01-001305PL Department Of Health, Board Of Medicine vs. John Rozanski, M.D. Status: Closed Recommended Order on Monday, November 5, 2001.

Summary: Petitioner failed to prove that Respondent`s cardiac clearance for back surgery deviated from the applicable standard of care.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, BOARD )

OF MEDICINE, )

)

Petitioner, )

)

vs. ) Case No. 01 - 1305PL

)

JOHN ROZANSKI, )

)

Respondent. )

______________________________)

RECOMMENDED ORDER

Robert E. Meale, Administrative Law Judge of the Division

of Administrative Hearings, conducted the final hearing in

Miami, Florida, on July 26, 2001.

APPEARANCES

For Petitioner: John E. Terrel, Senior Attorney

Agency for Health Care Administration

Post Office Box 14229

Mail Stop 39 - A

Tallahassee, Florida 32317 - 4229

For Respondent: Paul R. Regensdorf

Akerman, Senterfitt & Eidson, P.A.

Las Olas Centre II, 16th Floor

350 East Las Olas Boulevard

Fort Lauderdale, Florida 33301

STATEMENT OF THE ISSUE

The issue is whether Respondent practiced medicine within

the applicable standard of care, as required by Section

458.331(1)(t), Florida Statutes, and, if not, what penalty

should be imposed.

PRELIMINARY STATEMENT

By Administrative Complaint dated April 27, 1999,

Petitioner alleged that, on January 4, 1993, H. T., aged 58

years, presented to Respondent for a preoperative cardiovascular

evaluation to determine his cardiovascular stability for back

surgery scheduled for the next day. Respondent allegedly

performed an electrocardiogram and exercise stress test and

cleared H. T. for surgery.

The Administrative Complaint alleges that H. T. underwent

back surgery on January 5, 1993. The Administrative Complaint

alleges that, during surg ery, H. T. suffered a lack of oxygen to

the brain and that H. T. consequently suffered a postoperative

coma, from which he did not recover. H. T. died on January 22,

1993.

The Administrative Complaint alleges that an autopsy

uncovered cardiovascular dise ase, "[a]lthough not directly

related to the cause of . . . H. T.'s death." The

Administrative Complaint alleges that a reasonably prudent

similar physician would have interpreted H. T.'s

electrocardiogram and exercise stress test as indicating

cardiovasc ular disease and would not have cleared H. T. for

surgery before performing further cardiovascular testing.

The Administrative Complaint alleges that Respondent

therefore violated Section 458.331(1)(t), Florida Statutes, by

failing to practice medicine wi th the level of care, skill, and

treatment that is recognized by a reasonably prudent similar

physician as being acceptable under similar conditions and

circumstances.

At the hearing, Petitioner called two witnesses and offered

into evidence eight exhibit s: Petitioner Exhibits 1 - 8.

Respondent called one witness and offered into evidence two

exhibits: Respondent Exhibits 1 - 2. All exhibits were admitted.

The court reporter filed the transcript on August 30, 2001.

Petitioner filed a proposed recommend ed order on September 19,

2001. Respondent did not file a proposed recommended order.

FINDINGS OF FACT

1. At all material times, Respondent has been a licensed

physician, holding license number ME 30404. He earned his

medical degree in 1974. Respondent h as been Board - certified in

the specialty of internal medicine since 1977 and in the

subspecialty of cardiovascular disease since 1981.

2. At the time of the incident in question, Respondent was

a staff cardiologist with the Cleveland Clinic Florida, which is

located in Fort Lauderdale. At present, he is an attending

cardiologist with the Broward General Medical Center, which is

located in Fort Lauderdale.

3. H. T., a 58 year - old male, was scheduled for a spinal

fusion on January 5, 1993, at the Cleveland C linic Florida.

This back surgery was expected to take 8 - 10 hours. Although the

surgery was not an emergency, H. T. was suffering from complex

pain that was worsened by standing, walking, and bending forward

and was intensifying with time. Dissatisfied w ith his current

level of functioning, H. T. was a suitable candidate for back

surgery, based on his symptoms and diagnosis.

4. On December 30, 1992, H. T., now suffering "severe"

lower back pain, reported to the Cleveland Clinic Florida for a

preoperative evaluation. He took a resting electrocardiogram

(EKG). The computer program that interpreted the results

identified a possible inferior myocardial infarction of an

undetermined age and a possible left atrial enlargement.

Another cardiologist with the C leveland Clinic Florida,

Dr. Vincent Font, examined the computer - generated interpretation

and did not reject it.

5. The radiology report from the December 30, 1992,

examination was completed by Dr. Robert J. Hyman of the

Cleveland Clinic Florida. The repor t notes that H. T.'s heart

was enlarged.

6. Due to the results of the preoperative evaluation done

on December 30, 1992, H. T. had to obtain a cardiac clearance

before his back surgery on January 5, 1993. Thus, on January 4,

1993, H. T. presented to Respon dent at the Cleveland Clinic

Florida to obtain a cardiac clearance.

7. On January 4, 1993, H. T. provided Respondent with a

history of 60 pack - years of cigarette smoking, which had been

discontinued two months earlier. Respondent's blood pressure

was 196 /98. He stood five feet, eleven inches, and weighed 192

pounds. Based on the values considered normal at the time,

H. T.'s blood pressure was somewhat elevated and his weight was

somewhat excessive. However, H. T.'s only significant cardiac

risk factors were his history of cigarette smoking and, to a

lesser extent, his age.

8. Respondent administered a stress EKG on January 4,

1993. The report states:

This patient had uneventful pre - exercise

maneuvers and then had a sub - maximal level

exercise performance limited by left leg

pain. He exercised for 6 min. according to

the modified Bruce protocol. Patient

attained a maximum heart rate of 124 bpm

which was 76% of the maximum predicted heart

rate of 162 bpm. There was exaggerated

blood pressure reaching a m aximum of 242/104

during peak exercise. Test was terminated

because of leg and back pain. There was no

ventricular hypertrophy with upsloping ST

segment depression of about 2 mm. in the

inferior and lateral leads, consistent with

secondary changes due to LVH. Post - exercise

recovery phase was uneventful.

9. Respondent added the following clinical impressions to

the report:

1. No chest pain during exercise.

2. Adequate functional capacity limited by

left leg pain.

3. Abnormal EKG due to left ventricula r

hypertrophy with secondary ST T - wave

abnormalities.

10. The most important part of Respondent's physical

examination of H. T. was his observation of the exercise stress

test. At no time during or after the test did H. T. exhibit any

sign of cardiac insuffi ciency, such as shortness of breath or

pallor. Nor did H. T. experience any pain in the front of his

chest.

11. Respondent also examined H. T.'s medical records, in

which H. T. reported a cerebrovascular accident, seizures, and a

transient ischemic attack. H owever, this history was

contradicted by other history provided by H. T. ten weeks

earlier, at which time H. T. had denied any history of

convulsions or strokes. Discussing the history with H. T.,

Respondent learned that H. T. had erroneously indicated th at he

had suffered these three conditions.

12. After examining the relevant information, Respondent

concluded that, within a reasonable degree of medical

probability, H. T. was appropriate, from a cardiac perspective,

for serious orthopedic surgery. In his co nsultation report,

Respondent noted that H. T. denied any history of hypertension,

and Respondent suggested that H. T.'s blood pressure was high

due to anxiety over surgery. The report also notes that H. T.

denied chest pain at rest or under exertion and also denied

shortness of breath or other symptoms of heart failure.

13. Regarding the electrocardiogram, the consultation

report states that H. T. displayed a normal sinus rhythm and his

septal Q - saves were consistent with early left ventricular

hypertrophy, which was consistent with possible mild

hypertensive heart disease.

14. Regarding the stress EKG, the consultation report

states that H. T. achieved exaggerated blood pressure response

with frequent premature atrial contractions, although these were

of minor significance. The report notes that the EKG pattern

was characteristic of left ventricular hypertrophy with

secondary ST T - wave abnormality. The report suggests that H. T.

have his blood pressure rechecked.

15. Central to Respondent's cardiac clearance of H. T. for

extensive back surgery was the fact that the stress EKG

subjected H. T. to more stress than he would experience during

and after surgery, the test adequately raised H. T.'s blood

pressure, and the EKG returned to normal once H. T.'s blood

pressure returned to normal. Respondent placed considerable

emphasis on H. T.'s cardiac response to six minutes' stress,

under the modified Bruce protocol, without experiencing pain.

Respondent terminated the test due to leg pain that was

consistent with the sym ptoms to be alleviated by the back

surgery.

16. After Respondent cleared H. T. for back surgery, the

surgery took place on January 5, 1993. H. T. emerged from 11

hours of surgery in stable condition. When he awakened

postoperatively, H. T. followed commands and spoke with his

wife. However, early the next morning, H. T. suffered

respiratory depression. His treating physician withdrew the

morphine that H. T. had been receiving; after responding well,

H. T. again exhibited respiratory depression, rapidly foll owed

by respiratory arrest.

17. H. T. fell into a coma, secondary to a deprivation of

oxygen to the brain. However, he did not exhibit signs of an

acute myocardial infarction and never displayed any signs

suggesting that he had not tolerated the surgery well from a

cardiac perspective. After the withdrawal of certain life -

support interventions, H. T. died on January 22, 1993.

18. An autopsy took place about seven hours after H. T.

died. The autopsy found that all three major vessels

constituting the coronary art eries were more than 90 percent

occluded. However, a serial section of the myocardium did not

reveal definite recent or remote infarcts. The medical examiner

concluded that there was "no clear cut finding to explain the

course of [H. T.]" and that furthe r examination of abnormalities

in the heart and brain would be necessary.

19. Subsequent examination of the heart resulted in

findings of, among other things, "severe" coronary

atherosclerosis with 90 to 95 percent narrowing and concentric

left ventricular hyp ertrophy.

20. A cardiologist performing a cardiac clearance must

take the patient's history, perform a physical examination,

examine relevant medical records, and finally evaluate the

patient and stratify the cardiac risk posed by the subject

surgery. Respond ent performed all of the necessary steps of a

cardiac clearance in evaluating the likelihood that H. T. could

undergo extensive back surgery without serious cardiac

complications.

21. The abnormalities in H. T.'s EKG during the stress

test most likely sugges ted the presence of left ventricular

hypertrophy, not a myocardial infarction. Left ventricular

hypertrophy is consistent with several other factors suggestive

of longstanding hypertension.

22. Moreover, a cardiac clearance for noncardiac surgery

is generally appropriate if the patient, as did H. T.,

completes six minutes of the stress test, elevates his blood

pressure and pulse, experiences no chest pain, and displays no

pallor. The cardiac clearance of such a patient is appropriate

even though he suffers f rom an underlying cardiac disease.

23. The postmortem findings of atherosclerotic disease do

not establish functional cardiac disease. The postmortem

findings cannot assess the extent of occlusion of vessels under

pressure, as opposed to vessels no longer u nder pressure. Also,

the postmortem findings do not assess the vulnerability of the

plaque.

24. Petitioner has failed to prove that Respondent's

cardiac clearance of H. T. deviated from the applicable standard

of care. H. T. required intensive back surgery t o obtain relief

from severe pain. The abnormalities reported in the resting EKG

did not suggest a recent myocardial infarction. The

abnormalities in the stress EKG likely revealed a thickening of

the left ventricle, probably resulting from hypertension. These

findings did not necessitate additional cardiac testing before

clearing H. T. for extensive back surgery.

25. Most significantly, H. T. underwent the rigors of the

stress EKG without significant cardiac symptoms. An experienced

cardiologist, Responde nt assessed H. T.'s cardiac function under

conditions that approximated the stress of the spinal fusion.

Later, undergoing the surgery, Respondent suffered no cardiac

problems. Even if Petitioner had proved an underlying cardiac

condition, such as severe occlusion or a myocardial infarct,

Petitioner did not prove that these conditions precluded H. T.

from obtaining much - needed back surgery prior to resolving any

and all underlying cardiac conditions.

CONCLUSIONS OF LAW

26. The Division of Administrative Hea rings has

jurisdiction over the subject matter. Section 120.57(1),

Florida Statutes.

27. Section 458.331(1)(t), Florida Statutes Petitioner may

discipline Respondent's license if he is guilty of

. . . the failure to practice medicine with

that level of care, skill, and treatment

which is recognized by a reasonably prudent

similar physician as being acceptable under

similar conditions and circumstances.

28. Petitioner must prove the material allegations by

clear and convincing evidence. Department of Banking and

Finance v. Osborne Stern and Company, Inc. , 670 So. 2d 932 (Fla.

1996) and Ferris v. Turlington , 510 So. 2d 292 (Fla. 1987).

29. Petitioner has failed to prove that Respondent

deviated from the applicable standard of care in providing

Respondent with a cardi ac clearance for extensive back surgery.

RECOMMENDATION

It is

RECOMMENDED that the Board of Medicine enter a final order

dismissing the Administrative Complaint against Respondent.

DONE AND ENTERED this 5th day of November, 2001, in

Tallahassee, Leon Co unty, 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 5th day of November, 2001.

COPIES FURNISHED:

Tanya Williams, Executive Director

Board of Medicine

Department of Health

4052 Bald Cypress Way

Tallahassee, Florida 32399 - 1701

William W. Large, General Counsel

Department of Health

4052 Bald Cypress Way, Bin A02

Tallahassee, Florida 32399 - 1701

Theodore M. Henderson , Agency Clerk

Department of Health

4052 Bald Cypress Way

Bin A02

Tallahassee, Florida 32399 - 1701

John E. Terrel, Senior Attorney

Agency for Health Care Administration

Post Office Box 14229

Mail Stop 39 - A

Tallahassee, Florida 32317 - 4229

Paul R. Regen sdorf

Akerman, Senterfitt & Eidson, P.A.

Las Olas Centre II, 16th Floor

350 East Las Olas Boulevard

Fort Lauderdale, Florida 33301

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this recommended order. Any exceptions

to this recommended order must be filed with the agency that

will issue the final order in this case.