The Issue Whether Respondent's license to practice medicine should be disciplined for alleged violations of Chapter 458, Florida Statutes.
Findings Of Fact At all times material to this proceeding, Respondent was licensed as a physician in the State of Florida having been issued licensed number ME 0025012. On January 1, 1990 Respondent's license to practice medicine in the State of Florida became inactive. Respondent was not aware that his license had become inactive because he had not received the usual notice from the Board that his license was due to be renewed. The notice had been mailed to Respondent's last known address. At Respondent's own admission, Respondent continued to practice medicine in the State of Florida after his license had become inactive. However, Respondent immediately ceased such practice when he learned that his license was inactive. Respondent's license has never been reactivated. Given these facts, Respondent's practice of medicine after his license had become inactive constitutes only a minor violation of Section 458.331(1)(x), Florida Statutes. The penalty for such a violation should be minor. Therefore, a letter of reprimand would be appropriate in this case. In 1984, Dr. Cooper was employed as a staff physician in the emergency room of Tallahassee Memorial Regional Medical Center. On March 30, 1984, Patient D.J.D., a nineteen year old male, ingested an unknown quantity of the drug Asendin. Asendin is a tricycline antidepressant drug. Patient D.J.D. told his roommate what he had done. His roommate called an ambulance. The ambulance transported Patient D.J.D. to Tallahassee Memorial Regional Medical Center (TMRMC) While D.J.D. was being transported to TMRMC, the Respondent, who was on duty in the TMRMC emergency room, gave the paramedics who were treating Patient D.J.D. en route orders by phone to give patient D.J.D. 30 cc's of Ipecac with water to induce vomiting. The Ipecac was administered but Patient D.J.D. did not vomit. When the paramedics arrived at the hospital at 8:16 p.m., Patient D.J.D. was coherent and responded appropriately to questions. He was conscious and was sitting up with his eyes open. Approximately twenty minutes after D.J.D. arrived at the hospital, he had a grand mal seizure. Respondent was made aware of the seizure. Respondent performed an initial evaluation of Patient D.J.D. and wrote orders for an intravenous line, blood and urine analysis. The emergency room nurse did not inform Respondent that D.J.D. was an overdose patient. However, Respondent did not question the ER nurse about Patient D.J.D.'s history. At approximately 9:00 p.m., Patient D.J.D. had a second grand mal seizure. Following Patient D.J.D.'s second grand mal seizure, the Respondent administered Valium, Phenobarbital and Dilantin. After the drugs were administered Respondent asked the ER nurse about D.J.D.'s history. Although Respondent was made aware that Patient D.J.D. had overdosed on Asendin, at no time did he pump or lavage Patient D.J.D.'s stomach or administer charcoal. Charcoal is used with Asendin overdose patients to absorb the drug from the patient's system. It is usually diluted with sorbitor and pushed into the stomach. Gastric lavage involves washing the stomach contents out with saline solution. Dr. Jack F. Kareff, M.D., who has completed a three year residency in emergency medicine and who has been with Humana Hospital Bennett Emergency Department in Plantation, Florida, testified as an expert in emergency medicine. Dr. Kareff was of the opinion that Respondent should have lavaged or pumped Patient D.J.D.'s stomach and/or administered charcoal and that by not doing so, Dr. Cooper failed to practice medicine with that level of care, skill and treatment that is recognized as being acceptable in his treatment of Patient D.J.D.'s overdose. Respondent stated that he did not lavage Patient D.J.D.'s stomach or administer charcoal since it was not appropriate treatment for a patient who is seizing. Respondent stated that this is difficult to do as the teeth are clenched and it is difficult to force a tube in. However, the evidence showed that Patient D.J.D. had an oral air tube placed by either Respondent or the nurse after his first seizure. In fact, at one point during the treatment of Patient D.J.D., Respondent replaced the patient's airway tube. Such evidence indicates that Respondent's reasoning is not well founded. Respondent also states that he did not lavage patient D.J.D.'s stomach or administer charcoal because Asendin is absorbed very rapidly. However, the better evidence demonstrated that in the case of an overdose of the tricyclic antidepressants, like Asendin, gastric stasis is accomplished. Therefore, the stomach does not empty as fast as it usually does and the drug may still be in the stomach up to 12 hours after ingestion. The failure of Dr. Cooper to administer such treatment and immediately inquire about the patient's history constitutes a violation of Section 458.331(1)(t), Florida Statutes by falling below the standards of practice of medicine recognized in the community. Dr. Kareff testified that the Respondent failed to keep written medical records justifying the course of treatment of Patient D.J.D. in that the records did not justify Respondent's failure to pump or lavage his stomach and administer charcoal. However, in 1984, a doctor was not required to keep records justifying a course of treatment not given and it is questionable whether practicably speaking such records can be kept. Therefore, Respondent is not guilty of violating Section 458.331(1)(m), Florida Statutes, and Count II of the Administrative Complaint should be dismissed.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is: RECOMMENDED: That the Board of Medicine enter a Final Order finding Respondent guilty of violating Sections 458.331(1)(t) and (x), Florida Statutes, and that Respondent be: 1) reprimanded, 2) fined $4,000.00, and 3) placed on probation for a period of two years. If is further recommended that Count II of the Administrative Complaint be dismissed. DONE and ORDERED this 1st d ay of October, 1991, in Tallahassee, Florida. DIANE CLEAVINGER 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 1st day of October, 1991. APPENDIX TO CASE NO. 90-2212 The facts contained in paragraphs 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 23 of Petitioner's Proposed Findings of Fact are adopted, in substance insofar as material. The facts contained in paragraph 24 of Petitioner's Proposed Findings of Fact were not shown by the evidence. COPIES FURNISHED TO: Francesca Small Senior Attorney Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 Gerald Cooper 2114 Owens Street Tallahassee, Florida 32301 Dorothy Faircloth Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 Jack McRay General Counsel Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 =================================================================
Findings Of Fact Based upon the record evidence, as well as the factual stipulations entered into by the parties, the following Findings of Fact are made: Respondent was certified by the Criminal Justice Standards and Training Commission on May 12, 1986, and issued certificate number 19-86-502-02, which he still holds. Respondent was employed by the Florida Department of Corrections (DOC) as a correctional officer from November 4, 1985, until August 3, 1988. He was initially assigned to the Dade Correctional Institution (DCI). On August 7, 1987, he was transferred to the South Florida Medical and Reception Center (SFMRC). He remained at SFMRC until April 3, 1988, the effective date of his resignation. On August 28, 1989, Respondent submitted to the DCI Personnel Department an application seeking reemployment as a correctional officer with DOC. As part of the application process, Respondent was required to submit to a drug test, which he did on September 29, 1990. Respondent had used cannabis on at least one occasion some time within a month or two prior to submitting to this test. Respondent personally appeared at the laboratory of Toxicology Testing Service in Miami on September 29, 1990. Once at the laboratory, he urinated into a small sterile sample container which was provided to him by Robert McCabe, a laboratory employee. Immediately after Respondent urinated into the container, he gave the container to McCabe. The container was then sealed with a lid and special tape designed to indicate tampering. McCabe assigned Respondent's urine sample the unique bar code number 410405 and the unique laboratory reference number 77334. He thereupon placed the container in a storage area in the laboratory. Later that same day, laboratory employee Yolanda Escobio retrieved the container from the storage area and, after observing that there was no evidence of tampering, broke the seal on the container. Using a sterile pipette, Escobio removed a small portion of urine from the container to conduct an initial immunoassay screening of the urine for the presence of a controlled substance or controlled substance metabolites. Following the completion of the screening, Escobio recapped the container (which contained the remainder of Respondent's urine sample) and returned it to the laboratory storage area. Neither McCabe, Escobio nor anyone else contaminated or tampered with Respondent's urine sample. The container was not reopened until October 2, 1989, when laboratory employee Israel Sanchez did so in order to perform additional laboratory testing of the sample. Sanchez utilized gas chromotography-mass spectrometry, an extremely reliable confirmatory testing method, to verify the results of the immunoassay screen previously performed by Escobio. Sanchez's testing revealed the presence of cannabinoids in a concentration of 120 nanograms per milliliter. Cannabinoids are metabolites that are produced when cannabis (marijuana) is introduced into the body. Cannabis is the only substance known to produce cannabinoids. Toxicology Testing Service sent a written report of the test results to Alexander Greene, the DCI Personnel Manager. Greene received the report on October 16, 1989. Respondent had already been rehired. He had started working for DOC again earlier that very same day. After learning that Respondent had tested positive for cannabinoids, Greene, accompanied by DCI's Assistant Superintendent, met with Respondent later that day. They advised Respondent of the test results and told him that if he did not resign his position, his employment would be involuntarily terminated. Respondent responded by simply indicating that he would resign. His resignation was effective 5:00 p.m. that day.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby recommended that the Criminal Justice Standards and Training Commission enter a final order (1) finding Respondent guilty of having failed to maintain "good moral character," in violation of Section 943.1395(5), Florida Statutes, by virtue of his unlawful use of cannabis on or about September 29, 1989; and (2) revoking his certification, based on such a finding. RECOMMENDED in Tallahassee, Leon County, Florida, this 23rd day of April, 1991. STUART M. LERNER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 23rd day of April, 1991. COPIES FURNISHED: Joseph S. White, Esquire Florida Department of Law Enforcement Post Office Box 1489 Tallahassee, Florida 32302 Paul Sack, Esquire 5975 Sunset Drive Suite 701 Miami, Florida 33143 Jeffrey Long, Director Florida Department of Law Enforcement Post Office Box 1489 Tallahassee, Florida 32302 James T. Moore, Commissioner Florida Department of Law Enforcement Post Office Box 1489 Tallahassee, Florida 32302 Rodney Gaddy, Esquire General Counsel Florida Department of Law Enforcement Post Office Box 1489 Tallahassee, Florida 32302
