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Surgeon fined, suspended 6 months for error

Published Oct. 5, 2005

Tampa surgeon Rolando Sanchez, who became a nationwide symbol of hospital errors after he cut off the wrong foot of diabetic patient Willie King, will be allowed to return to work in January.

The Florida Board of Medicine on Saturday refused to follow the recommendations of a hearing officer who called for an additional 18 months of suspension and five years of strict probation, terms Sanchez's attorney called a "death sentence."

Instead, the board agreed to end Sanchez's suspension six months after his license was lifted by emergency order for mistakes in the King case and another case involving a toe amputation.

"I think the hearing officer is making him the sacrificial lamb for all the wrong-sited surgery we have seen," said board member Dr. Emilio Echevarria. "Dr. Rolando Sanchez is a good doctor and I think to put him out of the practice of medicine for this would be a total, total miscarriage of justice."

The board also reduced the hearing officer's recommended fine from $15,000 to $10,000. Hearing officer William Quattelbaum had made the recommendations after a three-day hearing in September.

Members of the board agreed to consider several factors, including Sanchez's reputation as an excellent physician, the mistakes made by other hospital employees before the amputation and the fact that the leg amputated in error was also diseased.

Sanchez, 51, who has practiced medicine for 14 years, appeared relieved, but refused to comment after the decision, saying only that he was tired. Members of his office staff and nurses who came to the board meeting hugged each other and cried with relief.

Sanchez's attorney, Michael Blazicek, had asked the board to reinstate Sanchez's license immediately, saying the doctor had suffered enough and had been punished more than other doctors who operated on the wrong part of a patient.

"His reputation has suffered considerably _ and yet all the evidence demonstrates that his reputation as a surgeon and as an individual are impeccable. And he is financially devastated," Blazicek told the board. "I would submit that the punishment to date has been extreme, profound and it will have lasting impact."

Blazicek said later the board's decision was fair, but "still too harsh."

Sanchez's son, Ron Sanchez, credited the board with trying to be fair. But he said he thinks the board had to maintain a tough stance in the face of the extensive publicity the case has received.

"I think they still must make the appearance of protecting the public," Ron Sanchez said.

Just what it takes to protect the public was a major issue during the board's discussion. Hearing officer Quattelbaum had argued that the stiff penalties he proposed would serve not only to prevent Sanchez from making mistakes in the future, but would help deter other doctors from making errors.

That doesn't make sense, Blazicek argued, because that kind of deterrence only works for intentional acts of misconduct, not mistakes.

Board members agreed.

This was a very serious mistake, said board member Dr. Edward A. Dauer, but it clearly was a mistake by an otherwise competent doctor in a situation that involved a series of mistakes by hospital personnel.

"We all know that the primary purpose of this board is to protect the public, but the board must also be sure that the punishment must be fair to fit the violation," Dauer said. "I think people need to understand that doctors are not God and hospitals are not heaven and mistakes happen."

Echeverria pointed out the extensive publicity about Sanchez already has had the effect of helping to protect the public from medical mistakes because hospitals have reviewed their procedures.

The incident that got Sanchez in trouble occurred in February when King, 51, was a patient at University Community Hospital in Tampa. King was suffering severe circulatory disease in both legs.

Attempts to restore circulation in both legs had been unsuccessful and King, who was tiring of extensive medical treatment, decided against further surgical attempts. Sanchez, with King's agreement, decided to amputate the right leg below the knee because it was painful.

Several errors led to the left leg being amputated below the knee by mistake. The wrong leg was indicated on both a blackboard and a surgical schedule in the operating suite. Operating nurses also prepared the wrong leg for surgery.

Board members on Saturday said the fact that the left leg was in very poor shape also helped lead to the mistake, although it does not excuse the error. It was clear from King's medical condition, board members agreed, that the left leg would have had to be amputated soon anyway.

Cecile M. Scoon, a non-physician member of the board, said that in judging a physician, the board needs to look not just at the outcome of a case, but the process a doctor followed. In this case, she said, many of the procedures in place to prevent such errors failed. The fact that the leg also looked bad was the last of several factors that led to the mistake.

In the other case, the state accused Sanchez of amputating 67-year-old Mildred Schuler's toe without her consent. The hearing officer found that Sanchez did nothing wrong medically because the toe was black and had no circulation. While Sanchez was trying to remove dead tissue from the toe, it broke from the foot and the hearing officer agreed it was necessary at that point to amputate.

The hearing officer said Sanchez should have obtained Schuler's consent before the operation for an amputation because it should have been clear that an amputation may become necessary during the procedure. Board members agreed that the only mistake Sanchez made was not including amputation in the consent form.

To ensure that Sanchez practices safely when his license is reinstated, the board put Sanchez on probation for two years. During that time, he will be supervised indirectly by another physician who will review some of his cases. The board also required that another surgeon verify the surgical site before every operation Sanchez performs during the probation.

The hearing officer had recommended five years of probation during which Sanchez would have to be directly supervised by another surgeon during every procedure. Blazicek told the board that punishment that severe would have put Sanchez out of business.

"This is the death penalty," Blazicek said in his opening statement. "The impact in this case is clear. He will not practice again."

Board members agreed that Sanchez should not be forced out of medicine.

"There's not one of us here that does not agree that this was a serious offense," said board member James Cerda. "But we're talking about a man who really had an unblemished record up to this period of time and who really enjoys a great reputation in Tampa."

Board member Dr. Fuad Ashkar agreed that the board should take into consideration Sanchez's previous record and reputation.

"Although we'd like to see perfect practice in this state . . . I can assure you that this is not the case," Ashkar said. "These things do happen. It's the equivalent of friendly fire in the military."