01-003164PL Department Of Health, Board Of Medicine vs. Ronald A. Ford, M.D. Status: Closed Recommended Order on Tuesday, February 5, 2002.

Summary: Doctor failed to come to hospital to examine patient admitted from emergency room with small bowel obstruction and failed to call for a surgical consult. Probation, fine, and continuing education recommended.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, )

BOARD OF MEDICINE, )

)

Petitioner, )

)

vs. ) Case No. 01 - 3164PL

)

RONALD A. FORD, M.D., )

)

Respondent. )

__________________________________)

RECOMMENDED ORDER

Pursuant to notice, a formal hearing was held in this

case on November 6 and 7, 2001, at Lakeland, Florida, before

Susan B. Kirkland, a designated Administrative Law Judge of

the Division of Administrative Hearings.

APPEARANCES

For Petitioner: Robert C. Byerts, Esquire

Agency for Health Care Administration

Post Office Box 14229

Tallahassee, Florida 32317 - 4229

For Respondent: William B. Taylor, IV, Esquire

McFarland, Fergu son & McMullen

400 North Tampa Street

Suite 2300

Tampa, Florida 33620

STATEMENT OF THE ISSUES

Whether Respondent violated Section 458.331(1)(t),

Florida Statutes, and, if so, what discipline should be

i mposed.

PRELIMINARY STATEMENT

On August 25, 2000, Petitioner, Department of Health,

Board of Medicine (Department), filed an Administrative

Complaint against Respondent, Ronald A. Ford, M.D. (Dr. Ford),

alleging that he violated Section 458.331(1)(t), Flo rida

Statutes. Dr. Ford requested a formal hearing, and the case

was forwarded to the Division of Administrative Hearings on

August 13, 2001, for assignment to an Administrative Law

Judge.

The parties filed a Prehearing Stipulation in which they

agreed to certain facts contained in paragraphs 1 - 6 of Section

E of the Prehearing Stipulation. Those facts have been

incorporated into this Recommended Order.

At the final hearing, the Department called the following

witnesses: Ronald Lee Barbour, M.D.; Lorena Duncan, R.N.;

Lisa Hanshaw deSaenz, R.N.; Lynn Teagles, R.N.; and Laurence

Neufeld, M.D. Petitioner's Exhibits 1 - 4 were admitted in

evidence. Dr. Ford testified on his own behalf and called

John J. Carthy, M.D., and Larry Williams, M.D. as his

witnesses . Respondent's Exhibits 1 - 3 were admitted in

evidence. Joint Exhibit 1, the medical records for Patient

R.A.L., were admitted in evidence.

At the final hearing, the parties agreed to file their

proposed recommended orders within 30 days of the filing of

the Transcript, which was filed on November 28, 2001. The

parties timely filed their Proposed Recommended Orders, which

have been considered in the rendering of this Recommended

Order.

FINDINGS OF FACT

1. At all times material to this proceeding, Dr. For d

was a licensed physician in the State of Florida. His

license, numbered ME 0051042, was issued on July 8, 1987.

2. Patient R.A.L, presented to the Emergency Department

of Winter Haven Hospital (Hospital) at approximately 1:35 p.m.

on October 9, 1997. R.A.L.'s initial chief complaint was

right flank pain since 9:00 a.m. that day. He reported a

history of vomiting and diarrhea and stated that it felt like

a kidney stone, of which R.A.L. had a history. Right flank

pain is common with a patient having a kidney stone or kidney

problem.

3. R.A.L. was initially examined by Dr. David Siegel

about 30 minutes after R.A.L. came to the emergency room. On

physical examination palpation, there was no flank pain, but

R.A.L. did have moderate pain diffusely throu ghout all areas

of his abdomen. His abdomen was not acutely distended, and

there were normal bowel sounds.

4. On Dr. Siegel's order R.A.L. was given Toradol

intravenously at 2:22 p.m. to relieve the pain. Toradol is a

non - steroidal anti - inflammatory dr ug. R.A.L. was also given

fluids intravenously.

5. R.A.L.'s symptoms did not provide Dr. Siegel with a

definitive diagnosis. Dr. Siegel ordered the following tests

to be performed: a complete blood count, an amylase, a

urinalysis, a PTPDT, and X - ray s of the abdomen.

6. The complete blood count was done to make sure that

the patient was not anemic and to see if there was an elevated

white blood count, which would be indicative of some type of

infection or acute abdominal process. The complete bloo d

count showed a significantly elevated white blood cell count

of 24.3. The test also revealed that there was a left shift

of a differential, which means that there was a high

differential percentage - wise of segmented and banded white

blood cells. The co mbination of the significantly elevated

white blood cell count and the left shift indicated that there

was an acute infectious process or an acute illness.

7. The amalyse test measures a serum enzyme that is

secreted from the pancreas. If the serum enz yme is elevated,

it could be indicative of pancreatitis. The amalyse test was

normal.

8. The urinalysis would show whether there was an

infection and would show some abnormalities if there were a

kidney stone. R.A.L.'s urine checked out normal.

9. At 3 :00 p.m. R.A.L. voided. His urine was strained,

but there were no kidney stones present.

10. R.A.L. did not have an adequate response to the

Toradol. He was given Demerol intravenously at 3:10 p.m.

11. Based on the test results, Dr. Siegel was unable t o

make a definitive diagnosis. Because of R.A.L.'s clinical

condition and his continued pain, Dr. Siegel ordered an

abdominal Computed Tomography (CT) scan to see if he could

further define what was going on in R.A.L.'s abdomen. Because

of the absence of flank pain, the elevated white blood cell

count, and the normal urinalysis report, Dr. Siegel did not

rule out the possibility of kidney stones, but did feel that

some abdominal process of significance was higher on the list

of possible diagnoses than kid ney stones.

12. Dr. Siegel went off duty at 5:30 p.m. and turned the

care of R.A.L. over to Dr. Ronald Barbour. Dr. Siegel gave

Dr. Barbour an oral report of his findings and indicated that

he was primarily concerned about a serious intra - abdominal

proce ss. Before finishing his shift, Dr. Siegel dictated a

written report, which was immediately transcribed and placed

in R.A.L.'s chart. Dr. Siegel expected Dr. Barbour to get the

results of the CT scan and determine whether the results would

allow a diagno sis.

13. When Dr. Barbour came on duty, he went to see

R.A.L., who told Dr. Barbour that he was still having some

pain. R.A.L. asked for something to relieve the pain, and

Dr. Barbour ordered Demerol for him.

14. Dr. Barbour received a call from the r adiologist,

who said that the CT scan was consistent with a small bowel

obstruction. Dr. Barbour told R.A.L. that it appeared he had

a bowel obstruction and that he would be admitted to the

Hospital.

15. It is the Hospital's policy to contact a patien t's

primary care physician when a patient is being admitted to the

Hospital from the Emergency Department. Dr. Ford was R.A.L.'s

primary care physician. Dr. Ford was called by an Emergency

Department nurse. Dr. Barbour spoke with Dr. Ford and advised

hi m that the CT scan showed a small bowel obstruction.

Dr. Ford stated that he would admit R.A.L. No mention was

made of a surgical consult during the conversation.

Dr. Barbour did not call a surgeon for a consult because

normally if the patien t has a primary care physician, the

primary care physician would choose the surgeon should a

surgical consult be necessary.

16. R.A.L. was admitted to the Hospital at approximately

8:45 p.m. At that point, the responsibility for the care and

treatment of the patient shifted from Dr. Barbour to Dr. Ford.

Dr. Ford gave admission orders to Lorina Duncan, a nurse in

the Emergency Department. The orders included administering

Demerol and Phenergan as needed and giving the patient a

saline solution intravenou sly. Dr. Ford also ordered tests to

be done the following morning. The nurse's notes do not

indicate that Dr. Ford told her to order a surgical consult

for the next morning.

17. R.A.L. was given Demerol and Phenergan in the

Emergency Department at 9:55 p.m. At 10:10 p.m. R.A.L. was

signed out of the Emergency Department to the medical/surgical

floor of the Street Building, which is known as Street One.

18. When R.A.L. was admitted to the Hospital, his

abdomen was not distended. By the time he was admi tted to

Street One, his abdomen was distended and firm, and he was

complaining of abdominal pain and nausea. When he was placed

in his bed, he positioned himself in a fetal position, which

is indicative of being in pain. He had no bowel sounds.

While th e nurse was getting a medical history, R.A.L. was

lethargic and would drift off in the middle of the admission

questions. His breathing was shallow and rapid.

19. It took the nurse over an hour to complete the

admission assessment on R.A.L. after he had come to Street

One. At 11:50 p.m., R.A.L. was complaining that his pain had

increased throughout his stomach. He indicated that his

nausea was better. R.A.L. requested a patient - control

anesthetic (PCA), which allows the patient to administer a

metered dose of pain medication to himself by pushing a

button.

20. Around midnight the nurse had the hospital operator

page Dr. Ford. He returned the nurse's call. She told

Dr. Ford that R.A.L.'s abdomen was distended and that he was

lethargic. R.A.L. had had no pain medication administered

since being admitted to Street One, and his next dose of pain

medication was to be given at 1:00 a.m. The nurse told

Dr. Ford that R.A.L. was complaining of pain and wanted to

have a PCA. Dr. Ford gave an order fo r a Demerol PCA, which

would allow a five - milligram dose every five minutes with a

maximum of 150 milligrams in four hours.

21. The nurse told Dr. Ford that R.A.L. had been

complaining of nausea. Dr. Ford asked whether R.A.L. had

vomited, and she advised the doctor that R.A.L. had not. They

discussed the possible use of a naso - gastric (NG) tube, which

extends from the nose down to the stomach. It is used to

aspirate the contents of the stomach, which decreases nausea

and distention. Dr. Ford did not order a NG tube.

22. At 12:30 a.m., October 10, 1997, the Demerol PCA was

started. At 4:30 a.m., R.A.L. was complaining of shortness of

breath. His abdomen was more distended and firm. Dr. Ford

was paged, and he gave orders for lab work to be done.

23. At 4:45 a.m. R.A.L. went into distress and died.

Dr. Ford arrived at the Hospital about 5:05 a.m.

24. A small bowel obstruction is a condition

characterized by the inability of gastrointestinal fluid and

material to pass through the small bowel due to some sort of

blocka ge. Symptoms include pain, nausea, vomiting and a

change in or cessation of bowel sounds. Small bowel

obstructions generally cause the bowels to become inflamed and

swollen, which can lead to a cut off of the blood supply to

the bowel and result in the r upture of the bowel. If the

bowel ruptures, it is a very acute, life - threatening situation

which must be treated rapidly.

25. Small bowel obstructions are generally classified as

a partial or simple obstruction, and a complete or

strangulated obstruction. A strangulated small bowel

obstruction means the vascular system has been compromised and

the blood supply to a part of the bowel has been cut off. If

the blood supply has been cut off, the bowel tissue will

become gangrenous, then necrotic, and finally die . Surgery

can alleviate the strangulation.

26. Strangulated small bowel obstructions represent 20

to 40 percent of all small bowel obstructions. Post - operative

adhesions, bands of scar tissue which form inside the abdomen,

are the predominate cause of strang ulated bowel obstructions.

Severe and constant pain, as opposed to cramping, intermittent

pain, can characterize a strangulated small bowel.

27. A strangulated small bowel is a very serious

condition. Diagnosis requires obtaining a careful history,

recogniti on of previous operations, a "hands on" physical

examination and diagnostic testing. With a small bowel

obstruction, a patient’s condition can change rapidly,

sometimes in a matter of hours. Because any change in the

condition of the patient can indicate a significant problem,

serial abdominal examinations are important. Early detection

and evaluation of complications from small bowel obstructions

are also important.

28. In the case of R.A.L., the level of care, skill, and

treatment which is recognized by a reasonably prudent similar

physician as being acceptable under similar conditions and

circumstances would have been for Dr. Ford to come to the

Hospital and physically examine R.A.L. when the patient was

admitted to the Hospital under his care and after Dr. Ford was

called by the nurse around midnight, apprising him of R.A.L.’s

condition.

29. Dr. Ford did not come to the Hospital to examine

from the time R.A.L. was admitted to the Hospital under his

care to the time R.A.L. died.

30. A strangulated bowel is a su rgical emergency. If a

physician fails to diagnose and treat a strangulated small

bowel, the patient will likely die. The physician will

normally consult a surgeon when the patient presents with a

small bowel obstruction. In performing a surgical consul t,

the surgeon will make the determination of whether and when to

perform surgery. The sooner the surgeon is involved, the less

the chances of compromising the patient’s bowel or general

physical condition. Calling a surgeon early in the course of

treati ng a patient with a small bowel obstruction is the

prudent thing to do.

31. In the case of R.A.L., the level of care, skill, and

treatment, which is recognized by a reasonably prudent similar

physician as being acceptable under similar conditions and

circumsta nces, would have been for Dr. Ford to call for a

surgical consult when R.A.L. was admitted to the Hospital

under his care. Dr. Ford did not call for a surgical consult

from the time R.A.L. was admitted to the Hospital under his

care to the time R.A.L. die d.

CONCLUSIONS OF LAW

32. The Division of Administrative Hearings has

jurisdiction over the parties to and the subject matter of

this proceeding. Sections 120.569 and 120.57, Florida

Statutes.

33. The Department has alleged that Dr. Ford has

violated Section 458.331(1)(t), Florida Statutes, which

provides that the following acts are grounds for disciplinary

action by the Department:

Gross or repeated malpractice or 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.

34. The Department must establish the allegations in the

Administrative Complaint by clear and convincing evidence.

Department of Banking and Finance v. Osborne Stern & Co. , 670

So. 2d 932 (Fla. 1996); Ferris v. Turlington , 510 So. 2d 292

(Fla. 1987).

35. The Department alleged that Dr. Ford violated

Section 458.331(1)(t), Florida Statutes, in that he "did not

examine Patient R.A.L. or order a consultation with a general

surgeon at any time during the approximately eight (8) hours

between the time Respondent admitted Patient R.A.L. to his

service and the time of Patient R.A.L.’s death, despite being

apprised of Patient R.A.L.’s condition."

36. The D epartment has established by clear and

convincing evidence that Dr. Ford failed to practice medicine

with the level of care, skill, and treatment which is

recognized by a reasonably prudent similar physician as being

acceptable under similar conditions and circumstances when he

failed to come to the Hospital to examine R.A.L. and when he

failed to order a surgical consult for R.A.L. Dr. Ford has

violated Section 458.331(1)(t), Florida Statutes.

RECOMMENDATION

Based on the foregoing Findings of Fact and Con clusions

of Law, it is RECOMMENDED that a Final Order be entered

finding that Ronald A. Ford, M.D. violated Section

458.331(1)(t), Florida Statutes, placing him on two years'

probation, imposing an administrative fine of $5,000, and

requiring him to take f ive hours of continuing medical

education in the area of risk management and 16 hours of

continuing medical education in the area of diagnosing and

treating abdominal and gastrointestinal disorders.

DONE AND ENTERED this 5th day of February, 2002, i n

Tallahassee, Leon County, Florida.

___________________________________

SUSAN B. KIRKLAND

Administrative Law Judge

Division of Administrative H earings

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 February, 2002.

COPIES FURNISHED:

Robert C. Byerts, Esquire

Agency for Health Care Administration

Post Office Box 14229

Tallahassee, Florida 32317 - 4229

William B. Taylor, IV, Esquire

McFarland, Ferguson & McMullen

400 North Tampa St reet

Suite 2300

Tampa, Florida 33620

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

Tallahas see, Florida 32399 - 1701

Tanya Williams, Executive Director

Board of Medicine

Department of Health

4052 Bald Cypress Way, Bin A02

Tallahassee, Florida 32399 - 1701

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written excepti ons within

15 days from the date of this Recommended Order. Any

exceptions to this Recommended Order should be filed with the

agency that will issue the Final Order in this case.