using defibrillator on Monday, but says it did not work. Patient had suicidal thoughts for 1-2 weeks, but feels guilty about doing it. Says it was stupid to hurt himself. Weight loss of 14 pounds in two and one-half months, decreased appetite. No SI(suicial ideation)/ No HI(homicidal ideation)/ No AH(auditory hallucinations)/ No VH(visual hallucinations)/ No PI(paranoid ideation) at present. During the course of Respondent’s evaluation, J.R. related that he had been seen at PPS on July 30, 1996, that he had an appointment to see Betti Pate the following day, and that arrangements were being made by PPS for him to begin PHP at Charter; however, Respondent did not have J.R.’s PPS evaluation nor Betti Pate’s notes at the time of J.R.’s office visit. J.R. also related that he had a supportive wife, although Respondent did not have any personal contact with Mrs. J.R. at this time. Respondent’s evaluation of J.R. lasted over one hour. In his diagnosis Respondent determined that J.R. had major severe depression, and that J.R. presented a moderate suicide risk. In his recommendation/plan for J.R. Respondent’s notes reflect the following: "Increased Serzone 100mg two Bid; continue out-patient counseling; start Xanax 0.25 mg. 1/2-1 tid prn.; follow up in 2 weeks; and, made aware of 24 hours availability." Respondent also advised rest for 2 weeks. At this time Respondent did not know when J.R. would begin PHP at Charter. After leaving Respondent’s office J.R. went home and expressed to his wife some difficulty in understanding Respondent who is a native of India. The next day Thursday, August 1, 1996, Mrs. J.R. contacted PPS to inquire about J.R. seeing a different psychiatrist. Neither J.R. nor Mrs. J.R. contacted Respondent, and PPS did not refer J.R. to another psychiatrist. Because of J.R.’s use of the defibrillator, PPS requested medical clearance from J.R.’s primary care physician Dr. Smitherman prior to admission to PHP at Charter. On Thursday, August 1, 1996, J.R. telephoned Dr. Smitherman and received medical clearance to begin PHP at Charter. J.R. was scheduled to begin PHP at Charter on Monday August 5, 1996. J.R. received no mental health therapy or counseling from the time he left Respondent’s office on Wednesday, July 31, 1996, until Monday, August 5, 1996, when he arrived at Charter. J.R. spent some of this time doing routine shopping, errands and going to the beach where he regularly exercised by swimming. J.R. and his wife also discussed future plans together. On Monday, August 5, 1996, J.R. was admitted to PHP at Charter. At this time Charter telephoned Respondent for admission instructions for J.R., which Respondent as the attending physician gave for J.R. During the course of the day, J.R. attended group therapy sessions at Charter. The Charter records indicate that J.R. presented a flat appearance, and was not actively engaged in the therapy sessions. The following day, Tuesday August 6, 1996, J.R. had a previously scheduled appointment with his rheumotolgist, Dr. Rosen. Because of this previously scheduled appointment J.R. was allowed to miss his therapy sessions at Charter on August 6, 1996, with the understanding that he would return and continue his therapy at Charter on Wednesday August 7, 1996. On Tuesday, August 6, 1996, J.R. went to his appointment with Dr. Rosen. At some time after leaving Dr. Rosen’s office J.R. returned home and committed suicide by hanging himself in the garage where his wife found him later that day. Respondent had no contact with J.R. subsequent to July 31, 1996. Three expert witnesses in the field of psychiatry presented testimony in this matter: Dr. Martin Rosenthal; Dr. Arturo Gonzalez; and, Dr. Daniel Sprehe. All three expert witnesses concur that Respondent’s diagnosis of J.R. was correct and met the appropriate standard of care. Moreover, all three expert witnesses agree that Respondent’s prescribed medications for J.R. were correct and met the appropriate standard of care. While Drs. Gonzalez and Sprehe opined that Respondent’s treatment plan for J.R. was appropriate, Dr. Rosenthal testified that Respondent’s treatment of J.R. in "certain limited ways" did not meet the standard of care. Specifically, Dr. Rosenthal opined that even though J.R. was a moderate suicide risk, he would have hospitalized J.R. The medical literature submitted as part of the record in this case is consistent in stating that suicide in an individual patient is not a predictable event. The factors that are considered by psychiatrists in evaluating the risk of suicide are subjective to the individual patient. In order to be of imminent risk, a patient must have suicidal intent, lethal means, and opportunity. All the experts in this case agree that Respondent made the proper diagnosis of J.R., which included a finding that when Respondent saw J.R., the patient had no suicidal ideation. At the time J.R. was seen by Respondent the evidence shows not only did J.R. have no present suicidal ideation, but he also expressed regret over having made a suicide attempt, and specifically stated to Respondent that he felt stupid about trying to hurt himself. The expert evidence is supported by the medical literature, that under such circumstances the appropriate standard of care does not require immediate hospitalization.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered dismissing the February 3, 1998, Administrative Complaint against the Respondent, Ashok M. Patel, M.D. DONE AND ENTERED this 30th day of December, 1998, in Tallahassee, Leon County, Florida. RICHARD A. HIXSON 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 Filed with the Clerk of the Division of Administrative Hearings this 30th day of December, 1998. COPIES FURNISHED: Kristina Sutter, Esquire Agency for Health Care Administration 2727 Mahan Drive Post Office Box 14229 Tallahassee, Florida 32317 A. S. Weekley, Jr., M.D., Esquire Holland & Knight 520 Vonderburg Drive, Suite 3005 Brandon, Florida 33511 Angela T. Hall, Agency Clerk Department of Health 2020 Capital Circle, Southeast Bin A-02 Tallahassee, Florida 32399-1703 Dr. James Howell, Secretary Department of Health Bin A00 2020 Capital Circle, Southeast Tallahassee, Florida 32399-1701 Pete Peterson, General Counsel Department of Health 2020 Capital Circle, Southeast Bin A-02 Tallahassee, Florida 32399-1703 Tanya Williams, Executive Director Board of Medicine Department of Health Northwood Centre 1940 North Monroe Street Tallahassee, Florida 32399-0750
The Issue The issue in this case is whether Respondent has been convicted or found guilty of a crime directly relating to the practice of respiratory care or his ability to practice respiratory care and, if so, what penalty should be imposed.
Findings Of Fact Petitioner is a licensed respiratory therapist, holding license number RT 0000039. He has not been previously disciplined. Following his completion of a training program in respiratory care at the University of Central Florida in June, 1979, Respondent began his full-time employment at the Orlando Regional Medical Center as a neonatal ICU therapist became a supervisor three years later. Almost three years after becoming a supervisor, in April, 1985, Respondent became an educational coordinator. He was employed in this capacity at the time of the events in question. During his employment at the Orlando Regional Medical Center, Respondent met a nurse, whom he began to date. The relationship endured for about six years. At first, they got along well, but, after about four years, the relationship deteriorated. Seeking marital counselling, Respondent and his female companion were told that each was manipulating the other and their relationship involved unhealthy, obsessive aspects. On the evening of June 12, 1990, Respondent confronted his female companion about another man whom she was dating later that evening. In a jealous rage when she did not return to her home when she had said she would, Respondent drove to her house and entered without permission, using a key that he had obtained without her consent. Respondent found the woman, who had since returned home, and initiated an angry, violent altercation. Respondent grabbed the woman, inflicting four or five bruises and scratches. The marks were mostly on the woman's arms with one small scratch on her neck. Ripping the woman's clothing, Respondent forcibly removed a tampon from her vagina. He lied to her that he had already killed her new male friend and threatened to kill her. When he finally calmed down, he and the woman spoke for sometime before he left the house. Once he left, the woman called the police and reported what Respondent had done. She was very frightened by the incident and was crying when the police arrived. After being arrested on various charges, Respondent eventually pleaded guilty to the felonies of aggravated battery and burglary of a dwelling. The sentencing section of the final order states that "adjudication of guilt was withheld, a finding of guilt entered." The judge sentenced Respondent on November 5, 1990, to 24 months' community control followed by 10 years' supervised probation. To date, Respondent has completed his sentence satisfactorily, including counselling to enable him to control his anger. He has since married a woman other than the woman who was the subject of the incident described above, and they have recently had a child. Numerous coworkers, supervisors, friends, and family testified in support of Respondent. His professional colleagues uniformly described Respondent as a highly competent practitioner, whose practice was never affected by the above-described incident or other acts of ill-temper. Respondent has above-average skills as a respiratory therapist and has ably trained other persons in the profession. All of the witnesses described Respondent as a supportive, patient, and caring person for whom the subject incident was out of character. The loss of his license would have a severe effect upon Respondent's ability to support is family. If allowed to continue to practice as a respiratory therapist, Respondent would not represent any risk to the public or his patients.
Recommendation Based on the foregoing, it is hereby RECOMMENDED that the Board of Medicine enter a final order imposing an administrative fine of $1000 and placing Respondent on probation for a period of five years, during which time Respondent shall undergo such supervision and monitoring as the Board deems suitable. ENTERED this 8th day of November, 1991, in Tallahassee, Florida. ROBERT E. MEALE 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 8th day of November, 1991. COPIES FURNISHED: Jack McCray, General Counsel Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Dorothy Faircloth Executive Director Board of Medicine 1940 North Monroe Street Tallahassee, FL 32399-0792 Francesca Plendl, Senior Attorney Department of Professional Regulation 1940 North Monroe St. Tallahassee, FL 32399-0750 Mark S. Blechman Lubet & Blechman 209 East Ridgewood St. Orlando, FL 32801
The Issue Whether Harold W. Barney, deceased, was "killed in the line of duty" as that term is used in Chapter 121, Florida Statutes (1975). Petitioner contends: That chief Harold Barney, deceased, was killed in line of duty because the congestive heart failure from which he died was caused by a pulmonary thromboembolus, which was caused by an on-the-job injury, or by the strenuous work that he had to do, in terms of mental stress. That therefore, the widow and Petitioner, Mrs. Barney, is entitled to receive the widow's benefit provided by Section 121.019(7)(c)1., Florida Statutes (1975). That the presumption of Section 185.34, Florida Statutes, permits the Respondent to assume that the death was in line of duty or that he was killed in-line-of duty if it could be shown that he died of heart disease, hypertension or hardening of the arteries. Respondent contends: That there was no nexus or medical connection between Chief Barney's employment with the Dade County Department of Public Safety and the incident which caused his death. Therefore, Petitioner is not entitled to the benefits of a widow of one killed in line of duty. That the presumption contained in Section 185.34, Florida Statutes, is inapplicable.
Findings Of Fact Depositions of Robert J. Myerburg, M.D., Eric Lian, M.D., and E. Wilson Purdy have been considered in this order. The portions of the depositions on matters that are not in evidence are not considered in this order. Cloyice B. Barney, the Petitioner, is the surviving spouse of Harold W. Barney, a deceased member of the Florida Retirement System under Chapter 121, Florida Statutes, who was employed by the Dade County Public Safety Department at the time of death, on June 3, 1975. Petitioner timely filed her petition for administrative hearing upon denial by the agency, the Division of Retirement, of her request of payment pursuant to the in-line-of-duty death benefits provision, Section 121.019(7)(c)1., Florida Statutes (1975). The decedent, Harold Barney, was involved in an automobile accident on October 4, 1972, at approximately 6:15 P.M. He was driving a county car which suffered damages estimated at One Hundred Fifty Dollars ($150.00). There is no substantial evidence that Mr. Barney was injured in this accident. He did not mention any injury to his family, his employer or to his personal physician. His son testified that he did not notice any physical change in his father immediately after the accident, but state that after a period of time he began to limp off and on for a couple of days and then maybe months later he's start to limp again. Upon questioning, the deceased would respond he was tired but did not attribute the limp to any accident. Dr. Harvey L. Jorgenson first saw the deceased on October 3, 1974. Chief Barney did not relate a history of any type of injury to Dr. Jorgenson, but Dr. Jorgenson testified that his walk "was a little bit different. . . it wasn't exactly a limp." Two or three weeks before his death Mr. Barney awoke feeling extremely tired. He continued to follow his normal work schedule until May 30, 1975, when he left work to see his personal physician who admitted him to the hospital. He died in the hospital three days later, on June 3, 1975. Dr. Joseph H. Davis, Chief Medical Examiner for Dade County, Florida, performed the autopsy at the request of the family, on June 4, 1975. When asked his opinion of the cause of death, he stated, In my opinion, the cause of death was congestive heart failure due to pulmonary thromboemboli. That means blood clots which break loose within the veins of the body and are carried through the venous system to the lungs to lodge in the lungs, due to bland plebothrombosis of lower extremities -- phlebo meaning vein, thrombosis, clots, lower extremities meaning from the groin region down, somewhere in that area, having origin in that area. And by bland, I mean that there was no evidence of an active inflammatory condition, in which case the diagnosis would have been thrombophlebitis, meaning inflammation of veins. They had the shape and the configuration of origin from lower extremity as opposed to, say, upper extremity or pelvis. Dr. David stated that he found evidence of the following diseases: (1) moderately enlarged heart of "the type of weight increase [of the heart] that would be seen with somebody with hypertension," (2) a small tumor in the center of one of the adrenal glands called a pheochromocytoma, and (3) both kidneys were enlarged with cysts, polycystic kidneys associated with hypertension. He found no evidence of prior injury or arterial disease. He was puzzled as to how the thromboemboli was formed. The dissection of the deceased lower extremities was confined only to the area immediately above the knee joint, the back of the knee where there is a major collection of veins, the large popliteal vein is formed; and, also, my dissection continued from the back of the knee, the popliteal area, down to about midway on the calf. I did not go into the ankles nor did I carry my dissection of the femoral and afemoral veins up through the thigh. In reply to the query, "Did you find any evidence yourself of prior trauma to the lower extremities?" he stated, No. The extremities appeared symmetrical and normal in appearance. There were no obvious, significant scars, swelling, discolorations; and, in the history, my inquiry of Dr. Jorgenson revealed no history of trauma. In answer to the question, "Would the fact that this accident occurred in 1972 rule out the possibility that the blood clots were formed from a trauma that occurred in 1972?" Dr. Davis replied, It would rule it out in the sense that, in one mechanism -- that is, a mechanism inflammatory reaction -- that type of mechanism, I think, would be pretty-well ruled out because, had that been the case, I would expect, despite an individual being stoic, episodes of swelling of the extremities and incapacitation and discolorations of the skin from poor circulation and so forth. The other type of tie, where there can be a tie-in, is where the original episode was severe enough to result in thrombi, distortion of the veins, healing with scarring and partial interference with blood flow through the veins so that, instead of a normal smooth-walled flexible tube with valves placed at regular intervals, there are valves that would have been distorted by thrombus, obliterating that area of the vein, and then the valve is no longer competent and the walls are narrowed in one area, but not in other areas. And, if that situation occurs, then the stage is set for the subsequent formation of thrombi at some indetierminant time in the future; and that's the only way -- If there were trauma in 1972 and if, over a period of time, the apparent symptoms of the trauma disappeared and everything was quiescent and then this occurred, if there is a link it would have to be on the basis of distortion of the veins left over from the previous trauma and, at this particular time, the interference with blood flow was sufficient to produce some additional clots in this area that was set up for it. Dr. Davis testified that the limping if it occurred subsequent to the accident and that if there was no prior diagnosis of arthritis or something, then, following a trauma, showed residual signs of discomfort, incapacitation, to wit: limping, then that would set the stage for consideration of the original trauma as possibly playing a role in the subsequent events which led to this death. Dr. Davis did not dissect the legs stating, it's not my custom to dissect lower extremeties due to the funeral customs of this country. So, if I encounter a person with a pulmonary embolus and where there is a perfectly logical explanation based on circumstances -- a person, say, with congestive heart failure, cancer, et cetera, severe disease process, he's been confined to bed -- I usually don't dissect the legs. Dr. Davis stated that the emboli that he found in the lungs were in various stages of healing and there "was some where the margin of the clot was already being incorporated into the wall of the pulmonary artery by scar tissue." He stated, "It wasn't something that had impressed me as having been there much longer" than perhaps two weeks or so. Dr. Davis was asked the question, "If he had suffered an injury to such an extent that it caused him recurrent limping and we will assume further that each time there was a flare-up or some of the time there was a flare-up if there would be clot formed, would that, be a reasonable possibility that that could happen?" Dr. Davis replied, "It's a possibility, yes, but" and in answer to the question, "Can you say on that evidence, [as to his limping] within a reasonable degree of medical probability, that the accident was the cause of the emboli?" Dr. Davis replied, "No, I cannot." Dr. Harvey L. Jorgenson first saw Mr. Barney on October 3, 1974, and found that Mr. Barney had had a kidney stone removed in 1971 and that he had repeated attacks of malarial fever after World War II but none after 1971. He found that he weighed 204 pounds where his normal weight should have been 185 and therefore, was about 20 pounds overweight. His blood was normal except his uric acid was 8.5 whereas the upper limit is 8 in the normal range. His blood cholesterol was 380 but should have been not higher than 300. His blood pressure was 140 over 100 and should have been not more than 90. It was suggested that he diet and take a medication prescribed for his blood pressure. Dr. Jorgenson saw him on the 11th of April, 1975, and suggested that he reduce a little more in weight and continue to take medicine for his blood pressure, which had improved. He was told to report to the doctor if anything changed. The next time Dr. Jorgenson saw Mr. Barney was the 30th of May, 1975, at which time he was very ill and was sent to the hospital. Dr. Jorgenson stated that there were many veins in the body that are the size and shape of the leg veins and stated that it was an enigma to him as to the cite of the emboli. Dr. Eric Lian stated, The most frequent site for venous thrombosis is in the popliteal -- what I mean, in the posteria vein, in the posteria area, the calf vein, the veins of the calf." When asked, "Is there any connection between hypertension and increased coagulability?" he said, It depends on the causes of hypertension and its consequences. If a patient has essential hypertension and then develops a congestive heart failure, certainly suggest increased chance of thromboembolism. [Question:] Is that what happened in this case? This patient, I think one can't say with certainty. He has a history. It's possible, but I don't think one can say it with certainty. And I will say most of the causes of thromboembolism, even young, healthy people, you cannot find any cause at all, nor any concurrent theory on this, you can't find." He also stated: [Question:] "Can you state, categorically that that stress was not linked to his death? I cannot say it's a cause of death. That's all I can say. Okay? Stress, itself, it cannot be a cause of death -- mental stress-- unless you have physical abnormality to begin with." Dr. Robert J. Myerburg stated that the shape of the emboli was from the vein rather than from the heart but that he did not know where the emboli came from. He stated, "I would suspect that the veins of the legs being most likely in an obese individual." Dr. Myerburg in answer to the question whether it is impossible for emotional stress to cause the venous thrombi to occur stated, "Well, the present state of knowledge knows of no relationship between emotional stress and the formation of venous thrombi." Dr. James R. Jorgenson, an assistant county attorney, stated that there were two major events occurring in addition to the major event of administering a large metropolitan police agency that was under investigation in the two or three week period before Mr. Barney died. That the deceased held a very responsible position and in addition was pursuing a college degree and was president-elect of the downtown Kawanis Club. Chief E. Wilson Purdy, Director of Public Safety and Sheriff of Dade County, testified that the deceased was an extremely conscientious employee and his main assistant. His duties were stressful and complex and he also used his time to pursue his education and civic involvement which was encouraged by his employer. The Hearing Officer finds: There was a possibility that the deceased, Mr. Barney, suffered bodily injury in the accident in which he drove his automobile into a car rail and sustained One Hundred Fifty Dollars ($150.00) damage to the vehicle. There is a possibility he injured his lower extremities. The fact of an injury was not established. There is a possibility that an injury caused the blood clot or embolism which ultimately reached the heart and caused the death of Mr. Barney. There is a possibility said injury was the same injury which might have been sustained on October 4. The fact that an injury caused the clot was not established. Mr. Barney lived a very stressful active life which included a difficult job, a hard course of educational pursuit and a position of leadership in the community particularly as an officer in the Dade County Kawanis Club. There has been no evidence produced to show stress caused the death of the deceased although some feel it is a factor in developing coronary artery disease, heart attacks and sudden death. The fact that job stress caused the death was not established. The proposed recommended orders together with the briefs of the parties have been carefully considered in the rendition of this order as has the depositions of the two doctors and the Director of Public Safety and Sheriff of Dade County, Florida, and the testimony adduced at the public hearing.
Recommendation Deny the request for payment under Section 121.091(7)(c)1., Florida Statutes (1975). DONE AND ORDERED in Tallahassee, Leon County, Florida, this 25th day of October, 1977. DELPHENE C. STRICKLAND Hearing Officer Division of Administrative Hearings Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 25th day of October, 1977. COPIES FURNISHED: Stephen S. Mathues, Esquire Division of Retirement 530 Carlton Building Tallahassee, Florida 32304 Brian S. Duffy, Esquire Post Office Box 1170 Tallahassee, Florida 32302
The Issue Whether Petitioner, the surviving spouse of Ralph Timmerman, is entitled to receive "in line of duty" death benefits?
Findings Of Fact Petitioner is the surviving spouse of Ralph Timmerman, who died on January 23, 1998, at 48 years of age. Petitioner and Mr. Timmerman had been married since September 5, 1981. They had two daughters, who are now four and thirteen years of age. Mr. Timmerman was a member of the Florida Retirement System. At the time of his death, Mr. Timmerman was employed by Martin County as the Assistant Building Maintenance Superintendent. Mr. Timmerman had been Martin County's Building Maintenance Superintendent until December of 1990, when he suffered a heart attack and had five-vessel by-pass surgery. Following his return to work, he was reassigned to the position of Assistant Building Maintenance Superintendent. This was a new supervisory position that had been specifically created for him. By design, it was less demanding than the Building Maintenance Superintendent position he had formerly held. One of Mr. Timmerman's former subordinates, Harold Markey, was tapped to succeed Mr. Timmerman as the Building Maintenance Superintendent, a decision that Mr. Timmerman supported. As the Assistant Building Maintenance Superintendent, Mr. Timmerman worked under Mr. Markey's supervision. Mr. Markey made an effort to avoid assigning Mr. Timmerman any tasks that, given Mr. Timmerman's history of heart problems, might jeopardize Mr. Timmerman's health. Mr. Timmerman's primary duties were to directly supervise the building maintenance staff and to deal with contractors hired by Martin County to perform building maintenance and repair work. Mr. Markey did not ask Mr. Timmerman to attend or make presentations at Martin County Board of County Commissioners meetings because he knew that Mr. Timmerman would feel uncomfortable performing these duties. Neither did Mr. Markey require Mr. Timmerman to do any physically demanding work. In fact, whenever, he saw Mr. Timmerman engaged in such physical labor, he would intervene and instruct Mr. Timmerman to stop. Whenever Mr. Timmerman indicated during the course of the work day that he was tired or not feeling well, Mr. Markey allowed Mr. Timmerman to leave work and go home.7 Notwithstanding these accommodations made for him, Mr. Timmerman, on a number of occasions, complained to Mr. Markey about (what Mr. Timmerman perceived to be) Mr. Markey's lack of understanding and compassion as a supervisor. He expressed these views in a loud and argumentative manner.8 As a general rule, following these outbursts, Mr. Timmerman apologized to Mr. Markey for the manner in which he had acted. It was during such an outburst on January 23, 1998, at his work site and during his normal working hours, that Mr. Timmerman suffered cardiac arrest and subsequently died. The day before, Mr. Timmerman and members of his staff had attended a meeting with Mr. Markey. Among the subjects discussed at the meeting was the response of Mr. Timmerman and his staff to a water main break that had occurred at the Martin County-operated library in Hobe Sound on January 20, 1998. The discussion concerning this subject lasted approximately 15 to 20 minutes. Mr. Markey was not at work on January 20, 1998, and therefore it was Mr. Timmerman's responsibility to coordinate the efforts to repair the break and remedy any water damage that had occurred at the library. Mr. Timmerman was notified of the water main break by Teresa Van Cardo, a Martin County employee occupying the position of Administrator Coordinator II for General Services. After some time had passed, Ms. Van Cardo became concerned that Mr. Timmerman had not yet arrived at the library. She therefore telephoned Mr. Markey at home to express her concerns about Mr. Timmerman's delay in responding to the scene. (Huey Cummings, Martin County's lead plumber, however, was on the scene and assessing the situation.) After speaking with Ms. Van Cardo, Mr. Markey telephoned Mr. Timmerman and told him that "he needed to get to the site and he needed to make an assessment of it." Mr. Timmerman replied that Huey Cummings was already at the library. When Mr. Timmerman came home from work that day he told Petitioner about what had happened at the library and that he was "very pleased at the way the whole situation was handled" by his staff. At the January 22, 1998, staff meeting (which was a regularly scheduled meeting), Mr. Markey voiced his criticism of the manner in which the staff had responded to the water main break at the library two days before,9 and he indicated what improvements the staff needed to make in responding to similar incidents in the future. It should not be necessary, he told his subordinates at the meeting, for anyone to have to bother him at home for guidance in dealing with a situation such as the one that arose at the library. At least one of the employees at the meeting (Patti Smith) could sense (based upon her observations of Mr. Timmerman's body movements as Mr. Markey spoke) that Mr. Markey's comments upset Mr. Timmerman. Indeed, Mr. Timmerman was upset. He felt that Mr. Markey's criticism was unwarranted, and, after Mr. Markey had voiced his criticism, Mr. Timmerman told Mr. Markey and the others at the meeting that, in his opinion, "everybody responded exceptionally." That evening, when he arrived home from work, Mr. Timmerman was still upset about the negative comments that Mr. Markey had made at the staff meeting earlier that day. Mr. Timmerman shared with Petitioner what Mr. Markey had said at the meeting and expressed his disappointment that Mr. Markey had criticized, rather than praised, his subordinates. The following morning (January 23, 1998), Mr. Timmerman woke up at 5:30 a.m. He ate a small breakfast and, after spending time with his youngest daughter, left for work at 6:30 a.m. He appeared to be "very calm" when he left. Mr. Timmerman arrived at work at or about 7:00 a.m. At around 7:30 a.m., Mr. Markey, at the request of another employee, went to Mr. Timmerman's office (which was located in a different building than Mr. Markey's office) and requested that Mr. Timmerman not park his assigned Martin County- vehicle in the staff parking lot (which was reserved for personal vehicles). Mr. Timmerman reacted with displeasure to the request. He told Mr. Markey, "This is bull crap," or at least used words to that effect. Mr. Markey repeated his request and then left Mr. Timmerman's office. Shortly thereafter, Mr. Markey discovered that two expensive vacuum cleaners were missing from the storage area where they were supposed to be kept. A few months earlier, Mr. Markey had instructed Mr. Timmerman to put up a "sign-out" sheet outside the storage area for employees to sign whenever they removed an item from the storage area. After discovering that the vacuum cleaners were missing from the storage area, Mr. Markey looked for, but did not find, such a "sign-out" sheet. When he returned to the building where Mr. Timmerman's office was located, Mr. Markey confronted Mr. Timmerman and asked him where the vacuum cleaners were. Mr. Timmerman told Mr. Markey that it was not his (Mr. Timmerman's) day to watch the vacuum cleaners and that he did not know where they were. Mr. Markey then said to Mr. Timmerman, "We need to get them located today," to which Mr. Timmerman responded, "Well, later on today, I will get somebody on it and we'll try to find them." Mr. Markey was not satisfied with Mr. Timmerman's response. He advised Mr. Timmerman that he wanted Mr. Timmerman, not someone else, to look for the vacuum cleaners and that he wanted Mr. Timmerman to look for them that morning, not later in the day. He also told Mr. Timmerman that he expected Mr. Timmerman to place a "sign-out" sheet outside the storage area before the morning was over. Mr. Markey then walked away and left the building. When Mr. Markey was approximately 30 feet away, Mr. Timmerman yelled out to him, "What do you have up your ass today?" Mr. Markey stopped and replied, "Obviously you." Mr. Markey then continued walking and returned to his office. Approximately four or five minutes later, an obviously very upset Mr. Timmerman stormed into Mr. Markey's office, yelling and screaming that Mr. Markey mistreated his staff and lacked understanding and compassion. Mr. Markey told Mr. Timmerman to calm down so that they could discuss what was bothering Mr. Timmerman. Mr. Timmerman, however, continued to yell and scream. In fact, if anything, he became louder. Mr. Markey made further attempts to persuade Mr. Timmerman to sit down and talk calmly about his grievances, but these efforts were to no avail. During his exchange with Mr. Timmerman, Mr. Markey, like Mr. Timmerman, raised his voice. Mr. Timmerman left Mr. Markey's office in a huff. As he was walking down the hallway, he shouted back to Mr. Markey, "I take-up for you all of the time with the guys," and then added, "I treat you like a F-en prince, and this is what I get." Mr. Timmerman then went into another employee's (Sharon Barnes') office and started pacing back and forth. His face was red and he was visibly agitated. Ms. Barnes told Mr. Timmerman to calm down. He replied to her that it was "too late." Mr. Timmerman thereupon returned to Mr. Markey's office and continued his ranting. Mr. Markey shouted back at Mr. Timmerman. When Mr. Markey told Mr. Timmerman to "sit down," Mr. Timmerman said that he "couldn't" and then turned to leave. Mr. Markey asked where Mr. Timmerman was going. Mr. Timmerman responded that he was going to take a ride in his truck. As Mr. Timmerman exited Mr. Markey's office and walked toward his truck, Mr. Markey followed behind him. Mr. Markey believed that, given Mr. Timmerman's agitated emotional state, Mr. Timmerman was in no condition to drive. He urged Mr. Timmerman not to go to his truck. Mr. Markey was ultimately able to convince Mr. Timmerman to sit down on a bench outside the building where Mr. Markey's office was located. Mr. Timmerman remained on the bench, however, for just a couple of seconds before getting up and walking away. As Mr. Timmerman walked away, he continued to yell and scream at Mr. Markey. Mr. Markey shouted back at Mr. Timmerman, repeating his plea that Mr. Timmerman not drive off in his truck. When Mr. Timmerman was approximately 20 feet from the bench, he started breathing heavily and leaned against a wall for support. Mr. Markey ran over to Mr. Timmerman to make sure that he did not fall. Mr. Markey again exhorted Mr. Timmerman to calm down. Mr. Timmerman, as he had done previously, told Mr. Markey that he "couldn't." Mr. Timmerman then collapsed in Mr. Markey's arms. After gently lowering Mr. Timmerman to the ground, Mr. Markey ran to Ms. Barnes' office window, which was approximately ten or 15 feet away. When he got Ms. Barnes' attention, he instructed her to "call 911." Paramedics subsequently arrived on the scene. They were unable to revive Mr. Timmerman. He was pronounced dead at 8:35 a.m. on January 23, 1998. An autopsy was performed the following day by Frederick Hobin, M.D., the Medical Examiner for the 19th Medical Examiner District of Florida. Dr. Hobin is a Florida-licensed physician, who is board-certified in anatomic, clinical, and forensic pathology. Following the completion of the autopsy, Dr. Hobin prepared an autopsy report, which contained the following findings and observations, among others (which the undersigned accepts as accurate): PATHOLOGIST'S OPINION MECHANISM OF DEATH: SUDDEN CARDIAC DEATH DUE TO ISCHEMIC CARDIOMYOPATHY CAUSE OF DEATH: OCCLUSIVE CORONARY ARTERIOSCLEROSIS MANNER OF DEATH: NATURAL . . . GROSS AUTOPSY PROTOCOL EXTERNAL EXAMINATION . . . INTERNAL EXAMINATION . . . CARDIOVASCULAR SYSTEM The heart weighs 680 grams. The increase in weight is attributed to biventricular hypertrophy. All of the chambers are markedly dilated. There is a dense gray scar throughout the posteroseptal myocardium. There are some focal areas of hyperemia in the inferior septum. The cardiac valves appear functionally intact. The coronary arteries have diffuse calcific occlusive arteriosclerosis. There is indication of a double remote bypass coronary graft procedure. There is some sclerosis of both of the grafts and one of the grafts appears to have been occluded by thrombus material throughout its entire length. The thrombus material appears remote in age and it is gray and friable. There is moderate arteriosclerosis of the aorta with some reduced elasticity. . . . FINDINGS AT GROSS AUTOPSY Arteriosclerotic cardiovascular disease. Occlusive coronary artery disease. Remote coronary artery bypass graft. Remote thrombosis of coronary artery graft. Ischemic cardiomyopathy. Healed posteroseptal myocardial infarction. . . . MICROSCOPIC EXAMINATION HEART There is marked hypertrophy of the myocardium as well as very extensive scarring. This is associated with sclerosis of the coronary artery bypass grafts and they are occluded by degenerated thrombus material. There appears to be minimal fibrosis of the mitral valve. Appended to Dr. Hobin's autopsy report were the written results of laboratory tests that had been conducted in conjunction with the autopsy. Such testing, according to the written results, revealed the presence of cannabinoids (cannabis metabolites) in Mr. Timmerman's blood.10 Although at the time of his death, Mr. Timmerman (as the autopsy reflected) was suffering from a chronic, degenerative, life-threatening cardiovascular disease that had evolved over a prolonged period of time, he was able to, and did in fact, lead a relatively normal life notwithstanding his disease. He was still able to work, and he continued his employment with Martin County11 until his death. Mr. Timmerman, however, because of his disease, was vulnerable to sudden cardiac death. Sudden cardiac death is a term the medical profession uses to indicate that a person has undergone a rapid, fatal deterioration as a result of an adverse cardiac event. In most, but not all, instances, the adverse cardiac event is an arrhythmia (as was the situation in Mr. Timmerman's death). Emotional stress and excitement can produce physiological changes that increase cardiac demand and consequently may precipitate an arrhythmia that leads to sudden cardiac death. Whether a particular incident or situation will produce such a result depends, not only on the individual's physical health, but on his or her emotional makeup as well. In the instant case, it appears, within a reasonable degree of medical probability, that work-related emotional distress (which manifested itself during the confrontations Mr. Timmerman had with Mr. Markey immediately preceding Mr. Timmerman's death) aggravated Mr. Timmerman's preexisting cardiovascular disease and thereby precipitated his demise.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Division of Retirement issue a final order finding that Petitioner is qualified to receive "in line of duty" death benefits from the account of her late husband, Ralph Timmerman. DONE AND ENTERED this 13th day of August, 1999, in Tallahassee, Florida. STUART M. LERNER 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 13th day of August, 1999.
Findings Of Fact Jose Alfredo Lopez-Martinez was born on September 29, 2004, at Manatee Memorial Hospital in Bradenton, Florida. He weighed 3,125 grams at birth. Donald Willis, M.D. (Dr. Willis), was requested by NICA to review the medical records for Jose. In a report dated May 24, 2012, Dr. Willis opined as follows: I have reviewed the records for [Jose Lopez- Martinez]. The mother, Natividad Martinez was a 22 year old G2 P1 with late pregnancy care. Pregnancy care was started during the third trimester. She was admitted to the hospital in labor at term. Her cervix was dilated 4 cms on admission. Amniotic membranes were ruptured with clear fluid. Fetal heart rate (FHR) monitor during labor shows a normal baseline heart rate of 130 bpm. FHR variability is reactive. FHR monitor tracing does not suggest fetal distress during labor. Spontaneous vaginal delivery was accomplished without complications. Birth weight was 3,125 grams. The newborn was not depressed. Apgar scores were 9/9. The baby cried and had spontaneous respiratory effort at birth. No resuscitation was required. The baby had a normal newborn hospital course and discharged home on DOL 2. * * * In summary, Labor and delivery were uncomplicated. FHR monitor did not suggest fetal distress during labor. The baby was not depressed at birth. The newborn hospital course was uncomplicated. There was no apparent obstetrical event that resulted in loss of oxygen or mechanical trauma to the baby's brain during labor, delivery or the immediate post delivery period. A review of the file in this case reveals that there have been no expert opinions filed that are contrary to the opinion of Dr. Willis. The opinion of Dr. Willis that Jose did not suffer a neurological injury due to oxygen deprivation or mechanical injury during labor, delivery, or immediate post- delivery period is credited.
The Issue The issue in this case is whether Petitioner, whose husband, a county police officer, died of heart failure at work, is entitled to receive “in line of duty” death benefits under the Florida Retirement System, which Respondent administers.
Findings Of Fact The Dispute, in a Nutshell On the morning of March 10, 2000, while on duty, Officer Randall Kugler (“Officer Kugler”) of the Miami-Dade Police Department suffered a fatal heart arrhythmia and died at the wheel of his police cruiser. He was 37 years old. Officer Kugler’s wife, Petitioner Marilyn Kugler (“Mrs. Kugler”), and their two minor children survive him. Officer Kugler was a member of the Florida Retirement System (“FRS”), which is administered by Respondent Department of Management Services, Division of Retirement (“Division”). Mrs. Kugler maintains that she is the surviving spouse of a member “killed in the line of duty” and thus is entitled to receive generous “in line of duty” death benefits under the FRS. The Division disagrees with her position and, thus, has denied Mrs. Kugler’s application for such benefits. Their dispute spawned the instant administrative litigation. The Events Preceding Officer Kugler’s Death Officer Kugler was an expert in inspecting heavy equipment (cranes, trucks, bulldozers, etc.) to determine if such property might have been stolen or otherwise involved in criminal activity. As a specialist in this area, Officer Kugler was assigned to an auto theft task force that conducted investigations in cooperation with other local law enforcement agencies as well as the FBI and the U.S. Customs Service. At about 9:00 a.m. on March 10, 2000, Officer Kugler arrived at the King Ocean Yard in Port Everglades, Florida, where he had been sent to assist U.S. Customs Service inspectors with the examination of two heavy machines destined for export. The pieces——a crane and a bulldozer——were very large; each weighed many tons. A crucial object of such inspections is to locate the public identification number, or PIN, of the subject piece of equipment. The PIN is a starting point in determining whether the machine is stolen. Finding the PIN on heavy equipment can be difficult because, among other reasons, the area to be searched is large; the numbers are frequently hidden in hard-to- access places (to thwart those who might want to remove them); and the numbers are often covered by paint, rust, dirt, and grease. As he went about his work that morning, Officer Kugler climbed aboard and poked around the equipment. His on-the-job activities——e.g. bending, crawling, climbing, walking——clearly involved some physical exertion. In addition, to expose concealed PINs, Officer Kugler was required to scrape or brush away paint and other obstructions, and this, too, entailed physical exertion. To facilitate the removal of layers of paint, rust, grease, and the like, Officer Kugler customarily used solvents marketed for cleaning carburetors and removing gaskets. These products contained a chemical known as Xylene. The Miami-Dade Police Department issued its officers, including Officer Kugler, two different brands of such cleaning agents, which were packaged in aerosol spray cans. Officer Kugler used one or both of these employer-issued sprays on March 10, 2000, and thus was exposed to Xylene.1 Officer Kugler’s inspection of the crane and bulldozer took about one hour. After finishing his work at King Ocean Yard, Officer Kugler left Port Everglades to return to Miami. Sadly, less than an hour later, he was found in Opa Locka, Florida, slumped over the steering wheel of his vehicle with the engine running and the doors locked, having died, still on duty, en route to his next assignment at Kauff’s Towing. Causes of Death The record contains the depositions of three physicians who opined as to the causes of Officer Kugler’s death. Two of these doctors are pathologists who were, at all times material to this case, medical examiners in the Miami-Dade Medical Examiner Department; as such, they participated in Officer Kugler’s autopsy. The third is a cardiologist named James Margolis. Mrs. Kugler retained Dr. Margolis as an expert witness for purposes of this litigation. The testimony of these experts is generally consistent——that is, their opinions do not conflict on any material matters. All are in agreement (and the undersigned finds) that the immediate cause of Officer Kugler’s death was a sudden and unexpected fatal heart rhythm disturbance (or arrhythmia). There is also no genuine dispute (and the undersigned finds) that Officer Kugler’s left descending coronary artery was partially blocked at the time of his death. (His other vessels, however, were normal.) This type of blockage (or occlusion) is associated with a common form of heart disease known as arteriosclerosis. Officer Kugler’s diseased artery was about 50 to 70 percent obstructed. Such blockage tends to become symptomatic at around 70 percent. As it happened, Officer Kugler had not experienced any symptoms, been diagnosed as having, or been treated for any heart disease. The pathologists were largely noncommittal when asked to identify the trigger(s) that precipitated Officer Kugler’s fatal heart rhythm disturbance. Dr. Margolis, on the other hand, who had reviewed the depositions of the two medical examiners as well as those of the several law enforcement personnel who were with Officer Kugler at the King Ocean Yard before he died, did form an opinion as to the substantial cause of the fatal arrhythmia, which he expressed as follows: It’s my opinion within a reasonable degree of medical probability that Mr. Kugler did, indeed, suffer a fatal arrhythmia and the fatal arrhythmia was caused either directly or indirectly by the heavy exertion in the presence of Xylene fumes, and that these in combination with what would have been otherwise a benign form of heart disease caused the fatal arrhythmia. The undersigned accepts the uncontroverted opinion of Dr. Margolis as to causation and determines, as a matter of fact, that Officer Kugler’s death resulted from a combination of work-related activities and exposures operating in conjunction with an undiagnosed and undetected preexisting condition (arteriosclerosis), which factors together precipitated the fatal heart arrhythmia. On the Credibility of Dr. Margolis The Division disputes the validity of Dr. Margolis’s opinion on causation, arguing that it is unfounded. Normally, the undersigned, as the trier of fact, does not explain why he has credited certain evidence. Dr. Margolis’s testimony, however, could be considered the linchpin of Petitioner’s case. Moreover, because Dr. Margolis did not testify in person at the final hearing, the undersigned was unable to witness his demeanor and other indicia of credibility that personal observation permits. Therefore, the undersigned will explicate several factors that he regarded as important in deciding to accept Dr. Margolis’s testimony. To begin, as mentioned, Dr. Margolis’s opinion on causation was not refuted. The pathologists’ opinions——which, to be sure, stopped short of linking Officer Kugler’s death to the performance of job-required duties——were outcome neutral (and consistent with Dr. Margolis’s testimony) because neither medical examiner excluded work-related factors from among the contributing causes of Officer Kugler’s death. And the Division, it should be stressed, presented no expert medical testimony to contravene Dr. Margolis on the subject of causation. While the undersigned, as the fact-finder, could reject unrebutted expert testimony, he would need to offer a reasonable explanation for doing so.2 He can think of none. Instead of offering evidence, the Division elected merely to contend that Dr. Margolis’s opinion is unsupported, urging that the depositions of the witnesses who saw Officer Kugler at work on March 10, 2000, do not support the factual assumptions which underlie the expert’s testimony, namely, that Officer Kugler engaged in “heavy exertion in the presence of Xylene fumes.” The Division’s arguments are not persuasive for several reasons. First, the Division failed to cross-examine Dr. Margolis on these points. If Dr. Margolis had been asked, for example, what he meant by “heavy exertion” or otherwise been challenged to defend that description, perhaps he would have offered a brilliant explanation——or perhaps he would have stumbled and undermined his opinion. Absent such inquiry, however, the undersigned considers it basically irrelevant whether Officer Kugler’s exertion is characterized as “heavy” or not. The bottom line is, the expert concluded that Officer Kugler’s exertion was sufficiently “heavy” to help trigger the fatal arrhythmia, and the Division has not shown, through proof, that Dr. Margolis was incorrect in this regard. Second, the record shows that Dr. Margolis reviewed all the pertinent evidence in rendering his opinion on causation.3 Indeed, Dr. Margolis examined the depositions that are in evidence in this case——the very depositions that the Division contends fail to support his opinion. The Division argues that the expert misinterpreted these data sources. The Division’s argument, however, is not evidence; Dr. Margolis’s opinion, in contrast, is. Without countervailing proof, the undersigned finds no reasonable grounds for second-guessing the cardiologist on medical matters within his area of expertise. Finally, to the extent the Division contends that Dr. Margolis is mistaken because Officer Kugler was not shown to have been exposed to Xylene, its position is untenable in light of the undersigned’s finding that Officer Kugler was, in fact, exposed to the chemical in the hours before his death.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Division enter a final order awarding Mrs. Kugler the “in line of duty” death benefits to which she is entitled under the Florida Retirement System. It is further ORDERED that Petitioner’s Request to Reserve Jurisdiction is denied because Mrs. Kugler has not articulated a statutory basis for awarding attorneys’ fees and costs in this case. DONE AND ENTERED this 21st day of January, 2003, in Tallahassee, Leon County, Florida. JOHN G. VAN LANINGHAM 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 21st day of January, 2003.
Findings Of Fact The Respondent is a state agency which initiated a proceeding with the filing of an Administrative Complaint against Marc Richman, D.O. The said complaint was assigned to the Division of Administrative Hearings pursuant to a request for Administrative Hearing pursuant to Chapter 120 and was assigned Division of Administrative Hearing Case Number 88-5258. On June 24, 1989, the Department of Professional Regulations issued a notice of voluntary dismissal in the above captioned proceeding and dismissed all charges against Marc Richman, D.O., in that case. Marc Richman, D.O. is a prevailing small business party within the meaning of Section 57.111(3)(c) and (d). The amount of attorney's fees and cost sought by the Petitioner in the Petition for Attorney's Fees is reasonable for the Representation of Marc Richman, D.O., in the defense of the Administrative Complaint through the date of issuance of the Notice of Dismissal. The Department of Professional Regulation maintains that the proceeds (sic) above-captioned were substantially justified at the time the Administrative Complaint was initiated by the state agency in that it maintains that there existed a reasonable basis in law and fact at the time of the filing of the Administrative Complaint. This position is disputed by the Petitioner, Marc Richman, D.O. The request for attorney's fees in the amount of $8,572.00 and costs of $563.96 for a total of $9,225.96 is reasonable for the representation of Petitioner throughout the instant proceeding. These proceedings were initiated by the filing of a complaint on September 16, 1986 with the Department of Professional Regulation (DPR), Petitioner in Case 88-5258, by the parents of G.H. who died October 18, 1984. G.H. was a long time patient of Dr. Jaffee, D.O. who called in Dr. Richman, an orthopedic surgeon to consult and perform an arthodesis on the left ankle of G.H. to relieve constant pain. G.H. was a 34 year old male accountant who had suffered from juvenile rheumatoid arthritis since the age of 4. Although badly crippled he was able to lead a relatively independent life. As a result of his malady G.H. had for years taken steroid and corticosteroid medications. These medications depress the body's immune system and the ability to fight off infections. Accordingly, G.H. was at more than normal risk anytime he was exposed to infectious diseases. After Petitioner explained the procedure and the risks to G.H., the latter elected to have Petitioner perform the arthodesis. This operation consists of grafting bone into the ankle to stabilize that joint. The donor site chosen for the bone to graft to the ankle was the crest of the left ilium of the patient. This operation was successfully performed on August 2, 1984 at Metropolitan General Hospital, Pinellas Park, Florida. In the hospital on August 9, 1984, while G.H. was being adjusted in his bed, he felt a pop in his left hip and a large hematoma developed over the wound at the donor site. It is not unusual for hematomas to develop over surgical wounds but it is important that such conditions be closely watched because hematomas are a fertile field for an infection. The hematoma on G.H.'s hip showed no evidence of infection and G.H. was discharged from the hospital August 12, 1984 and sent home. Arrangements were made by Petitioner for Robert's Home Health Services, Inc. of Pinellas Park to send a nurse 3 times per week to check on G.H., take his vital signs, dress his wounds and attend to any other medical needs he may have. Verbal reports were made by the nurse to Richman reporting the condition of G.H. While being helped from his wheel chair into bed by his parents on or about August 15, 1984, G.H. apparently fell and caused additional bleeding of the wound on the left hip. On August 16, 1984 the nurse reported to Richman the additional bleeding and she was directed to have G.H. taken to the hospital to be seen by Richman. On August 16, 1984, Petitioner examined the wound, noted the reports that the hematoma was neither inflamed nor more tender, and that G.H.'s temperature had remained normal since the hematoma developed. He sent G.H. back home without further tests. The classic signs and symptoms of infection are redness, swelling, heat and pain. Redness of the skin due to intense hyperemia, is seen only in infections of the skin itself. Swelling accompanies infection unless the infection is confined to the bone which cannot swell. Heat results from hyperemia and may be detected even in the absence of redness. Pain is the most universal sign of infection. Along with pain goes tenderness, or pain to the touch, which is greatest over the area of maximal involvement. (Exhibit 12, Principals of Surgery, Fourth Edition). The hematoma on G.H.'s left hip between its inception and September 13, 1984 never exhibited any sign of infection. On September 6, 1984, G.H. reported to the visiting nurse that he had a pain in his stomach and didn't feel well. The nurse described this as having flu-like symptoms. This was reported to Petitioner and the nurse received no additional orders. On the nurse's next visit on September 10, 1984, G.H. reported his abdomen was still hurting and he didn't feel good. At this time his temperature was elevated at 101. The nurse called Dr. Jaffee's office and was told to have the patient admitted to Metropolitan Hospital. Upon admission to the hospital on September 10, 1984, G.H. was nauseous, vomiting, and had a high fever (103). He had no complaints regarding his ankle or iliac crest and the hematoma had decreased greatly. On September 13, 1984, while G.H. continued showing signs of infection (high fever) Petitioner operated on G.H. to remove the hematoma. At this time aerobic and anaerobic cultures were obtained. Forty-eight and seventy-two hours later these cultures had grown no infectious substance. Further studies and tests revealed that G.H. had bleeding ulcers and surgery was required to patch the ulcers. At this time the spleen was also removed. Following this surgery G.H. was more debilitated and with the precarious condition of his immune system he continued to go down hill until he expired on September 18, 1984. Cause of death was cardiac pulmonary arrest caused by candida septicemia. During the initial stage of the investigation, which was initiated some two years after the death of G.H., the investigator interviewed the parents of G.H., who had filed the complaint, and assembled the medical records including those kept by the home health agency. The parents contended that when the hematoma was removed by Dr. Richman he told the parents that he had found infection at that site. Dr. Richman denies making any such statement to the parents of G.H. and the medical records support the conclusion that there was no infection in the hematoma on September 13, when the hematoma was excised. The parents complained of the treatment that G.H. received from Drs. Jaffee and Richman as well as Roberts Home Health Services. Accordingly the investigation started with both Jaffee and Richman charged with malpractice by the parents of G.H. The investigator selected an orthopedic surgeon, Dr. Richard M. Couch, D.O., from DPR's consulting list and forwarded to him on January 7, 1987, the patient records of G.H. and requested he review those records and give his opinion on whether Drs. Jaffee and Richman diagnoses and treatment of G.H. was appropriate. In this letter (Exhibit 1) the investigator advised Dr. Couch that following surgery a hematoma developed, that after G.H.'s discharge from the hospital the hematoma ruptured and that G.H. was taken back to the emergency room where Dr. Richman saw the patient but found nothing significant about the hematoma. He also told Dr. Couch that when Richman cleaned out the hematoma he advised the family (of G.H.) that infection was found, and that, after this G.H. started internal bleeding which ultimately resulted in the patient's death. Dr. Couch responded to this request with two letters, the first of February 16, 1987 and a second on March 6, 1987. In his first letter Dr. Couch concluded that the iliac wound began draining on or about August 14, 1984 and cultures of this wound were not secured until after G.H.'s hospitalization on September 10, 1984. Since the hematoma was a post-operative complication he opined that Richman failed to adhere to certain tenets regarding wound care in this situation. However, Dr. Couch suggested the records be referred to an internist who reviewed the treatment provided by Dr. Jaffee. In his second letter Dr. Couch opined that Richman was at fault for not incising, debriding and draining the hematoma when it developed and for not taking cultures when Richman saw G.H. in the emergency room on later dates. He also found Richman at fault for not referring G.H. to a consultant in infectious diseases. A letter similar to the letter sent to Dr. Couch was sent by the investigator to Neal B. Tytler, Jr., D.O., an internist. Although the investigator contends he submitted the records maintained by Roberts Home Health Services in this case to Dr. Tytler it is obvious that before he submitted his report on June 5, 1987, Dr. Tytler had not read those records and was concerned regarding the absence of medical records during the period between G.H.'s discharge from the hospital on August 12, 1984, and his readmission on September 10, 1984. In his report Dr. Tytler carefully noted G.H.'s long term medication for juvenile rheumatoid arthritis and the serious side effects, viz depression of the immune system, which results from long-term steroid therapy. Recognizing the risk to G.H. from any surgery Dr. Tytler questioned the wisdom of the arthodesis but recognized that this was more of an orthopedic problem than an internal medicine problem. From the records received, Dr. Tytler concluded that G.H. developed a hematoma after his departure from the hospital and before September 6, 1984. Significantly, Dr. Tytler reported "Of concern to me is the apparent lack of records to document the events which transpired between August 12, 1984 and September 10, 1984. In this one month period an abscess formed at the surgical site and led to disastrous consequences. Unfortunately it can only be inferred that the first recognition of any problem occurred on September 6, 1984, when the patient developed `flu-like symptoms'. He was not examined and no one perceived that his problems were serious." When the probable cause panel met on June 25, 1988 to consider the charges against Drs. Jaffee and Richman, no probable cause was found as to Jaffee. One of the two members of the probable cause panel disclosed at the opening of the panel meeting that he knew Dr. Richman socially and that Richman had been his treating physician for a finger injury. He was excused from further participation and the hearing was tabled regarding Dr. Richman. At a subsequent panel meeting by telephone conference call, after a substitute lay panel member was selected and had been furnished the medical records, a vote was taken to find probable cause. The excerpt from those proceedings (Exhibit 8) shows that the DPR attorney opened the conference call by stating that Richman was charged with medical conduct falling below acceptable minimal standards and "at the last probable cause panel meeting you voted to find probable cause, and asked that administrative complaint be issued. At this time the Department recommends that you do find probable cause to believe that this violation exists." Following receipt of this erroneous information regarding the previous probable cause panel meeting, the Chairman, Mr. Wheeler, stated that after reviewing the entire file he believes probable cause exists to file an Administrative Complaint. Dr. Barker concurred. The case against Dr. Richman began to unravel when the deposition of Dr. Tytler was taken on February 24, 1989. Prior to taking this deposition Dr. Tytler had been provided records from Metropolitan General Hospital, records from Roberts Home Health Services and a copy of the Administrative Complaint. In response to questions regarding the treatment of G.H. as afforded by Dr. Richman, Dr. Tytler stated that a review of all medical records clearly demonstrated that after the hematoma developed at the donor site for the transplant no indication of infection ever appeared; that considering the medical history of G.H. and his high susceptibility to infection it would be more dangerous to the patient to evacuate the hematoma and risk additional infection than it would to continue to observe the hematoma and let it cure itself; that the cultures taken on September 13, 1984, when the hematoma was evacuated clearly and unequivocally demonstrated that the hip wound was not the source of the infection that ultimately led to the demise of G.H.; and that the treatment rendered by Petitioner was in all respects in conformance with required medical standards and procedures. Dr. Tytler further opined that treating an immune compromised patient with antibiotics without a specific infection in mind "could lead to the very scenario that caused his (G.H.) death", namely secondary infection. Further, with respect to the contention of Dr. Couch regarding the failure of Petitioner to take cultures at the hematoma site before September 10, 1984, Dr. Tytler opined that indiscriminate taking of cultures when no evidence of infection is present could result in a positive culture unrelated to the wound but which the doctor would be called upon to treat. This could invite a major change in therapy and an inappropriate prescribing of an antibiotic. Following the deposition of Dr. Tytler, DPR referred the medical records to another orthopedic physician and this doctor concurred with the opinion of Dr. Tytler that Dr. Richman's treatment of G.H. was not below minimally acceptable standards, that no malpractice was involved and that the treatment was in accordance with acceptable medical standards. The Department then dismissed the Administrative Complaint. In his deposition the physician member of the probable cause panel, James H. Barker, D.O., emphasized that his conclusion that probable cause existed to go forward with the Administrative Complaint was significantly influenced by the fact that no culture was done at the hematoma site. From his subsequent testimony it is clear that Dr. Barker was unaware, when he voted to find probable cause, that the culture taken from the hematoma site on September 13, 1984 was negative. The record clearly shows this to be a fact. As stated by Dr. Tytler in his testimony "hematoma yes; infection no." Dr. Barker was also concerned, and perhaps rightly so, that any time that someone goes in for an elective procedure and he dies "that alone makes you think there may be probable cause here." However, there must be factual evidence to support a finding of probable cause and here there was no such evidence.
