The Issue The issue is whether Petitioner is entitled to a passing grade on the chiropractic examination.
Findings Of Fact Petitioner took the November 1999 examination for chiropractic licensure. He passed the written part and the technique portion of the practical part. However, Petitioner failed the physical diagnosis and X-ray interpretation portions of the practical part. The physical diagnosis portion of the examination supplies candidates with a brief case history followed by several questions. Score sheets provide standards for the scoring of responses. Question 3 of the physical diagnosis portion of the examination requires the evaluators to ask the candidate to demonstrate and describe an abdominal examination and explain the significance of a digital rectal examination on the patient, who has complained of cramping, bloatedness, and distention, as well as alternating stool consistency with an irregular pattern of defacation. The evaluators assigned Petitioner no points for his responses to Question 3. For the demonstration of an abdominal examination, Petitioner failed to ensure that the abdominal muscles were relaxed in order to permit a useful examination. Petitioner attempted to listen to the spleen, prior to performing percussion and palpation, but he was not in the left lower quadrant, which is the location of this organ. Petitioner palpated the abdominal area with his fingertips, rather than his palms, and failed to perform deep palpation. Petitioner also failed to outline the liver in his demonstration. The purpose of the digital rectal examination, for this patient, was to detect blood or a palpable lesion. Petitioner incorrectly responded that the purpose of this examination was to perform a prostate examination. Petitioner's misdiagnosis of diverticulitis, in response to Question 8, reflects his limited insight into this patient's condition, for which the correct diagnosis was irritable bowel syndrome, colitis, or spastic colon. Question 17 of the physical diagnosis portion of the examination required a demonstration of the gluteus maximus and peroneus muscles. The evaluators credited Petitioner for the correct demonstration of the gluteus maximums, but not the peroneus. Petitioner incorrectly grasped the patient's calf and ankle, which precluded the isolation of the peroneus. Failing to grasp the metatarsal end of the foot prevented Petitioner from properly isolating the peroneous muscle. At the hearing, Respondent gave Petitioner full credit for his response to Question 24 of the physical diagnosis portion of the examination. Question 3 of the X-ray interpretation portion of the examination required Petitioner to examine two X-ray films, taken two years apart, and render a probable diagnosis. The vast destruction of bone mass suggested a case of neuropathic joint resulting from syphillis, but Petitioner diagnosed post-traumatic joint disease, focusing instead on the patient's physically demanding profession and her age of 37 years. However, the extensiveness of bone destruction over a relatively short period favored the diagnosis of neuropathic joint over Petitioner's diagnosis. Question 5 of the X-ray interpretation portion of the examination required Petitioner to identify the anatomical structures outlined at lumbar-3 on a specific X-ray. Petitioner identified the structures as lamina, but they were the pars interarticulares, which are isthmus between the lamina and pedicle. Question 38 of the X-ray interpretation portion of the examination required Petitioner to explain why the neural foramen, as revealed on an X-ray, appeared enlarged. Rather than cite the nondevelopment of the cervical-6 pedicle, Petitioner incorrectly chose neurofibromatosis, despite the failure of the exposed structures to reveal the angularity characteristic of this condition and the absence of any bony structure subject to the process of deterioration resulting from neurofibromatosis. Despite the concession by Respondent on Question 24 on the physical diagnosis portion of the chiropractic licensure examination, Petitioner has failed to prove that he is entitled to additional credit on the physical diagnosis or X-ray interpretation portion of the chiropractic licensure examination that he should have passed either portion of the examination.
Recommendation It is RECOMMENDED that the Board of Chiropractic enter a final order dismissing Petitioner's petition. DONE AND ENTERED this 26th day of September, 2000, in Tallahassee, Leon County, Florida. ROBERT E. MEALE 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 26th day of September, 2000. COPIES FURNISHED: Joe Baker, Jr., Executive Director Board of Chiropractic Department of Health 4052 Bald Cypress Way, Bin C07 Tallahassee, Florida 32399-3257 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Angela T. Hall, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Gregory W. Stancel 2256 Iris Way Fort Myers, Florida 33905 Cherry A. Shaw Senior Examination Attorney Department of Health General Counsel's Office 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1703
The Issue Whether osteochondral autograft transplant surgery should be authorized for Petitioner pursuant to Workers' Compensation Law.
Findings Of Fact In 1998, Jackson fell at work and sustained an injury to her left knee. Jackson made a workers' compensation claim for the treatment of the injuries. She underwent treatment for her injuries, and her treating physician requested authorization from Jackson's Employer/Carrier to perform a surgical procedure commonly referred to by the trade name of OATS, but also known as mosaicplasty. The Employer/Carrier denied the authorization on the ground that OATS was investigative or experimental within the meaning of Rule 59B-11.002, Florida Administrative Code, and referred the request to the Agency for a determination under Section 440.13(1)(m), Florida Statutes, and Rule 59B-11.002(4), Florida Administrative Code. The Agency requested Dr. B. Hudson Berrey, the Chair of the Department of Orthopedics and Rehabilitation at Shands Hospital and Clinic at the University of Florida, to review Jackson's case to determine whether the procedure was investigative and whether the procedure would provide significant benefits to the recovery and well-being of Jackson. Dr. Berrey has been board certified in orthopedic surgery since 1982. After three years of practice, he took a fellowship in orthopedic oncology at Massachusetts General Hospital in Boston, Massachusetts. He then served as Chief of Orthopedic Oncology and, later, as Chief of Orthopedic Surgery at Walter Reed Army Medical Center in Washington, D. C. After his retirement in 1993, he served on the faculty of the University of Texas Southwestern Medical Center. He has been the Chair of the Department of Orthopedics and Rehabilitation at the University of Florida College of Medicine since 1996. In addition to his teaching duties, he continues to see patients weekly and to perform orthopedic surgery twice a week. His duties require him to keep abreast of developments in the field of orthopedic surgery. In preparation for rendering his opinion for the Agency, Dr. Berrey reviewed the medical literature, seeking articles discussing clinical trials of OATS. A clinical trial is an investigation in which patients with a certain condition may receive a treatment under study if they meet certain objective standards for inclusion. The treatment parameters are defined and outcomes are assessed according to objective criteria. Dr. Berrey found very little in peer-reviewed literature discussing clinical trials of OATS or mosiacplasty. Instead he found retrospective reviews and case reports. Based on his review of the medical literature, Dr. Berrey formed the opinion that mosaicplasty may be safe and efficacious; however, because the procedure has not been subjected to clinical trials, the procedure remains investigative. OATS involves the transfer of a patient's cartilage from one portion of the knee that is not considered weight- bearing or that is considered as having a minimal weight-bearing load to an area that receives greater force or is more weight- bearing. Dr. Berrey is of the opinion that OATS may be effective to treat isolated chondral defects on the weight- bearing surface of the knee. He describes the type of injury for which the procedure is effective as a focal lesion in an otherwise normal knee. Three components comprise the knee: the patella, the femoral articulating surface, or femoral condyle, and the tibial articulating surface or tibial plateau. The femoral condyle and tibial plateau are bony structures lined with articular cartilage that provide the gliding surface of the knee. The patella articulates with the femur at the patellar femoral joint, and the tibia articulates with the femur at the tibial femoral joint. The tibial femoral joint is made up of medial and lateral components. Other structures present in and about the knee include the menisici, the cruciate ligaments, and the collateral ligaments. Jackson's medical records, including the MRI report, show that there is a subchondral cyst and/or osteochondral defect on the anterior articular margin of the mid-media femoral condyle. There are subchondral cysts along the posterior portion of the mid-tibial plateau. In addition, there is a prominent osteochondral defect involving the patella. Jackson has articular damage to all three compartments of the knee: the femoral condyle, the patella, and the tibial plateau. Based on the degenerative changes in all three compartments of the knee, Jackson's changes are probably generalized. She does not have a focal defect of the articular cartilage of the knee. Her symptoms relate primarily to the patellar femoral joint. Her medical records describe her injuries as including chondromalacia of the patella. The term "chondromalacia" applies to a continuum of deterioration of the articular cartilage of the patella, from softening to frank fraying to fibrillation where the cartilage may be worn down to the bare bone. OATS or mosiacplasty is designed to address a localized, focal lesion. Because of the generalized nature of the diseased condition of Jackson's knee and the probability that her symptoms are related to the deterioration of her patellar femoral joint, the proposed procedure is not likely to improve her condition or to enable her to return to work.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered denying authorization for the OATS or mosaicplasty to be performed on Virginia Jackson. DONE AND ENTERED this 14th day of June, 2000, in Tallahassee, Leon County, Florida. SUSAN B. KIRKLAND Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 14th day of June, 2000. COPIES FURNISHED: Michelle L. Oxman, Esquire Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Building 3, Suite 3421 Tallahassee, Florida 32308-5403 Virginia Jackson 5555 Northwest 17th Avenue Apartment 2 Miami, Florida 33142 Sam Power, Agency Clerk Agency for Health Care Administration Fort Knox Building 3, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308-5403 Julie Gallagher, General Counsel Agency for Health Care Administration Fort Knox Building 3, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308-5403
Findings Of Fact Aiden Curtis Gordon Morris was born on September 15, 2011, at Sacred Heart Hospital in Pensacola, Florida. He weighed 3,300 grams at birth. NICA requested that Donald Willis, M.D., an obstetrician specializing in maternal-fetal medicine to review the medical records of Ms. Greenough and Aiden. The purpose of his review was to determine whether an injury occurred in the course of labor, delivery, or resuscitation in the immediate post-delivery period in the hospital due to oxygen deprivation or mechanical injury. Dr. Willis reviewed the records and made the following findings, which he set forth in an affidavit attached to the Motion for Summary Final Order. According to the medical records, the mother Natalie Greenough was a 16 year old G1. She presented to the hospital at 38 weeks gestational age in labor. Her cervix was dilated 5 to 6 cms on admission. Amniotic membranes were ruptured with clear fluid. The fetal heart rate (FHR) monitor on admission shows a reactive heart rate pattern with a normal baseline rate of 120 to 130 bpm. Some variable FHR decelerations and episodes of reduced FHR variability are noted during labor. An abnormal FHR pattern with reduced heart rate variability and variable decelerations continued for about 90 minutes prior to delivery. Severe variable decelerations with a drop in FHR to <60 bpm occurred about 40 minutes before delivery. Cesarean delivery was done for the non- reassuring FHR pattern. Birth weight was 3,300 grams. The newborn was depressed with Apgar scores of 1/4/6. Umbilical cord blood gas was abnormal with a reported pH of 6.99. Initial resuscitation included bag and mask ventilation with a good improvement in heart rate. Despite the improvement in heart rate, poor perfusion and respiratory depression continued. Intubation for mechanical ventilation was required. Admission physical exam in the NICU describes the baby as lethargic with poor perfusion of the extremities and on the ventilator for respiratory depression. Body cooling was initiated due to hypoxic ischemic encephalopathy (HIE). The newborn hospital course was complicated. Multisystem failure occurred. Poor perfusion required intravenous fluid boluses. Respiratory depression was present at birth and required intubation and mechanical ventilation. Disseminated intravascular coagulation manifest with hematuria and required fresh frozen plasma. Platelet count dropped to 91,000. Seizure activity was noted on DOL 2. EEG was consistent with mild HIE. MRI on DOL 7 was reported as normal. In summary, labor was complicated by fetal distress, requiring Cesarean delivery. The newborn was depressed. Umbilical cord blood gas showed significant acidosis with a pH or 6.99. The baby was lethargic, had poor perfusion and respiratory depression at birth. Hospital course was complicated by multisystem organ failure. Although the MRI on DOL 7 was reported as normal, EEG was consistent with HIE. Dr. Willis opined that there was an apparent obstetrical event that resulted in loss of oxygen to the baby's brain during labor, delivery, and continuing into the immediate post delivery period, which resulted in brain injury. He could not opine on the severity of the injury. NICA requested Raymond J. Fernandez, M.D. (Dr. Fernandez), a pediatric neurologist, to review the medical records for Aiden and to conduct an independent medical examination of Aiden. Dr. Fernandez examined Aiden on August 8, 2012. He made the following findings, which he set forth in an affidavit attached to the Motion for Summary Final Order, based on the medical records and a history from Ms. Greenough. Aiden's mother, Ms. Natalie Greenough, was admitted to the hospital on September 15, 2011, in active labor. The expected date of delivery was September 24, 2011. She received adequate prenatal care and the pregnancy was uncomplicated. Mrs. Greenough was 16 years old during the pregnancy. Her blood pressure on admission was 110/50 and pulse rate was 80. There was arrest of descent during labor and a nonreassuring fetal heartrate with bradycardia detected, requiring delivery by Cesarean section. The Apgar scores were 1, 4, and 6 and the umbilical artery cord blood pH was 6.9. Aiden required intubation in the delivery room. In the initial newborn examination he was described as having decreased movement and tone, poor perfusion and apnea. Upon admission to the Neonatal Intensive Care Unit, birth weight was 3,300 grams, length 52 centimeters, head circumference 36 centimeters, temperature 101, heart rate 154 and blood pressure was 55/22. He was lethargic and movement was reduced. He aroused during the examination. The Moro reflex was present. Sucking reflex was present, but diminished. Gag reflex was present as were plantar and palmar grasping reflexes. He was intubated and receiving assisted ventilation. He met clinical and neurological criteria for whole body cooling, which was initiated promptly (criteria for whole body cooling included periodic hypotohnia, decreased activity and lethargy). There was reduced urine output and hematuria due to urethral trauma during insertion of a Foley catheter. Seizures were a concern on September 16th, treated with Phenobarbital. There was seizure recurrence on September 18th and Phenobarbital was continued. On September 21, 2011, muscle tone and activity were decreased, but improving. Body rewarming began on September 21, 2011. Cranial ultrasound on September 15th was normal and MRI of the brain on September 21, 2011 was normal also. Specifically, there were no areas of restricted diffusion. An EEG on September 20, 2011, was abnormal due to a somewhat poorly organized background, consistent with a mild encephalopathy, but no seizures. In the discharge summary dated September 25, 2011, it was stated that muscle tone and activity were normal. MRI of the brain at four months of age was reportedly normal. * * * Following discharge, he was healthy. He displayed some periodic eye rolling movements for which he was examined by his Neurologist who performed a brain scan and an EEG that he stated were normal. These episodes have nor recurred and he has not required antiepileptic drug treatment since he was in the nursery. Initially, it was felt that Aiden had mild cerebral palsy because of tightness in his arms, but this has resolved. His neurologist in the Pensacola area thought that his development and his physical examination were normal at the time of the last visit and he did not feel that a return appointment was necessary. Aiden was evaluated by the Early Steps Development Program and he has been enrolled in physical therapy. He has been able to shift himself to the sitting position for several weeks. He crawls or creeps and about a month ago began pulling himself to the standing position. He is able to stand for a few seconds independently, but does not yet take independent steps. He cruises along furniture. Aiden was described as being alert, attentive, and inquisitive. He babbles, imitates sound, says "ma-ma" and "da-da" meaningfully and says and waves "bye-bye" meaningfully. He plays pat-a- cake. He uses both hands well. Picks up small objects with thumb and index finger, feeds himself and claps his hands in play. After performing a physical examination on Aiden on August 8, 2012, Dr. Fernandez made the following findings: PHYSICAL EXAMINATION: Head circumference 47 centimeters (50th percentile). Weight last week was 20 pounds 13 ounces. No dysmorphic features. No skin abnormalities of neurological significance. Funduscopic examination was limited, but grossly normal. Heart, lung and abdomen were normal. No orthopedic abnormalities. Skull was symmetric. There were no abnormalities over the spine. Aiden was alert. Attentive and inquisitive. He played appropriately with toys and spinning and rotating parts that he manipulated well. He consistently turned when his name was called. He babbled and said and waved "bye-bye" when leaving the room. Vision and hearing were grossly normal. Eyes were well aligned and eye movement was full, horizontally and vertically, without significant nystagmus. There was no drooling. Muscle tone was normal, proximally and distally. He shifted himself to sitting and crawling positions and pulled to stand. He cruised along furniture and took steps with hands held. He had good sitting balance and shifted position quickly and in well coordinated fashion. He moved about either in the crawling or sitting position by pushing with his arms or either leg. He did not yet crawl in reciprocal fashion. Muscle tone was normal and he moved all limbs well. There were no focal or lateralized motor abnormalities. No tremor or involuntary movement. He had well-coordinated pincer grasp, bilaterally, and transferred smoothly from hand to hand. He held one block in each hand and banged them together. He stretched his arms and leaned forward for toys that were otherwise out of reach. He looked for objects that were hidden from view. Deep tendon reflexes were 2+. There were no pathological reflexes elicted. Based on his review of the medical records, discussions with Ms. Greenough, and a physical examination of Aiden, Dr. Fernandez opined that there was no evidence of brain injury due to oxygen deprivation during labor and delivery resulting in substantial and permanent mental or motor impairment. He felt that Aiden should continue to improve in all areas and did not anticipate that in the future that there would be evidence of substantial mental and motor impairment due to oxygen deprivation during labor and delivery. 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. Fernandez. The opinion of Dr. Fernandez that Aiden is not substantially and permanently mentally and physically impaired is credited.
The Issue The issue in the case is whether the allegations of the Administrative Complaint filed by the Petitioner against the Respondent are correct and if so, what penalty should be imposed.
Findings Of Fact The Petitioner is the agency responsible for licensure and regulation of physicians practicing in the State of Florida. The Respondent is a Florida licensed physician, holding license number ME 0034599. The Respondent is a board-certified general and thoracic surgeon. In March of 1997, the Respondent was in private practice and a member of the medical staff at Englewood Community Hospital, in Englewood, Florida. On March 25, 1997, emergency medical service personnel transported an 81-year-old male (patient) to the Englewood Community Hospital emergency room at about 5:00 p.m. The patient had fallen in his home, hitting his head on a door frame and sustaining an injury to this right chest, apparently near his ribs. Upon arrival at the hospital, the patient was examined by Dr. William B. Caldwell, an ER physician employed by a company that provided emergency services by contract with the hospital. Dr. Caldwell did not have admitting privileges at the hospital. Only a physician who was a member of the hospital's medical staff could admit a patient. Upon initial examination, Dr. Caldwell observed a laceration on the patient's forehead and pain on the patient's right side near the ribs. The patient was alert and described the event, stating that he fell, hit his head on the door frame and hurt his ribs. There was no indication of neurological change or loss of consciousness. There was no indication of cervical injury. Bleeding was controlled. According to the patient's history, the patient had chronic obstructive pulmonary disease, coronary artery disease, a prior heart attack, and periodic atrial fibrillation. The patient also had an abdominal aortic aneurysm of approximately four centimeters, apparently unaffected by the event based on the initial examination in the emergency room. The patient was taking coumadin, commonly known as a blood "thinner" which delays clotting time. The patient was sent for X-rays, which confirmed the chronic obstructive pulmonary disease and an old rib fracture. Upon return from X-ray, Dr. Caldwell noticed that a developing hematoma on the right side of the patient's chest, indicating that there was active bleeding occurring in the chest cavity, apparently related to a new rib fracture. At that point, the patient was having breathing difficulty. Dr. Caldwell ordered breathing treatments for the patient, which resulted in some improvement. Initial lab work indicated that the patient's "prothrombic time" was at a "panic value" level, according to the Petitioner's expert witness, which warranted admission to the hospital. According to the time of the lab report, the information was available at 6:45 p.m. There is no credible evidence that Dr. Caldwell reviewed the lab report. Dr. Caldwell discussed the case with a physician who was covering the practice of the patient's regular physician. Dr. Caldwell believed the patient should have been admitted to the hospital and discussed it with the general physician, who allegedly agreed. At about 7:10 p.m., the Respondent was called in to examine the patient. The Respondent's notes indicate he was called in for a "thoracic and surgical consultation." Dr. Caldwell discussed the case with the Respondent, and reviewed the X-ray information. Dr. Caldwell testified that he "believed" the Respondent had assumed responsibility for the patient. The Respondent asserts that he was called in to consult on the case, and did not accept responsibility for patient care. The evidence fails to establish that the Respondent agreed to assume responsibility for the patient. There is no credible evidence that Dr. Caldwell asked the Respondent to admit the patient to the hospital, or that Dr. Caldwell advised the Respondent that he and the general physician believed admission was appropriate. Shortly after reviewing the X-rays with the Respondent, Dr. Caldwell left the hospital for the night, having finished his work shift. He failed to dictate any records of his examination or treatment of the patient prior to leaving the hospital. The Respondent sutured and bandaged the laceration on the patient's forehead. While suturing the wound, the Respondent discussed with the patient the advisability of being admitted to the hospital for observation based on his age and the nature of the fall. The patient wanted to return home and declined to be admitted to the hospital. The Respondent thereafter advised the patient to discontinue the use of coumadin and prescribed a medication to remedy the prothrombin deficiency as well as an antibiotic. The Respondent advised the patient to follow up with his regular physician. Shortly thereafter, the Respondent left the emergency room. The patient was discharged from the emergency room at 8:54 p.m. According to the nurse's notes, the Respondent approved the discharge. There is no documentation that the Respondent directed a nurse to discharge the patient. There is no direct evidence that the Respondent told the nurse to discharge the patient. Although the nurse expressed some concern about the patient's condition at the time of the discharge, there is no evidence that she relayed her concern to the Respondent. The patient returned to his residence and, within two hours after his discharge, died. At approximately 10:56 p.m., emergency medical service personnel were called to the patient's residence and confirmed that the patient was dead. An autopsy was performed on the body of the deceased patient. The autopsy report indicates that the cause of death was "blunt force cranio-cerebral, neck and thoraco-abdominal trauma." The autopsy report indicates the existence of an 11 x 9 centimeter contusion of the right flank with associated rib fractures, a fracture of the C4 level vertebral body with "posterior epidural blood extravasation of the C4 level spinal cord," and "traumatic leakage of the abdominal aortic aneurysm into the retroperitoneal and peripelvic soft tissue." Contributing factors were the patient's "severe chronic obstructive pulmonary disease and atherosclerotic cardiovascular disease."
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Agency for Health Care Administration, Board of Medicine enter a Final Order reprimanding Remo G. Gaudiel for failure to maintain appropriate medical records and imposing a fine of $1000. It is further recommended that the Respondent be required to complete within six months of the Final Order, a continuing education course related to proper completion and maintenance of adequate medical records that is acceptable to the Petitioner, in addition to any other applicable continuing education requirements. DONE AND ENTERED this 4th day of April, 2002, in Tallahassee, Leon County, Florida. WILLIAM F. QUATTLEBAUM 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 4th day of April, 2002. COPIES FURNISHED: Britt Thomas, Esquire Agency for Health Care Administration Office of the General Counsel 2729 Mahan Drive, Building 2 Mail Station 39-A Tallahassee, Florida 32308 Ross L. Fogleman, III, Esquire 3400 South Tamiami Trail, Suite 302 Sarasota, Florida 34239 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Tanya Williams, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
Findings Of Fact Respondent is a physician licensed to practice medicine in Florida. His office is located on Sanibel Island in Lee County. A Sanibel Island tourist, Mrs. Marion Wallace, presented herself as a patient at Respondent's office on the morning of March 2, 1981. She complained of abdominal pain and swelling. Mrs. Wallace was seen by Mr. Kern Barrow, a physician's assistant employed by Respondent. Barrow conducted a physical examination of Mrs. Wallace's abdominal region and took her medical history, noting abdominal distension, abdominal pain, anorexia, nausea, vomiting and dysuria. She had not been feeling well for several days and had experienced some nausea and vomiting in the early morning hours of March 2, 1981. Barrow conducted a routine physical examination that included examination of the abdominal region, neck, mouth and throat. No medical tests were ordered or conducted by Barrow other than a urinalysis. Barrow's preliminary diagnosis was viral gastroenteritis or urinary tract infection. He administered ampicillan and prescribed donnagel for her cramping and gaviscon for the abdominal distension or gas. He administered an injection of compazine to prevent further nausea and vomiting. Barrow could not remember consulting with Respondent concerning Mrs. Wallace on March 2, but told her to come back if her condition did not improve. He described Mrs. Wallace as looking ill, but not mortally ill. Respondent did not see Mrs. Wallace on March 2, but reviewed and initialed the chart prepared by Barrow. Respondent prescribed the medication "Tagamet," but did so only because the patient requested it, claiming to have received relief for gastritus from this medication. Mrs. Wallace returned to Respondent's office on the morning of March 3, continuing to complain of abdominal pain and swelling. Respondent examined the patient at that time, but did not perform a rectal examination. He did not order a blood test, barium enema or x-ray. He noted "observe" on her chart, but did not schedule a return visit. He tentatively diagnosed her condition as diverticulitis. Mrs. Wallace, who did not testify in this proceeding, claimed that her condition had worsened between her visits to Respondent's office on March 2 and March 3. This fact was not established by direct evidence. However, on March 4 she presented herself to another Fort Myers area physician who sent her to the hospital emergency room where her condition was diagnosed as "acute abdomen" necessitating immediate surgery. During the surgery performed on March 4, it was discovered that Mrs. Wallace had a perforated gangrenous appendicitis with abscess formation, peritonitis, and a small bowel obstruction. These are serious and dangerous medical conditions. The testimony of Respondent and the other physicians who testified in this proceeding established that his tentative diagnosis was not inappropriate given the patient's symptoms. However, his failure to perform tests (such as a blood test for white blood cell count, x-ray, rectal examination or barium enema) was a serious lapse in view of her condition and his tentative diagnosis. His prescribing of Tagamet was not shown to have been improper. Respondent's use of a physician's assistant for the initial examination was likewise not shown to have been improper. However, Respondent's inability to note any progression of her symptoms between March 2 and 3 resulted from his overreliance on the physician's assistant and failure to conduct even a minimal examination of her on March 2.
Recommendation From the foregoing, it is RECOMMENDED: That petitioner enter a Final Order (1) finding Respondent guilty of failure to practice medicine with that level of care, skill and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances; and (2) reprimanding and fining Respondent $1,000. DONE and ENTERED this 21st day of January, 1983, in Tallahassee, Florida. R. T. CARPENTER, Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 21st day of January, 1983. COPIES FURNISHED: J. Riley Davis, Esquire Post Office Box 1796 Tallahassee, Florida 32302 Leonard A. Carson, Esquire Post Office Box 1528 Tallahassee, Florida 32302 Dorothy Faircloth, Executive Director Board of Medical Examiners Dept. of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Samuel R. Shorstein, Secretary Dept. of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 ================================================================= AGENCY FINAL ORDER ================================================================= BEFORE THE BOARD OF MEDICAL EXAMINERS DEPARTMENT OF PROFESSIONAL REGULATION, BOARD OF MEDICAL EXAMINERS, Petitioner, vs. CASE NO. 82-815 STANLEY P. WEGRYN, M.D., License Number: 23028, Respondent. /
The Issue The issues in this case are whether Respondents performed a wrong procedure on patient C.C., as set forth in the second amended administrative complaints, and if so, what is the appropriate sanction.
Findings Of Fact The Department of Health, Board of Medicine, is the state agency charged with regulating the practice of medicine in the state of Florida, pursuant to section 20.43 and chapters 456 and 458, Florida Statutes. At all times material to this proceeding, Respondents were licensed physicians within the state, with Dr. Kenneth D. Stahl having been issued license number ME79521 and Dr. Eddie Ward Manning having been issued license number ME110105. Dr. Stahl has been licensed to practice medicine in Florida since 1999 and in California since 1987. He has never had disciplinary action taken against either license. Dr. Stahl is board certified by the American College of Surgeons in general surgery, cardiac and thoracic surgery, and trauma and critical care surgery. Dr. Stahl's address of record is 3040 Paddock Road, Fort Lauderdale, Florida 33141. Dr. Manning has been licensed to practice medicine in Florida since May 31, 2011. He has never had disciplinary action taken against his license. On June 23, 2011, Dr. Manning was a resident in general surgery. Dr. Manning's address of record is 1900 South Treasure Drive, Apartment 6R, North Bay Village, Florida 33141. In February 2011, patient C.C., a 52-year-old female, was admitted to Jackson Memorial Hospital (JMH) with a diagnosis of perforated appendicitis. She also had a perirectal abscess. Her records indicate that she was treated with percutaneous drainage and a course of intravenous (IV) antibiotics. She was discharged on March 4, 2011. On June 22, 2011, patient C.C. presented to the JMH Emergency Department complaining of 12 hours of abdominal pain in her right lower quadrant with associated nausea and vomiting. Shortly after her arrival she described her pain to a nurse as "10" on a scale of one to ten. A computed tomography (CT) scan of patient C.C.'s abdomen was conducted. The CT report noted that the "the uterus is surgically absent," and "the ovaries are not identified." It noted that "the perirectal abscess that was drained previously is no longer visualized" and that the "appendix appears inflamed and dilated." No other inflamed organs were noted. The radiologist's impression was that the findings of the CT scan were consistent with non-perforated appendicitis. Patient C.C.'s pre-operative history listed a "total abdominal hysterectomy" on May 4, 2005. Patient C.C.'s prior surgeries and earlier infections had resulted in extensive scar tissue in her abdomen. Dr. Stahl later described her anatomy as "very distorted." Patient C.C. was scheduled for an emergency appendectomy, and patient C.C. signed a "Consent to Operations or Procedures" form for performance of a laparoscopic appendectomy, possible open appendectomy, and other indicated procedures. Patient C.C. was taken to surgery at approximately 1:00 a.m. on June 23, 2011. Dr. Stahl was the attending physician, Dr. Manning was the chief or senior resident, and Dr. Castillo was the junior resident. Notes indicate that Dr. Stahl was present throughout the critical steps of the procedure. Dr. Stahl had little recollection of the procedure, but did testify that he recalled: looking at the video image and seeing a tremendous amount of infection and inflammation and I pulled-–I recall that I myself went into the computer program and pulled up the CT scan and put that on the screen right next to the video screen that's being transmitted from the laparoscope and put them side-to-side and compared what the radiologists were pointing to as the cause of this acute infection and seeing on the laparoscopic video image that that indeed matched what I saw in the CT scan and I said, well, let's dissect this out and get it out of her so we can fix the problem. Dr. Stahl further testified that the infected, hollow organ that was dissected and removed was adherent laterally in the abdomen and was located where the appendix would normally be. He recalled that an abscess cavity was broken into and the infected, "pus-containing" organ that was removed was right in the middle of this abscess cavity. Dr. Stahl also recalled the residents stapling across the base of the infected organ and above the terminal ileum and the cecum and removing it. The Operative Report was dictated by Dr. Manning after the surgery and electronically signed by Dr. Stahl on June 23, 2011. The report documents the postoperative diagnosis as "acute on chronic appendicitis" and describes the dissected and removed organ as the appendix. Progress notes completed by the nursing staff record that on June 23, 2011, at 8:00 a.m., patient C.C. "denies pain," and that the laparoscopic incision is intact. Similar notes indicate that at 5:00 p.m. on June 23, 2011, patient C.C. "tolerated well reg diet" and was waiting for approval for discharge. Patient C.C. was discharged on June 24, 2011, a little after noon, in stable condition. On June 24, 2011, the Surgical Pathology Report indicated that the specimen removed from patient C.C. was not an appendix, but instead was an ovary and a portion of a fallopian tube. The report noted that inflammatory cells were seen. Surgery to remove an ovary is an oophorectomy and surgery to remove a fallopian tube is a salpingectomy. On Friday, June 24, 2011, Dr. Namias, chief of the Division of Acute Care Surgery, Trauma, and Critical Care, was notified by the pathologist of the results of the pathology report, because Dr. Stahl had left on vacation. Dr. Namias arranged a meeting with patient C.C. in the clinic the following Monday. At the meeting, patient C.C. made statements to Dr. Namias regarding her then-existing physical condition, including that she was not in pain, was tolerating her diet, and had no complaints. Dr. Namias explained to patient C.C. that her pain may have been caused by the inflamed ovary and fallopian tube or may have been caused by appendicitis that resolved medically, and she might have appendicitis again. He explained that her options were to undergo a second operation at that time and search for the appendix or wait and see if appendicitis recurred. He advised against the immediate surgery option because she was "asymptomatic." The second amended administrative complaints allege that Dr. Stahl and Dr. Manning performed a wrong procedure when they performed an appendectomy which resulted in the removal of her ovary and a portion of her fallopian tube. It is clear that Dr. Stahl and Dr. Manning did not perform an appendectomy on patient C.C. on June 23, 2011. Dr. Stahl and Dr. Manning instead performed an oophorectomy and salpingectomy. It was not clearly shown that an appendectomy was the right procedure to treat patient C.C. on June 23, 2011. The Department did convincingly show that patient C.C. had a history of medical problems and that she had earlier been diagnosed with appendicitis, had been suffering severe pain for 12 hours with associated nausea and vomiting, that she suffered from an infection in her right lower quadrant, that the initial diagnosis was acute appendicitis, and that the treatment that was recommended was an appendectomy. However, substantial evidence after the operation suggests that an appendectomy was not the right procedure. The infected and inflamed organ that was removed from the site of a prior abscess was not an appendix. After the procedure, patient C.C. no longer felt severe pain in her lower right quadrant, with associated nausea and vomiting. She was discharged the following day and was asymptomatic. It is, in short, likely that the original diagnosis on June 22, 2011, was incorrect to the extent that it identified the infected organ as the appendix. The pre-operative diagnosis that patient C.C.'s severe pain and vomiting were caused by a severe infection in an organ in her lower right quadrant was correct. Surgical removal of that infected organ was the right procedure for patient C.C. If that inflamed organ was misidentified as the appendix before and during the operation, that would not fundamentally change the correctness of the surgical procedure that was performed. The evidence did not clearly show that the wrong procedure was performed. It is more likely that exactly the right procedure was performed on patient C.C. That is, it is likely that an oophorectomy and salpingectomy were the right procedures to address the abdominal pain that caused patient C.C. to present at the JMH emergency room, but that the right procedure was incorrectly initially denominated as an "appendectomy," as a result of patient history and interpretation of the CT scan.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health, Board of Medicine, enter a final order dismissing the second amended administrative complaints against the professional licenses of Dr. Kenneth D. Stahl and Dr. Eddie Ward Manning. DONE AND ENTERED this 15th day of July, 2015, in Tallahassee, Leon County, Florida. S F. SCOTT BOYD Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 15th day of July, 2015.
