text:
On the eve of free agency, just wanted to start a topic that I've been thinking about and talking about with JonRud...
Everyone knows that Pete Carroll is "THE MAN" in Seattle. The head honcho, sheriff, etc. His ComPete and Win Forever philosophies are what drive this organization and the players on the field. Having said that, is Pete Carroll actually #4 on the Seattle football totem pole?
First, let me say that I LOVE Pete and there isn't a guy I'd rather have coaching the Hawks. His youthful exuberance, his charity work, I just think he's a great coach and a pretty cool person. There's nobody else I'd rather have in Seattle. However, is he the best gameday coach around? I don't think so. I know I've personally had many "WTF Pete?!" moments during his time in Seattle. In the end, I get over it because of everything he does for the team and the city. But is Pete Carroll REALLY still the most important man in the Seahawks organization? Here's my list of the "Big 4" and where I rank them relative to their importance to the team.
1) John Schneider - You could argue that Pete should be #1 because he hired John Schneider, but I still think Schneider deserves the majority of the credit for the work he's done constructing this roster. If Carroll were to retire, I think the team would soldier on with a new head coach. However, if Schneider were to leave town for his "dream job" in Green Bay (hypothetically speaking of course), I think it'd be impossible to find an equal replacement. Seattle would definitely take a hit. So let's hope that Schneider NEVER leaves. Make it happen Paul.
2) Russell Wilson - In due time, he'll probably take over #1 on the list. I don't think I need to explain why. He's going to be a Super Bowl champion, probably multiple times, and while Schneider is the reason Russell's in Seattle in the first place, we won't be able to overlook the performance on the field from #3.
3) Paul Allen - Some might rank him #1 on their list and he probably should be because he saved the team from certain death. He's the perfect sports owner in that he backs his team with unlimited resources and stays out of the way. That's hurt him, and the team, in the past on occasion though. Remember the Holmgren/Whitsitt feud? Don't know if there's anything he could have done to avoid that (don't know the backstage politics) but it happened regardless. Then there was also the Jim Mora move. That sucked. Having said all that, Allen is still the man and I'll always be grateful for everything he's done for us. He's a man that can do no wrong in my mind.
4) Pete Carroll - He's the guy I trust the least when it comes to the Hawks "Big 4." His gameday management is sometimes a little shaky but everything else is pretty great with Pete. Like I said, there's no one I'd rather have in charge of the Hawks. I can't wait to see him celebrating a Super Bowl victory with the Hawks, it's going to be incredible and it's going to piss off A LOT of non-Hawks fans. With Sherman and Carroll on board, the Hawks have a serious chance to be "hated on" by mostly anyone who's not a Hawks fan if they start winning some Super Bowl's. They'll be that team that people love to hate. Back to the topic at hand, I just think that Pete is the most replaceable guy on this list which isn't a knock on him but rather a testament to how great Schneider and Wilson have and may (WILL) become.
What's everyone else thinkin?


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Suffolk, ss. Division of Administrative Law Appeals
Joan Fournier,
v. Docket No. CR-06-476
Teachers' Retirement System,
Appearance for Petitioner:
Pro Se
10 Summit Street
Whitinsville, MA 01588-1912
Appearance for Respondent:
James C. O'Leary, Esquire
Deputy General Counsel
Teachers' Retirement System
One Charles Park
Cambridge, MA 02142
Administrative Magistrate:
Judithann Burke
Pursuant to G.L. c. 32 s. 16(4), the Petitioner, Joan Fournier, is appealing from
the July 10, 2006 action of the Respondent, Teachers' Retirement System (TRS), denying
her request for late enrollment in the RetirementPlus program. (Exhibit 1). The appeal
was timely filed. (Exhibit 2). A hearing was held on March 13, 2008 at the offices of
the Division of Administrative Law Appeals (DALA), 98 North Washington Street,
Boston, MA.
At the hearing, fourteen (14) exhibits were marked. Exhibit 8 was later stricken.
The Petitioner testified and argued in her own behalf. The TRB stated its argument for
the record. One tape was made of the proceedings.
Based upon the testimony and documents submitted at the hearing in the above-entitled matter, I hereby render the following findings of fact:
1. The Petitioner, Joan Fournier, is a retired member of the TRS with an effective retirement date of February 14, 2007. (Exhibit 7).
2. Between March 1, 2001 and June 30, 2001, the TRS issued 95,962 pre-filled out information packets to its active members at their home addresses. (Exhibit 10).
3. In addition, during the same time period, the TRS issued RetirementPlus information packets and blank election forms to all school districts in the Commonwealth. The number of packets issued to each school district was approximately equal to 8% of the number of active teachers the TRS had enrolled for each district. In addition, during this time period the TRS re-issued 1,800 packets in response to information regarding non-delivered information packets (i.e. post office returns as "undeliverable as addressed", etc.). (Id.).
4. Also from March to June 2001, the TRS made available to school districts, for printing through the TRS website, an on-line version of the information packet materials and required election form. (Id.).
5. TRS records reflect that an information packet was sent to the Petitioner at her home address during the spring of 2001. (Exhibit 9).
6. The Petitioner telephoned the TRS in March 2001. The Petitioner provided her name and social security number and requested that she be enrolled in RetirementPlus. She was informed that her call would be redirected to another unit. After the transfer, the phone rang and rang. The Petitioner did not speak to another person. (Testimony).
7. A few days after her March 2001 call to the TRS, the Petitioner received a RetirementPlus CD. Because no one else that she knew had received one of these, she believed that the CD reflected confirmation of her "registration as a RetirementPlus participant". (Testimony, Exhibit 13 and Attachment A).
8. Some time later in the spring of 2001, the Petitioner asked at the North Middlesex Regional School Superintendent's office for an early retirement form to fill out. She was told that these could not be located. She did not pursue the matter further with the school system. (Id.).
9. The TRS did not receive a completed election form from the Petitioner to participate in the enhanced retirement program provided for in G.L. c. 32 s. 5(3)(4)(i) (RetirementPlus) by June 30, 2001.
10. On July 1, 2001, the Petitioner was determined by the TRS to have been non-responsive to the election mailing, and was therefore considered to have made a negative election.
11. In a letter dated July 10, 2006, the TRS notified the Petitioner that it had neither the discretion nor the authority to accept any election to participate in RetirementPlus after the prescribed June 30, 2001 deadline. (Exhibit 1).
12. The Petitioner filed a timely appeal. (Exhibit 2).
The Petitioner is not entitled to prevail in this appeal. G.L. c. 32 s. 5(4)(i) specifies that the election into RetirementPlus must occur before July 1, 2001. There are no statutory exceptions to this deadline. The retirement materials that the Petitioner received in the mail, but did not thoroughly review or heed, informed her that, if she wished to participate in RetirementPlus, she needed to return her election form no later than June 30, 2001.
The Petitioner unreasonably relied on her placing a phone call to the TRB as the only act necessary for enrollment in the program. Further, she did not pursue the obtaining of an application to the program beyond her first inquiry. Her behavior was far too naïve and/or cavalier for one looking to establish an important legal relationship with the TRS.
In conclusion, neither the TRS nor the Contributory Retirement Appeal Board (CRAB) has the power to waive the deadline specified in the statute. The decision of the TRB is affirmed.
So ordered.
Division of Administrative Law Appeals,
Judithann Burke
Administrative Magistrate
DATED: May 9, 2008
This information is provided by the Division of Administrative Law Appeals .

subset: commoncrawl


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Garry Rayno's State House Dome: When good news isn't really so goodBy GARRY RAYNO
State House Bureau
April 28. 2013 12:13AM
Last week, Gov. Maggie Hassan and Attorney General Michael Delaney announced the state would receive $15 million in unexpected money from a settlement with tobacco companies.
Tobacco companies claimed states did not "diligently enforce" the 1998 master agreement that has netted New Hampshire between $42 million and nearly $50 million a year and sued while withholding about $4 million of its annual payment to the state beginning in 2006.
States were supposed to require non-settling tobacco companies to pay into an escrow account to protect the settling companies' market share, but few did.
So last week, the state recouped a little more than half of the money tobacco companies withheld.
You would think the extra money would be good news for budget writers working on the state's upcoming $11 billion biennial budget, but it is not.
The state received the money last week and so it will be banked in the current 2013 fiscal year. That will help balance this year's budget, which has a projected deficit - due to revenue shortfalls, unbudgeted expenditures and unrealized savings - of from $14 million to $20 million.
"These dollars will be key to addressing the projected fiscal year 2013 deficit and could help eliminate the need for alternative plans under consideration," Hassan said.
The House-passed budget gave Hassan authority to sweep, or as some say raid, dedicated funds such as the renewable energy fund for money to balance this year's budget.
The problem is House budget writers believed the tobacco money would arrive during the 2014 fiscal year and included $21.6 million as that year's revenue and an additional $2.5 million for 2015, totaling $24.1 million for the next biennium
With the money credited to 2013, the budget the House has sent to the Senate is short $24.1 million in revenue.
Senate budget writers were already concerned about what Senate Finance Committee Chairman Chuck Morse, R-Salem, said are overinflated House estimates for the Medicaid Enhancement Tax on hospitals and a 20 cent increase in the tobacco tax the House passed as part of its budget.
Having the tobacco money come now creates another money hole the Senate will have to fill through spending cuts or new revenue - i.e. taxes or fees - which is highly unlikely.
Morse and other finance members have expressed support for more money for uncompensated care for the state's hospitals and money for charter schools and school building aid, all cut by the House.
The $24 million is almost the same amount - $28 million - Hassan and the House added to the budget to improve the state's mental health system. Mental health patients and the federal government are suing the state over what they say are inadequate services.
The House cut $12 million in state aid to the University System of New Hampshire from Hassan's proposal as she restored about 75 percent of what was cut two years ago.
However, the new budget hole may actually serve Hassan and the Senate. They both want the House to pass SB 152 to establish one "high-end, highly regulated" casino along the state's southern border.
Hassan counts $80 million in casino licensing fees in her budget. The House budget does not.
The latest revenue shortfall could put additional casino pressure on the House, although the odds do not look good right now.
The House is currently reviewing the bill through three subcommittees and is not expected to act on the bill until May 29.
The Senate has not said when it will act on its proposed budget. The deadline is June 6.
Chances are the Senate will wait to see what the House does before it decides whether to include the $80 million in licensing fees from the gambling bill, which it passed on a 16-8 vote.
- - - - - - -
April Revenues: For the next few days, Senate budget writers may have one eye on the first-place Red Sox, but the other will be on April tax revenues.
March and April are the two biggest revenue months, mainly because of business tax and interest and dividends tax returns.
March is by far the biggest, and last month was a jackpot for the state. It reaped a $26.6 million windfall that went a long way toward closing what looked like a $40 million shortfall for the year.
The good news followed several months of plummeting numbers. A good April would go a long way to close the deficit for 2013 and cause revenue estimators in the Legislature and Hassan administration to celebrate.
As of Friday, revenues were close to the month's target of $256.7 million. However, the figure includes the $15 million from the tobacco tax and could include some significant money from the Medicaid Enhancement Tax, as several hospitals that had outstanding liabilities were given a deadline of Friday to pay up.
Currently the Medicaid Enhancement Tax is $34 million less than budget writers estimated.
The hospitals could ask for an extension, and that could change the picture, but in general, April revenues look like they will be good.
- - - - - - -
So Long: The relations between the House and Senate to date have been fairly cordial, but that is about to change.
Some of the House's hard-fought bills near and dear to many representatives' hearts are about to be upended by the Senate.
Decriminalizing the possession of less than a quarter-ounce of marijuana, which the House passed after lengthy debate, is slated to be killed when the Senate meets Thursday. The Senate Judiciary Committee voted, 5-0, to kill it.
The same committee is recommending on a 4-1 vote to study the bill that would allow industrial hemp to be grown as an agricultural crop. House Bill 153 would remove industrial hemp from the controlled-drug statutes.
The Senate Health, Education and Human Services Committee has not yet made a recommendation on House Bill 573, which would legalize medical marijuana, though the public hearing was nearly a month ago.
The Senate Finance Committee voted, 5-1, to kill House Bill 443, which would have forbidden the state to use private prisons or to turn over management of the system to a private company, and the Executive Departments and Administration Committee voted, 3-2, to kill House Bill 316, which would allow chemical cremations or alkaline hydrolysis.
The Senate will also be asked to kill House Bill 362, which would ban ethanol as a gas additive, and to study the Good Samaritan E-911 bill, which would grant criminal immunity for drug or alcohol overdose calls.
The Senate meets Thursday, and after that session, things may be a little chillier between the two chambers.
- - - - - - -
Environmental Caucus: A bipartisan group of lawmakers has organized an environmental caucus, saying a healthy environment is a cornerstone of New Hampshire's economy, heritage and attractiveness.
About 35 House members have signed on to the new caucus representing many House committees.
"Given the contentious state of our political affairs, it's worth recalling that the first Earth Day was a bipartisan initiative," said Rep. David Hess, R-Hooksett. "It was co-chaired by a Democratic senator from Wisconsin and a Republican from California. The original Clean Water and Clean Air legislation, both under a Republican President, were outgrowths of the original Earth Day in 1972."
The caucus was announced on Earth Day last week.
"New Hampshire has a well-earned reputation for respecting its forests, mountains, lakes and rivers," said Rep. Rebecca Brown, D-Sugar Hill. "Our state's appeal to tourists and new business investors, as well as our cherished lifestyle, are rooted in our scenic, healthy environment."
- - - - - - -
Chair at Caucus: GOP state party Chairman Jennifer Horn spoke at the House Republican caucus Wednesday along with former Speaker and current Rep. William O'Brien, R-Mont Vernon, who several weeks ago led a walkout during the caucus before the House session.
The message was party unity, said one Republican there. Several incidents have caused friction in the ranks, including a petition to remove the 189 members of the House who voted to repeal the "stand-your-ground" self-defense law passed in 2011.
Rep. Dan Itse, R-Fremont, said last week he would attempt to introduce the petition through the rules committee, as would be the normal process, but has yet to ask it be placed on the agenda of the committee's next meeting.


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The Mole-8.5 system at Institute of Process Engineering (IPE), Chinese Academy of Sciences (CAS), the first supercomputer in the world that uses the latest NVIDIA Tesla C2050 GPUs with a theoretical peak performance (Rpeak) of 1Pflops in double precision, ranked as the Top 3 supercomputer in China and the NO.19 of the 35th TOP500 List (released in Hamburger, Germany on 31st of May) worldwide, was built with TYAN FT72-B7015 platform.
The Mole-8.5 system consistsof 372 computing and data processing nodes based on the TYAN FT72-B7015 platform which is developed jointly by TYAN and IPE. Each platform is a 4U 2-way GPU barebones server, which embedded with (2) Intel Xeon 5520 series processors and(6) NVIDIA Tesla C2050 per each node, which will achieve a theoretical peak performance (Rpeak) of approximately 3TFlops in double precision. The Mole-8.5 system of IPE, CAS has achieved a Linpack performance (Rmax) of 207.3 TFlops and even higher performance in some real applications. Utilizing the TYAN hardware designs, this system will not only provide the highest performance, but also provides scalability and advanced floating point processing capabilities demanded by research and design industries.
"This is a fantastic platform!" said Prof. Wei Ge, project leader for the Mole-8.5 system at IPE, CAS. "We strongly believe it is the right choice for a wide range of applications that can take full advantage of high performance GPUs. It is one of the most cost-effective, energy-efficient, compact and reliable component we can find to build our system, and its capability has been demonstrated in our multi-scale discrete simulations for a number of scientific and industrial applications."
"Being the leading provider in the channel server market, TYAN is focused on advanced R&D capability and manufacturing ability," said Albert Mu, Vice President of TYAN Business Unit of MiTAC International Corporation. TYAN is devoted to adopting leading technology and developing cutting-edge platforms to allow our customers to become the leaders in their industries. The participation of the Mole-8.5 system projects of IPE, CAS is the demonstration of TYAN's commitment as the hardware provide behind customers.
TYAN FT72-B7015 computing solutions support up to 8 NVIDIA Tesla M2050 and M2070 GPU Computing Processors in a 4U chassis by supporting 2 Intel Xeon processor 5600 series or 5500 series, 8 PCI-Express 2.0 x16 slots, up to 144 GB of registered memory, 4 1-GbE network ports, and up to 2 2.5" internal disks for FT72-B7015 to provide an outstanding cost/performance ratio with extensive GPU expandability for HPC and GPGPU applications.


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The Recipe: A long-time favorite pie in the South and the Midwest, especially among men. Not too sweet, not too sharp, a classic!
The Conversation: What holiday do we celebrate on March 14? Hint, it's Pi Day!
Good morning, class.
What holiday do we celebrate on March 14th? [Puzzled looks. Furled brows.]
A hint? What might hungry mathematicians eat on the 3rd month's 14th day? [Suddenly a confident hand shoots up.]
Very good! Yes, class, today we celebrate Pi Day to honor pi, the revered mathematical constant of 3.14 and a trillion more digits.
On Pi Day, we make pie, today a classic recipe from America's south and heartland, a lemon meringue pie that is citrus-sweet and meringue-light. It earns high marks for deliciousness and is perfect for early spring when we yearn for summer like a classroom longs for recess. It's today's homework, an A+ pie.
Time-to-table: 1½ - 2 hours
Serves 8
- 1 baked pie shell, cooled
- 1/2 cup (100g) sugar
- 3-1/2 tablespoons (35g) cornstarch
- 1/2 teaspoon table salt
- 1-1/2 cups (335g) water
- 4 large egg yolks
- Zest & juice (about 4 tablespoons) from 2 lemons
- 3 tablespoons salted butter
- 4 large egg whites (see TIPS)
- 1/4 teaspoon table salt
- 1 teaspoon lemon juice or 1/4 teaspoon cream of tartar (optional)
- 1/2 cup super-fine sugar (see TIPS)
Heat oven to 350F.
LEMON FILLING In a medium saucepan, stir together sugar, cornstarch, salt and water. On medium-low heat, cook until mixture bubbles, stirring often; cook for 3 more minutes, stirring continuously. Turn heat off. Whisk yolks in a bowl, then whisk in a half cup of hot mixture, then whisk combined mixture into saucepan (see TIPS). On medium-low heat, return mixture to a bubble and cook 3 more minutes, stirring continuously. Turn off heat. Add lemon zest, juice and butter, stir until smooth.
MERINGUE In a clean bowl, beat whites, salt and lemon juice or cream of tartar until frothy. While still beating, add sugar in a slow stream. Continue beating until stiff peaks form.
COMBINE Pour filling into pie shell. With a spoon, arrange meringue around the perimeter, touching but not covering the crust's edge, then filling the center. Bake for 10 – 15 minutes until golden brown. Let cool 1-2 hours before serving.
What Makes a Lemon Meringue Pie So Yellow?
Is it the lemon juice? No, there's not enough color in lemon juice to create such rich color in the Lemon Filling. Give up? It's the egg yolks! The more yellow the yolks, the more yellow the "Lemon" Filling. Sweet, eh?!
This is my contribution to the pie recipes collecting from across the world here on Kitchen Parade, all to celebrate Pi Day and the wonder that is homemade pie with homemade pie crust.
More Pie Recipes
from Kitchen Parade
~ Honey Pumpkin Pie ~
from A Veggie Venture, my food blog
Shop Your Pantry First
© Copyright 2008, 2014 Kitchen Parade
And thanks for another lemon meringue recipe~ it's one of my favorites~
I do want to make a Lemon Meringue Pie with the meringue on top so that I can try Aunt Hen's "No Weep Meringue." It was one of her favorite recipes to share!
Happy Pi Day!!
Thank you for hosting this event, Alanna. Reading about your pie and everyone else's is making me think that perhaps I should gather my courage and give flaky pastry another try.
Post a Comment
Thank you for taking a moment to write! I read each and every comment, for each and every recipe. If you have a specific question, it's nearly always answered quick-quick. But I also love hearing your reactions, your curiosity, even your concerns! When you've made a recipe, I especially love to know how it turned out, what variations you made, what you'll do differently the next time. ~ Alanna


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As a popular destination on many travelers' bucket lists, Alaska offers nature, culture and luxury, but it doesn't have to break the bank. The year 2013, in fact, will be an especially good year to visit America's 49th state, thanks to added cruise values and extra memorable Northern Lights viewing. And there's more.
Here are some unique ideas to help maximize your next Alaska adventure.
Look Up, Catch Your Breath
NASA says the Solar Max is due in 2013, providing the best views of the aurora borealis in the past 50 years. Fairbanks, which sits under a unique ring-shaped region of the North Pole, will offer some of the best and most frequent sights. And many hotels will make sure you don't miss them: They'll place special wake-up calls to your room as soon as the Northern Lights appear.
See bears, Skip whales
OK, whale watching is a must-do on any Alaskan adventure. But drop anchor on Kodiak Island and venture inland for a special chance to view some of the 3,000 brown bears that call this island home. The Kodiak Brown Bear Center recently opened and allows small groups to venture into unspoiled territory that had been off-limits for almost two decades. Visits require minimum three-night stays (in modern cabins).
Go for the Air Tour, Skip the Land Tour
A floatplane ride or helicopter tour is an essential part to any Alaska vacation. Both can be done as day trips so they fall within a cruise line itinerary. Some helicopter tours include mountain top landings and outdoor activities such as hiking and dog-mushing, the popular Alaska sport using dog sleds. Special to 2013 might be an aerial trek to the peak of Mt. McKinley, North America's tallest mountains, since this year marks the 100th anniversary of its very first summit; Rust's Flying Service is introducing a "Pilot for a Day" program, where adventurers are led on six-hour, customizable tours by an experienced Alaska bush pilot. And if you're an avid skier, seek out a heli-ski operator, which will chopper you direct to classic slalom venues such as Alyeska Resort (45 minutes south of Anchorage) and Tsaina Lodge (near Valdez), which just reopened after a six-year revamp and can get 900 inches of snow a year.
Ride the Sea Cycles, Skip the Kayak
This adventure opportunity is new in 2013: Ketchikan-based and family-owned Alaska Sea Cycle Tours allows tourists to hop on a vessel that looks like a cross between and bike and a boat. It glides like a kayak but is powered by pedals, and it offers a unique way to explore the wildlife, history and culture of Ward Cove and Totem Bight State Park.
Embrace the Canopy, Get Off the Water
For those folks seeking the ultimate Alaska adventure, Alaska Canopy Adventures offers an eco-adventure tour including ziplining through a rainforest, channel-crossing on a speed boat and off-roading on a 4x4 all-terrain vehicle. Available out of Juneau and Ketchikan, these half-day tours feature the largest canopy courses in Alaska and offer an extraordinary sightseeing experience for thrill-seekers.
Ride the Highway, Pass on the Passage
Many cruise itineraries will take you down the iconic Inside Passage. But 2013 might be the year to ride the Alaska Marine Highway, celebrating 50 years of service. This 3,500-mile route connects Bellingham, Washington to Dutch Harbor, Alaska, and is a veritable lifeline to some 30 communities, many of which are not connected by roads. The views are stunning, and with a unique promotion this year -- visitors can win travel through a monthly Golden Ticket giveaway -- they can also be free.
Take a Seat at the Chef's Table, Skip the Jerky
Alaskan cuisine at its best just got easier to savor. The popular Alaska Fish House in Ketchikan launched its Chef's Table for 2013. The nightly four-course menu will change with each catch of the day. If wild salmon, halibut, black cod and Dungeness crab make your mouth water, pull up a seat.
Stay on a Luxury Cruise Liner, Skip the Igloo
Fulfill the fantasy of floating past majestic icebergs, orcas and humpback whales while having the luxurious amenities aboard an Alaskan cruise. Major cruise lines such as Celebrity and Princess are adding more ships and departures to Alaska in 2013 and, with more cabins to fill, we're expecting extra deals, especially for May and September travel.
Gabe Saglie is senior editor for Travelzoo. Alaska is one of Travelzoo's Top 5 WOW Deal Destinations for 2013. For bargains on Alaska cruises, check this out.


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LAS VEGAS (AP) — A son of rancher Cliven Bundy has withdrawn his children from Clark County schools after his daughter was barred from carrying a pocket knife on school grounds.
Ryan Bundy says that's a violation of his children's rights, and evidence of county school administrators' "communistic mentality."
He told the Las Vegas Sun (http://bit.ly/1CawI4K ) that he has decided to pursue education for his children elsewhere.
Virgin Valley High School Principal Cliff Hughes defended his decision to prohibit Bundy's daughter from carrying a pocket knife, citing safety concerns.
He says that if the Mesquite school allowed one student to carry a knife, it would have to allow others to do so.
Cliven Bundy and his armed states' rights supporters thwarted a roundup by the federal government of his cattle in southern Nevada in April.
Information from: Las Vegas Sun, http://www.lasvegassun.com


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Suffolk, ss. Division of Administrative Law Appeals
Board of Registration in Medicine,
v. Docket No. RM-07-1142
Ira Rex, III, M.D.,
Appearance for Petitioner:
Amy Sharff, Esq.
Patricia C. Garison, R.N.
Board of Registration in Medicine
200 Harvard Mills Square
Wakefield, MA 01880
Appearance for Respondent:
John P. Mulvey, Esq.
Sean Ennis, Esq.
Martin, Magnuson, McCarthy & Kenney
101 Merrimac Street
Boston, MA 02338
Administrative Magistrate:
Maria A. Imparato, Esq.
The Board of Registration in Medicine has not met its burden of proving that the Respondent did not meet the standard of care in his treatment of Patient A, except for his failure to dictate his operative note until four months after surgery.
On December 19, 2007, the Petitioner, Board of Registration in Medicine ("Board"), issued a Statement of Allegations ordering the Respondent, Ira Rex, III, M.D. to show cause why he should not be disciplined for: engaging in conduct which places into question his competence to practice medicine; engaging in misconduct in the practice of medicine; engaging in conduct what undermines the public confidence in the integrity of the medical profession; and committing malpractice within the meaning of G. L. c. 112, s. 61. The Respondent filed an Answer to the Statement of Allegations on January 15, 2008.
I held a pre-hearing conference on February 8, 2008 during which it was agreed that the Board would supply all documents to the Respondent no later than March 7, 2008; the Respondent would propound interrogatories to the Board no later than March 17, 2008; the Board would answer the Respondent's interrogatories no later than May 2, 2008; and the parties would return for a hearing on the merits to commence June 9, 2008, and continue day-to-day until June 12, 2008.
On April 11, 2008, we agreed to an additional hearing date of June 4, 2008 to hear the Board's expert witness. On May 2, 2008, the Board filed an assented-to Motion for Extension of Time to File Answers to Interrogatories. The Board filed its answer to interrogatories on May 6, 2008. On April 30, 2008, the Respondent filed a Motion to Compel Production of Complaint Committee Memorandum, with five exhibits appended, including: Ruling on Discovery Motion issued by Administrative Magistrate Judithann Burke on October 25, 2007 in case RM-07-142, Board of Registration in Medicine v. Sheela Gurbani, M.D.; the Statement of Allegations in the instant case; the Respondent's informal Request for Production of Documents; the Board's Production and Documents; and the Board's Annual Report of 2007.
The Board filed its Opposition to the Motion on May 19, 2008.
On June 3, 2008, I issued a Ruling on Respondent's Motion to Compel Production of Complaint Committee Memorandum and Petitioner's Opposition Thereto denying the Respondent's Motion to Compel.
The Respondent filed a Motion for Reconsideration of Order Denying Respondent's Motion to Compel Production of Complaint Committee Memorandum on June 4, 2008. I heard argument on the Motion to Reconsider on June 4, 2008. I denied the Motion to Reconsider on September 4, 2008.
The hearing on the merits began on June 4, 2008 to hear the testimony of the Board's expert witness. Both sides presented opening statements. The Board's expert witness then declined to testify on June 4, 2008 on the advice of his malpractice carrier who advised him to consult with an attorney before testifying. The hearing was continued to June 6, 2008 to determine how to proceed in light of this development.
On June 6, 2008, the parties agreed to check their schedules and the schedules of the prospective witnesses and to have a conference call later in the day to set new dates for the hearing. As a result of the conference call on June 6, 2008, I sent out a Notice of Hearing on June 9, 2008, canceling the hearing dates of June 9 through June 12, 2008, and rescheduling the case for September 8 through September 12, 2008. The parties agreed to exchange witness lists and documents no later than August 25, 2008, and to provide me with witness lists and documents to be submitted at hearing no later than September 3, 2008.
The hearing on the merits reconvened on September 8, 2008, and continued day-to-day until September 11, 2008. The hearing reconvened by agreement of the parties on December 11, 12, 15, 16 and 18, 2008. The hearing was canceled on December 19, 2008 when the Governor advised non-essential state employees not to report to work because of a snowstorm. By agreement of the parties after a conference call on January 7, 2009, the last day of hearing was February 3, 2009.
On December 15, 2008, the Respondent filed a Motion to Dismiss and/or for Summary Decision. The Petitioner filed its opposition to the Motion on January 15, 2009. I did not rule on the Motion.
The Respondent renewed his Motion to Dismiss on or about February 3, 2009. The Respondent also filed a Memorandum of Law Regarding Admissibility of Subsequent Remedial Measures
At hearing I marked documents into evidence. (Exs. 1 - 57) The Board offered the testimony of Patient A; Sumner Slavin, M.D., an expert witness; Charles Baham, Patient A's husband; Cynthia Hines, M.D., a fact witness; and Donald J. Morris, M.D., a fact witness.
The Respondent presented the testimony of Ira Rex, III, M.D.; Kenneth A. Marshall, M.D., an expert witness; and Henry Crowley, M.D., a fact witness.
The record closed on March 10, 2009, with the filing of post-hearing briefs.
1. Ira H. Rex, III, M.D., d.o.b. 1/25/1961, graduated from Brown University School of Medicine in 1987. He has been licensed to practice medicine in Massachusetts since 1992 under certificate number 76995. He is board-certified in plastic surgery. He has privileges at Charlton Memorial Hospital, St. Anne's Hospital and the Same Day SurgiClinic in Fall River. He has an office in Fall River. (Tr. X, 953-956; Ex. 50.)
2. Patient A, d.o.b. 5/8/1965, is a transgendered male to female. She is married to Charles Baham. Mr. Baham accompanied Patient A to all of her visits to Dr. Rex. (Tr. III, 69, 81; Tr. VI, 581.)
3. Patient A first consulted Dr. Rex on June 13, 1996 because she was concerned with hollowing of her cheeks, an increase in her nasal labial folds and lines on her forehead as the result of weight loss. Dr. Rex discussed with Patient A three methods of correcting the nasal labial folds, including placement of Goretex under the skin, the use of collagen and the use of fat harvested from the patient (autologous fat). (Tr. X, 960-961; Exs. 25, 26, 6/13/1996.)
4. Dr. Rex discussed with Patient A at the June 13, 1996 visit the risks and complications of this surgery. His office note states: "Will be swollen, may have contour deformity, swelling, pain, bruising. Wants to proceed. May lose result over time and req[uire] further procedure." ( Tr. X, 961-963; Exs. 25, 26, 6/13/1996)
5. Patient A elected to proceed and on August 8, 1996 Dr. Rex performed liposuction on Patient A's abdomen and injected autologous fat into Patient A's face. On August 22, 1996, Dr. Rex saw Patient A in follow-up and noted "good result face, wants more lateral correction now." Patient A was interested in cheek implants for more lateral projection in that area, and she wanted to discuss breast implants. (Tr. X, 963-964; Exs. 25, 26, 8/8/1996, 8/22/1996; Ex. 2, pp. 20-30.)
6. At the August 22, 1996 visit, Dr. Rex examined Patient A with respect to her desire for breast implants. Dr. Rex noted in his office note that Patient A's chest wall was wide, and there was a small amount of breast tissue. A wide chest wall makes it difficult to fill up the chest wall and create cleavage. A paucity of breast tissue means that a lot of what will be seen post-operatively will be the implants. (Tr. X, 964-966; Exs. 25, 26, 8/22/1006.)
7. Dr. Rex discussed with Patient A on August 22, 1996 the risks of breast implantation surgery outlined in the McGhan booklet that is put out by the F.D.A. His office note indicates that he discussed with Patient A "pain, swelling, infection, deflation, displacement, wrinkling, other. Scar will result." (Tr. X, 969-970; Exs. 25, 26, 8/22/1996.)
8. Dr. Rex discussed with Patient A on August 22, 1996 the possibility of intra-operative bleeding that could result in a hematoma, that is, a collection of blood around the implant that might or might not require surgical drainage.
(Tr. X, 970-971.)
9. Dr. Rex discussed the possibility of wrinkling of the implants with Patient A on August 22, 1996. Wrinkling is a common problem with implants and will be more obvious when there is very little breast tissue covering the implants. (Tr. X, 971-972.)
10. Dr. Rex noted in his office note for August 22, 1996 that Patient A would require a note from her transgender counselor to be certain that it would be healthy for Patient A to acquire breasts. (Tr. X, 972; Exs. 25, 25, 8/22/1996.)
11. Patient A visited Dr. Rex again on October 3, 1996 to discuss breast implant surgery. Patient A told Dr. Rex that she wanted large implants with cleavage, without too much step-off of the upper pole. Dr. Rex discussed with Patient A the fact that large implants had more of a tendency to have a significant step-off in the upper pole and might look unnatural in that area, and the fact that the weight of the implant could lead to early sagging that might require a corrective procedure. Dr. Rex explained that he might not be able to produce the kind of cleavage that Patient A wanted. (Tr. X, 973-976; Exs. 25, 26, 10/3/1996.)
12. Patient A decided to proceed with breast implants knowing the risks of large implants and the fact that she might not be able to obtain the cleavage that she desired. Dr. Rex performed bilateral breast augmentation on Patient A on October 11, 1996 using 450cc implants over-filled to 460cc. The surgery went smoothly. (Tr. X, 976; Exs. 25, 26, 10/3/1996, 10/11/1996; Ex. 2, pp. 32-48.)
13. Patient A returned to see Dr. Rex on October 24, 1996 for a follow-up visit. Dr. Rex noted that Patient A was happy with the implants, but wanted fuller and wider cheekbones. They discussed cheek implants and further fat injections. Dr. Rex informed Patient A that cheek implants would be inserted through the mouth, and that infection and displacement of the cheek implants was a possibility that could require corrective surgery. (Tr. X, 979-981; Exs. 25, 26, 10/24/1996.)
14. Patient A returned to see Dr. Rex on December 26, 1996 about facelift surgery that Dr. Rex said would serve her better than cheek implants. Physical examination of Patient A by Dr. Rex revealed coarse nasal labial folds and labial mandibular folds (also known as marionette lines), and loose skin on the cheeks and upper neck. (Tr. X, 981-982; Exs. 25, 26, 12/26/1996.)
15. Dr. Rex discussed with Patient A facelift surgery, "including extent of surgery, recovery, scars in scalp/around ear, possibly ugly scarring, poor results, asymmetry, contour deformities, motor nerve damage, numbness, hematoma, pain, swelling, infection, other." (Exs. 25, 26, 12/26/1996; Tr. X, 985-986.)
16. Dr. Rex informed Patient A that a facelift is major surgery that requires long incisions that Dr. Rex demonstrated through a pamphlet. He described for Patient A a SMAS (superficial musculoaponeurotic system) tightening facelift that would last about ten years rather than five years. Dr. Rex informed Patient A that there is a difficult recovery after facelift that requires the head to be elevated and requires the patient to avoid bending, lifting weights and sex to prevent blood pressure from rising. He explained that there would be post-operative visits for suture and staple removal. (Tr. X, 983-984.)
17. When Patient A pulled her facial skin up to tighten it, Dr. Rex told her that he could not produce that result and he demonstrated for her a less dramatic result. (Tr. X, 984-985.)
18. Patient A did not go ahead with a facelift at that time. Her next visit to Dr. Rex was on April 15, 1998 when she presented with a complaint of wrinkling of her breast implants. (Tr. III, 73; Tr. X, 997; Exs. 25, 26, 4/15/1998.)
19. On April 15, 1998, Dr. Rex and Patient A discussed the nature of wrinkling, the difficulty of eliminating wrinkling, and ways to eliminate wrinkling, including manipulation of the scar tissue around the implants and over-inflation of the implants. They also discussed the risks of surgery. (Tr. X, 998; Tr. III, 73; Exs. 25, 26, 4/15/1998.)
20. Dr. Rex's office notes for April 15, 1998 states, "Will plan overinflation by about 10%. May not eliminate all wrinkles or help at all. Wants larger implants." (Exs. 25, 26, 4/15/1998.)
21. Patient A decided not to attempt to remove the wrinkling by overinflation of the implants in April 1998 because Dr. Rex told her that overinflation would make the implants very hard. (Tr. III, 73.)
22. Patient A next visited Dr. Rex on December 29, 1999, when she returned to discuss implant size again. Patient A was not satisfied with her breast implants because of wrinkling, and because she felt the implants were not wide enough and did not fill in the middle area between her breasts. (Tr. III, 74 -76; Tr. X, 999; Ex. 1.)
23. During the visit of December 29, 1999, Patient A indicated that she wanted 900cc implants. Dr. Rex explained that because of the size and weight of those implants, there could be premature sagging that would require surgical correction. His office note for that date indicates, "She doesn't mind and is willing to accept multiple risks. Reviewed FDA risks. Will not be symmetric." (Tr. X, 999-1001; Exs. 25, 26, 12/29/1999.)
24. On January 7, 2000, Patient A cancelled surgery to replace her breast implants with larger implants. (Exs. 25, 26, 1/7/00; Tr. X, 1001; Tr. III, 84-86.)
25. Patient A's next visit to Dr. Rex was on April 7, 2004 to discuss an exchange of breast implants and a rhinoplasty. Patient A indicated that she was also interested in a facelift after Dr. Rex told her that cheek implants would not address her concerns about the folds that go from the nose to the corner of the mouth. (Tr. III, 77-78; Tr. X, 1001; Exs. 25, 26, 4/7/04.)
26. During the visit of April 7, 2004, Patient A said that she wanted larger, high profile implants that have more projection when filled. Dr. Rex reviewed with Patient A the booklet of risks issued by the implant manufacturer, Mentor. (Tr. X, 1004, 1008-1010; Exs. 25, 26, 4/7/04; Ex. 51, pp. 9-12.)
27. During the visit of April 7, 2004, Patient A said that she wanted a more feminine looking nose which required refinement of the bulbous tip and narrowing of the dorsum. (Tr. X, 1011; Exs. 25, 26, 4/7/04.)
28. Dr. Rex noted in his office note that he had a limited ability to refine the tip of Patient A's nose and narrow her dorsum because Patient A had thick, oily skin at the tip of her nose. When a plastic surgeon performs surgery on the underlying cartilage of the nose, he is not able to get the same type of re-draping of the skin that can be achieved in a patient with thinner skin. It is more difficult to narrow a wide dorsum because of the thickness of the bone. (Tr. X, 1012-1013; Exs. 25, 26, 4/7/04.)
29. Dr. Rex discussed the risks of rhinoplasty with Patient A on April 7, 2004, including bleeding, infection, asymmetry and dissatisfaction with the results. Dr. Rex reviewed with Patient A a pamphlet on rhinoplasty. (Tr. X, 1013;
Ex. 52.)
30. Patient A returned to see Dr. Rex on April 26, 2004 to discuss facelift surgery. Dr. Rex performed a physical examination of Patient A's face that revealed jowl laxity, neck laxity, and good skin tone. He wrote in his office note, "improvement expected but will be modest secondary to early changes. Wants to feel younger and more feminine. Pulls skin tight - unable to produce this effect entirely." (Tr. X, 1016-1017; Exs. 25, 26, 4/26/04.)
31. Dr. Rex expected only modest improvement because Patient A was a relatively young person so the expectations with respect to facelift surgery were more modest than the expected results of performing a facelift on a 70-year old person. By the end of the April 26, 2004 visit, Dr. Rex believed that Patient A understood his expectations with respect to each procedure that they
discussed. (Tr. X, 1018.)
32. Dr. Rex discussed the risks of facelift with Patient A on April 26, 2004, including infection, tissue loss, hematoma (the risk of which is greater in a genetic male), asymmetry, pain, numbness and scars that could require further touch-up surgery. (Tr. X, 1019-1020; Exs. 25, 26, 4/26/04.)
33. Dr. Rex reviewed a pamphlet with Patient A about facelift and gave the pamphlet to Patient A. In his notes Dr. Rex wrote, "Reviewed brochure and scars at length. Wants to proceed." (Tr. X, 1020-1023; Ex. 53.)
34. Dr. Rex told Patient A that there was a risk associated with anesthesia, but he left it to the anesthesiologist to explain the risks to Patient A and obtain informed consent from her. (Tr. X, 1024-1025.)
35. Patient A asked Dr. Rex whether she should have breast implant exchange, rhinoplasty and facelift in three separate operations rather than in one procedure. Dr. Rex told Patient A that it was less dangerous to be anesthetized once rather than three times, and she would have to pay the SurgiCenter and the anesthesiologist only once. Patient A agreed with that. (Tr. III, 88.)
36. A few days before the procedure a nurse from the SurgiClinic called Patient A and asked her whether she had discussed her planned surgery with Dr. Rex because "This is a lot of surgery." Patient A called Dr. Rex and told him what the nurse said. Dr. Rex asked Patient A to come in and see him. Patient A went to see Dr. Rex and he was angry and wanted the name of the nurse. Dr. Rex relieved Patient A's anxiety by telling her that he performed these procedures often. (Tr. III, 91-94.)
37. Patient A's surgery, including breast implant exchange, rhinoplasty and facelift went forward on April 29, 2004 at the Same Day SurgiClinic in Fall River. (Tr. X, 1026; Ex. 2, pp. 49-69; Exs. 25, 26, 4/29/04.)
38. Prior to surgery Patient A signed a Procedure Consent form for all three procedures, and a Consent for Anesthesia form. (Ex. 2, pp. 50-51.)
39. The surgery went smoothly. Anesthesia began at 8:10 a.m. The first incision was made at 8:30 a.m. The surgery was finished at 1:10 p.m. (Tr. XII, 1284-1285; Ex. 2, p. 54.)
40. Dr. Rex exchanged Patient A's breast implants for Mentor Smooth Round High Profile implants with a nominal fill volume of 630cc and a maximum fill volume of 750cc. He filled both implants to 840cc. (Ex. 21; Tr. X, 1075.)
41. After the surgery was completed, the blood had to be washed out of Patient A's hair, and she was bandaged. After Dr. Rex left the operating room, the anesthesiologist, Henry Crowley, M.D., asked Dr. Rex to return to the operating room to re-evaluate Patient A's bandages, and check an area of ecchymosis in Patient A's lower neck. Dr. Rex observed a minimal amount of staining on the bandages at the site of incisions that were stapled in the hairline above the top of the ear and in the hairline behind the earlobe. Dr. Rex's findings appeared to him to be normal and expected. (Tr. X, 1042-1044; Tr. XII, 1286-1287; Ex. 2, p. 56.)
42. Dr. Crowley did not have any concern that Patient A was actively bleeding or that Patient A was developing a hematoma. (Tr. XII, 1286-1287.)
43. Patient A was moved to the Post-anesthesia Care Unit and then to the Recovery Room at 2:10 p.m. (Ex. 2, p. 64; Tr. XII, 1288.)
44. Patient A was discharged from the SurgiCenter at 4:50 p.m. in the care of her husband, Mr. Baham, who was then her significant other. Her vital signs were stable, she had minimal discomfort, and there was no nausea or vomiting. Patient A could verbalize and ambulate; she was jovial. (Ex. 2, pp. 54, 64; Tr. XII, 1290-1291.)
45. Mr. Baham was given written discharge instructions with a phone number to call if help was needed. The printed instructions read in part: "If you should experience difficulty in breathing, bleeding that you think excessive, increased swelling, persistent nausea or vomiting, an increase in any discomfort or pain, or develop a fever, please call your physician. In the unlikely event that you cannot locate your physician, or the individual on call for the practice, go to a hospital emergency room." (Ex. 2, p. 68.)
46. Dr. Rex's handwritten instructions were as follows: "Don't do anything to elevate your blood pressure. Keep head elevated on 2-3 pillows or sleep in chair. Expect drainage tonight. Keep compression dressing in place until tomorrow. May remove dressings in AM, shower, and replace compression garment. Keep nasal splint dry and in place. Wear bra except to shower. Follow up 5-7 days." (Ex. 2, p. 68.)
47. Mr. Baham drove Patient A to their home to Malden where they arrived almost two hours later. (Tr. VI, 603.)
48. Mr. Baham tried to make Patient A comfortable by seating her upright on the couch surrounded by pillows. He used bags of frozen vegetables to help Patient A when she said she felt "warm." It then seemed to Mr. Baham that Patient A looked more swollen that he thought she should look, and he saw more blood than he thought he should see. Blood had started to drip down Patient A's neck onto her chest, and her bandages were starting to get wet with blood around the surface of Patient A's head. (Tr. VI, 605.)
49. Mr. Baham took pictures of Patient A at Patient A's request sometime between 8:30 and 10:30 p.m. (Tr. VI, 605-607; Exs. 3, 16, 42, 43, 44.)
50. Mr. Baham started to see blood not only around the top of Patient A's head, but around the back of her neck and around her cheek. He called the phone number listed on his discharge instructions and reached Dr. Rex's answering service. Within a few minutes Dr. Rex called Mr. Baham. (Tr. VI, 607-608.)
51. Mr. Baham told Dr. Rex, that Patient A "was really looking swollen and I was seeing signs of blood." Dr. Rex said it was normal to see a little trickling blood. Mr. Baham said it seemed like more than a trickle. Dr. Rex asked whether the swelling was over the entire face or on just one side. Mr. Baham said it was the entire face. Dr. Rex asked whether Patient A was in pain. Dr. Rex advised Mr. Baham to make Patient A relax, keep cold compresses around her, not let her move much, and give her a couple of pain pills. Dr. Rex said to call him immediately if there were any changes. (Tr. VI, 608-609; Tr. X, 1050-1053.)
52. Dr. Rex inquired about whether Patient A's swelling was over her entire face or only on one side, and whether Patient A was in pain, because pain and unilateral swelling are "significant indicators of facial hematoma." (Tr. X, 1051.)
53. Mr. Baham tried to make Patient A comfortable. A short time later Patient A said she was having trouble breathing. Patient A's face was swollen to two to three times its normal size. Mr. Baham tried to loosen the bandages that went from the top of Patient A's head to the bottom of her chin. He could see incisions and a lot of blood. Mr. Baham made a second call to Dr. Rex's answering service about one hour after his first call. (Tr. VI, 609-612.)
54. The answering service operator told Mr. Baham that she would give a message to Dr. Rex and have him get back to Mr. Baham. (Tr. VI, 613.) Dr. Rex did not get a call from the answering service. He did not hear from Mr. Baham again until early the next morning. (Tr. X, 1057.)
55. Mr. Baham did not get a call from Dr. Rex. Mr. Baham decided to take Patient A to the emergency room at New England Medical Center (NEMC) in Boston. (Tr. VI, 619.)
56. Upon arrival at NEMC Patient A was taken directly from the emergency room to the operating room for fiberoptic intubation by the ENT service, and evacuation of a hematoma by the Plastic Surgery service. (Ex. 39, p. 90.)
57. When Patient A was taken to the operating room, Mr. Baham made another call to Dr. Rex's answering service. The service told him that they would get a message to Dr. Rex and Dr. Rex would be in touch on Monday. Mr. Baham explained that he was at NEMC with a patient on whom Dr. Rex had operated that day. Five minutes later Dr. Rex called Mr. Baham. (Tr. VI, 621-622.)
58. Patient A was noted by the ENT service to have severe swelling of the face, lips and eyelids with a tense hematoma. An intra-nasal exam revealed inferior turbinate laceration on the right side, and diffuse mucosal bleeding on the left. Both nasal cavities were packed with surgifoam which controlled the bleeding. (Ex. 39, p. 92.)
59. The Plastic Surgery service then performed evacuation of the hematoma and ligation of bleeding vessels, including a left temporal artery branch and a vessel in the right neck. Patient A lost approximately 1.5 liters of blood. (Ex. 39, p. 89.)
60. While the Plastic Surgery service was evacuating the hematoma, the ENT service was called back in because of further nasal bleeding. Surgifoam was again packed into both nostrils which stopped the nasal bleeding. (Ex. 39, 94, Tr. VIII, 845.)
61. When Donald J.Morris, M.D., the plastic surgeon on call at NEMC first saw Patient A, he observed the most facial swelling he had ever seen. When Patient A's airway was safe, Dr. Morris removed all of the sutures and staples placed by Dr. Rex during the facelift and evacuated 500-700cc of blood. Dr. Morris found it "almost impossible to control the bleeding." He feared that Patient A would not survive. (Tr. VIII, 818.)
62. After Dr. Morris got Patient A's bleeding under control, he placed a drain on each side behind the ear and closed the wounds back up again. The drains were in the cheek, but did not go through Patient A's cheek. Dr. Morris did not make any new incisions, although it is possible that ENT or anyone assisting could have extended the existing incisions. (Tr. VIII, 826, 846-847; Ex. 39, p. 95.)
63. Patient A was transferred to the Intensive Care Unit. She was kept intubated for airway protection. On May 3, 2004, Patient A was extubated. On May 4, 2004, Patient A's drains were removed and she was transferred to the floor. On May 5, 2004, Patient A was discharged home. (Ex. 39, p. 89.)
64. After Dr. Rex spoke with Mr. Baham in the early morning of April 30, 2004 and learned that Patient A needed emergency care for a hematoma, Dr. Rex immediately called the Chief Resident. Dr. Rex made three calls to NEMC on April 30, 2004 to check on Patient A's condition. He was informed that she was doing well, was ventilated and agitated. (Tr. X, 1058-1059; Exs. 25, 26, 4/30/04.)
65. After April 30, 2004, Dr. Rex called NEMC at least twice a day to check on Patient A's status. He spoke with the ICU nurse caring for Patient A. Then he learned that Patient A had been discharged. Patient A called Dr. Rex's office on May 7, 2004 for medication. (Tr. X, 1060-1061; Exs. 25, 26, 5/7/04.)
66. Patient A went to Dr. Rex's office on May 10, 2004. Dr. Rex noted that she was healing normally except for an area behind her right ear that was necrotic. He noted moderate swelling. He removed sutures and noted that Patient A's nose was corrected. (Tr. X, 1064-1065; Exs. 25, 26, 5/10/04.)
67. During the visit of May 10, 2004, Mr. Baham expressed his anger at Dr. Rex's answering service for not allowing him to speak with Dr. Rex on his second call to Dr. Rex on April 29, 2004. Mr. Baham told Dr. Rex that the service advised him to go to the emergency room. Dr. Rex wrote a complaint to the answering service. (Tr. X, 1062-1063.)
68. Patient A's next visit to Dr. Rex was on May 18, 2004. Dr. Rex removed the staples and noted that Patient A's scalp was healing well. He noted decreased swelling and that all surgical sites were healing normally. Dr. Rex noted that Patient A's breasts were softening and were of a good size with good placement. He believed Patient A's nose showed good correction. (Tr. X, 1065-1066; Exs. 25, 26, 5/18/04.)
69. Patient A's next visit to Dr. Rex was on May 24, 2004. Patient A was concerned that the skin on her face was not tight enough. Dr. Rex could not pull the skin any tighter; a lot of skin had been removed in the surgery. Dr. Rex thought the result was as he had anticipated. Significant swelling after a facelift lasts about six weeks and continues to get better over six months. (Tr. X, 1067-1069; Exs. 25, 26, 5/24/04.)
70. Patient A's last visit to Dr. Rex was on June 14, 2004. She was still concerned about her facial skin not being tight enough. Dr. Rex told her he did not think further correction was possible. Patient A was concerned that one breast appeared bigger than the other, although Dr. Rex had put equal amounts of fluid in each implant during surgery. Dr. Rex explained that he could do a revision, but it was too early to make a decision on that. He noted that Patient A's face was healing well. (Tr. X, 1069-1070; Exs. 25, 26, 6/14/04; Tr. III, 126 - 137.)
71. Sometime in June 2004, Patient A had a telephone conversation with Dr. Rex in which she outlined her complaints about the outcome of her surgery. Patient A felt that Dr Rex was unresponsive to her concerns and she decided to contact Cynthia Hines, M.D., the CEO of the SurgiCenter. (Tr. III, 145-146.)
72. On June 25, 2004, Patient A consulted Jaromir Slama, M.D.at Beth Israel Deaconess Medical Center about a revision of her facelift and breast augmentation. She was advised that revision surgery only two months after a facelift was not advisable. She was told that the earliest to consider revision surgery was six to eight months after the initial surgery. Patient A was told of the low likelihood of improving the appearance of her nasal labial folds.
(Ex. 27.)
73. In or about the end of July 2004, Patient A wrote to Dr. Hines asserting that she had been trying for a month to get her medical records from Dr. Rex, and she had just learned from someone in the SurgiCenter records department that there was no operative note for the April 29, 2004 procedures. (Ex. 41.)
74. By letter of August 4, 2004, Patient A requested that Dr. Rex provide her with her medical records. (Exs. 17, 19.)
75. On August 4, 2004, Dr. Rex dictated his operative note for the procedures done on April 29, 2004. The note was transcribed on August 9, 2004. Dr. Rex did not dictate his operative note until he was informed by the SurgiCenter that there was no operative note in Patient A's chart. (Ex. 2, pp. 65-67; Ex. 55; Tr. X, 1073-1074.)
76. Dr. Rex's operative note contains an error. He did not insert 700cc implants filled to 840cc. He inserted 630cc implants filled to 840cc. (Tr. X, 1075.)
77. About three months after the surgery, Patient A had photographs taken. (Exs. 8-15; Tr. III, 126-137.)
78. By cover letter of August 11, 2004, Dr. Hines mailed to Patient A her medical records, including Dr. Rex's operative note. (Ex. 20.)
79. By letter of September 27, 2004, Patient A requested that Dr. Rex provide her with pre-operative pictures taken at his office. The photographs were provided to Patient A on or about October 18, 2004. (Ex. 18; Exs. 4-7.)
80. In November 2004, Patient A consulted Michael Yaremchuk, M.D. about having a chin reduction and a midface lift with reduction of the mandibular angles. Dr. Yaremchuk indicated that the combined procedures would cost $11,500.00 plus $350.00 to stay overnight. (Ex. 30; Tr. IV, 348.)
81. By letter of January 5, 2005, Patient A demanded that Dr. Rex return to her the money she had paid him for the procedures of April 20, 2004 which totaled $15,900.00. (Ex. 31; Tr. IV, 349.)
82. Dr. Rex responded by letter of January 25, 2005 agreeing to reimburse Patient A $15,900.00 if she would withdraw her complaint against him at the Board of Registration in Medicine with the following proviso: "The Board of Registration in Medicine must agree that it is appropriate to fully resolve this dispute with a monetary transaction and that no ethical or moral codes are thusly infringed." (Ex. 24; Tr. IV, 351-352.)
83. In May 2005, Patient A consulted Sheldon J. Sevinor, M.D. regarding revision surgery to her face, nose and breasts. Dr. Sevinor noted, "She states that at NEMC they had to extend the incision across the entire scalp and she was in the ICU for six days." Dr. Sevinor did not recommend revision surgery. He suggested Restalyne for the nasal labial folds and marionette lines. (Ex. 28.)
84. In an undated letter to Dr. Rex probably mailed sometime in May 2005, Patient A asked Dr. Rex to call her to bring the dispute between them to an end. (Ex. 23, Tr. IV, 356.).
85. In an undated letter to Dr. Rex, probably sent sometime in June 2005, Patient A expressed her desire to end her relationship with Dr. Rex. She stated. "You had Kim call my home and make an offer and a commitment, and then I never heard from you again." (Ex. 32; Tr. IV, 354)
86. Dr. Rex's office note from June 20, 2005 indicates that someone in Dr. Rex's office called Patient A and said Dr. Rex would be amenable to returning $19,000.00 to her. Patient A was to think about the offer and call back on June 23, 2005. The note also indicates that Dr. Rex told Patient A it would be improper for him to refer her to another plastic surgeon for revision surgery. (Exs. 25, 26, 6/20/05.)
87. Sometime after June 30, 2005, Patient A forwarded to Kim in Dr. Rex's office Dr. Yarmechuk's estimate for revision surgery prepared in November 2004. (Ex. 33, Tr. IV, 358.)
88. Dr. Rex's office notes for June 28, August 25 and August 29, 2005 indicate that Patient A had not returned phone calls to Kim with respect to Dr. Rex's offer of settlement. (Exs. 25, 26, 6/28/05; 8/25/05; 8/29/05.)
89. By letter of September 14, 2005, Dr. Rex mailed to Patient A a Mutual Release and Settlement Agreement. (Ex. 34.)
90. Patient A did not sign the Release. She wrote one more letter to Dr. Rex in or about October 2005, asking him to "refrain from initiating any and all communication with me." (Ex. 35, Tr. IV, 365-367.)
91. On February13, 2007, Patient A consulted Sumner Slavin, M.D. about revision surgery. Dr. Slavin opined that Patient A was a good candidate for revision of the facelift, but would continue to have severe scars. He suggested the use of gel implants with the use of AlloDerm to smooth the take off from the chest wall of the breast implants. Dr. Slavin referred Patient A to Mark B. Constantian, M.D. for rhinoplasty revision. (Ex. 37.)
92. On February 26, 2007, Patient A consulted with Dr. Constantian about revision of her thinoplasty. Dr. Constantian opined that he would not recommend a secondary facelift because he did not believe sufficient improvement could be obtained. He suggested Restalyne to correct the asymmetry of the nasal labial folds. (Ex. 29.)
The Board of Registration in Medicine has not met its burden of proving, by a preponderance of substantial evidence, that Ira H. Rex III, M.D.'s care of Patient A was substandard, except for the fact that he failed to produce an operative note until four months after surgery.
Risk of multiple surgical procedures performed at one time
The Board's expert witness, Sumner Slavin, M.D., testified that there is a difference of opinion among plastic surgeons about the increased risk of performing several plastic surgical procedures at one time. He opined that full disclosure of the risk of each procedure must be communicated to the patient, verbally and in writing. (Tr.V, 442-445; 495-496; Ex. 38, p. 2.)
Dr. Rex's expert witness, Kenneth A. Marshall, M.D., testified that the risk of performing several procedures at once is the risk of increased anesthesia. Otherwise, multiple procedures can be done safely in patients who are not otherwise compromised by significant systemic illness. (Tr. IX, 913-914; 934-935.)
I conclude that because there is a difference of opinion among plastic surgeons about the risks of multiple procedures, I cannot conclude that Dr. Rex's care of Patient A was substandard because he did not specifically speak with her about the increased risk of multiple procedures or the increased risk of longer anesthesia. Dr. Rex did advise Patient A extensively about the risks of breast implants, rhinoplasty and facelift as documented in his office notes. Furthermore, he provided Patient A with brochures that outlined the risks of each procedure.
Although both Patient A and Mr. Baham deny that Dr. Rex advised them of the risks of each procedure, and deny that Dr. Rex provided Patient A with a pamphlet relative to each procedure, I conclude that Dr. Rex's office notes made contemporaneously with Patient A's visits to him beginning in 1996 are more reliable than the respective memories of Patient A and Mr. Baham from more than 12 years ago. I have no doubt that Patient A and Mr. Baham testified truthfully. I believe their memories are faulty. I do not believe that Dr. Rex purposely put misinformation into his office notes and I relied upon his office notes in making my findings of fact.
Informed consent signed by Patient A
Patient A signed one consent form on April 29, 2004 relative to all three procedures. (Ex. 2, p. 51.) Dr. Slavin opined that this form is inadequate. (Tr. V, 444.) Dr. Marshall opined that it is not necessary for a patient to sign a different consent form for each procedure. (Tr. XI, 1158-1160.) Both experts agree that Dr. Rex disclosed to Patient A the risks of all three procedures as evidenced in his office notes.
The first paragraph of the consent form Patient A signed reads, "I have been made aware, to my complete understanding and satisfaction, of the nature and the purpose of the operation. Possible alternative methods of treatment, and the risks and consequences that are commonly associated with the procedure(s) or surgery described above."
The consent form Patient A signed contemplated that her doctor had already disclosed the risks of the procedures to her, as, in fact, Dr. Rex had.
In view of the fact that the experts disagree on whether the consent form is adequate, and in view of the fact that Patient A had been made aware of the risks of each procedure and acknowledged that she had been made aware when she signed the form, I conclude that Dr. Rex did not breach the standard of care by using this one consent form for all three of Patient A's procedures. It was not necessary for the consent form to reiterate all of the risks of all of the procedures of which Patient A had already been informed.
Failure to arrange for overnight care/traveling home
Dr. Slavin testified that he recognizes differences of opinion among plastic surgeons with respect to whether a genetic male, after undergoing facelift, rhinoplasty, and breast implant replacement requires overnight hospitalization. (Tr. V, 445-446.)
Dr. Marshall opined that Dr. Rex's postoperative care of Patient A met the standard of care because Patient A was stable at the time of discharge. There was no indication at the time of discharge that would require Patient A be kept in Fall River. There are good facilities close to Malden in case of an emergency, and Patient A was released into the care of Mr. Baham. (Tr. IX, 915-920; Tr. XI, 1192-1193.)
Dr. Marshall also opined that a patient should be informed that she has the choice to stay in a hospital after day surgery and pay for hospitalization if she so chooses. (Tr. XI, 1166-1167.) There is no evidence that Dr. Rex ever made Patient A aware of this choice, nor is there evidence that Patient A would have chosen to stay in a hospital in Fall River at her own expense if she had been informed of the choice. Neither expert testified that failure to offer this choice to Patient A was a deviation from the standard of care.
I conclude that Dr. Rex did not breach the standard of care on April 29, 2004 by allowing Patient A to return home in the care of Mr. Baham, in view of the fact that she was stable, and there were no indications that she was developing a hematoma at the time of discharge.
Mr. Baham's first telephone call to Dr. Rex on April 29, 2004
Mr. Baham told Dr. Rex that that "Patient A looked swollen and he was seeing signs of blood." Dr. Rex told Mr. Baham that trickling blood was to be expected. Mr. Baham said he thought it was more than a trickle. Mr. Baham did not testify that he told Dr. Rex he saw a "flow" of blood, or that blood was "flowing," or that Patient A was "actively bleeding," or that there was "blood coming out of a wound."
Dr. Rex inquired about the location of the swelling and the presence of pain because he was aware that unilateral swelling and pain could be an indication of a facial hematoma.
Dr. Slavin opined that if an observer who is not medically trained reports to a plastic surgeon that he sees a "flow" of blood, or "blood coming out of a wound," the surgeon ought to refer the patient to the emergency room for evaluation. (Tr. V, 448; 472.)
Dr. Marshall testified that it is not unusual to see swelling and staining of the bandages within the first twenty-four hours after a facelift, and that mere staining of the bandages is not an indication of major bleeding. (Tr. IX, 921-926; Tr. XI, 1168-1169.) Dr. Marshall reviewed the photographs Mr. Baham took of Patient A on the evening of April 29, 2004 (Exs. 3, 42, 43, 16) and opined that there was nothing visible in the pictures indicative of anything other than expected post-operative findings, and no indication of a hematoma. Dr. Marshall opined that the information provided to Dr. Rex by Mr. Baham during his first telephone call would not require the average qualified plastic surgeon to conclude that a hematoma was forming, or that Patient A should be directed to the emergency room at that time. (Tr. IX, 921-926.)
I conclude that Dr. Rex did not breach the standard of care by failing to recognize that Patient A was forming a hematoma based on the information provided to him by Mr. Baham. If Mr. Baham had said the blood was "flowing," or that there was "active bleeding," or that there was "blood coming out of a wound," I would reach a different conclusion. But based on the information provided to Dr. Rex, I accept the opinion of Dr. Marshall that there was insufficient information to form the conclusion that a hematoma was forming.
Dr. Rex's availability to Patient A during a postoperative crisis
Dr. Rex was available to Patient A by telephone on the night of her surgery. Dr. Rex called Mr. Baham back immediately after receiving the message from his answering service. Dr. Rex never received Mr. Baham's second message. Dr. Rex called Mr. Baham back immediately when he received Mr. Baham's call to the answering service from NEMC early on the morning of April 30, 2004.
Dr. Marshall opined that a doctor cannot be held responsible if an answering service does pass on a message to him. (Tr. IX, 927.)
Dr. Slavin opined that a doctor or his associates must be available to care for a post-operative patient as needed, and provide care "24/7.". (Tr. V, 477.)
I conclude that Dr. Rex was available to Patient A during her postoperative crisis, but his answering service negligently failed to pass on Mr. Baham's second call to Dr. Rex. I do not believe Dr. Rex can or should be held responsible for the failure of his answering service. I have no reason to believe that Dr. Rex would not have contacted Mr. Baham immediately if he had received the message, in light of the two telephone calls from Mr. Baham returned immediately upon receipt. Dr. Rex did not breach the standard of care.
New scars and deformities
Patient A has a small scar on her right cheek that was not there prior to surgery. (Compare, Exs. 5 and 10.) She has extensive scarring in her scalp. (Exs. 9, 13) She complains of pixie ears. She is not happy with the appearance of her nose. She is disappointed that her nipples are lateralized, and she feels her breast implants are too big.
Cheek scar
Dr. Slavin testified that he does not know whether the scar on patient A's cheek was done at NEMC. (Tr. V, 503.) Dr. Marshall testified that the scar on the cheek could have occurred from any damage to the skin, any intentional incision in that area, or from an untoward surgical complication. He opined that the injury could occur from underneath the skin with electrocoagulation or a pressure bandage. He opined that the scar is a recognized complication of both the original procedure as well as the NEMC emergency procedure. (Tr. IX, 933-934.)
Because it is unclear when and how this scar appeared, and in view of the fact that the scar could have resulted from Patient A's emergency procedure at NEMC, I conclude that there is insufficient evidence to conclude that Dr. Rex created this scar. I cannot conclude that Dr. Rex's care of Patient A was substandard based on the scar on her cheek.
Scalp scarring
Dr. Slavin testified that he has never seen facelift scars extend all the way around the back of the neck to join at the nape, and the scarring on top of Patient A's head is more extensive than he is familiar with. (Tr. V, 437-438.) He acknowledged that opening the original incisions at NEMC can affect the cosmetic result of the facelift. (Tr. V, 504.)
In Dr. Sevinor's letter of May 24, 2005, he indicated that Patient A told him that her incisions had to be extended across her entire scalp at NEMC. (Ex. 28)
Dr. Morris, who performed the NEMC surgery, testified that he did not extend the existing facelift incisions, but he acknowledged that the ENT service or anyone assisting in the surgery could have extended the existing incisions. (Finding #62.)
I conclude that Patient A's facelift scars, although extensive, are not as the result of substandard care provided by Dr. Rex. It is likely that the scars were extended over Patient A's scalp at NEMC, as Patient A reported to Dr. Sevinor. I cannot conclude that the extensive facelift scarring was caused by Dr. Rex's substandard care.
Pixie ears
Dr. Slavin testified, based on a review of pictures marked as Exs. 7, 10, 11 and 12 that Patient A does not have a pixie ear deformity in the pictures taken about three months after surgery. He noted some abnormal scarring of the lobe to the face which he opined was within the standard of care three months after surgery. (Tr. V, 452-453.)
I conclude that the condition of Patient A's earlobes are not as the result of substandard care provided by Dr. Rex.
Patient A's nose
After review of pictures of Patient A's nose before and after surgery (Exs. 5, 10, 11, 12), Dr. Slavin opined that he did not have an opinion regarding the appearance of Patient A's nose after surgery. (Tr. V, 465-466.) He noted in his consultation with Patient A that she had a line of demarcation on the profile of her nose between the tip area and other area that gave her a moderate supratip deformity, a fullness above the anatomy of the tip itself. He also noted the presence of a ridge on the profile. (Tr. V, 466-467; Ex. 37.)
Dr. Slavin acknowledged that the attempts made at NEMC to stop Patient A's bleeding from the hematoma, and the packing of SurgiFoam into the nose could disrupt what Dr. Rex accomplished during the rhinoplasty. (Tr. V, 489-492.)
Because Patient A's nose was packed with SurgiFoam on two occasions while Patient A was at NEMC, and because Dr. Slavin acknowledged that this can disrupt the cosmetic outcome of the rhinoplasty, I cannot conclude that the supratip deformity on Patient A's nose is the result of substandard care by Dr. Rex.
Lateralized nipples
Dr. Slavin testified that if the nipples are lateralized prior to surgery, then placement of a new implant that continues that appearance is reasonable. (Tr. V, 556-557.) A review of the pre-surgery pictures with the post-surgery pictures reveals that Patient A's nipples were lateralized prior to the implant exchange. (Exs. 1, 14, 15.) There is no evidence in Dr. Rex's office notes that Patient A ever complained to him about lateralization of her nipples after the first surgery. I cannot conclude that lateralization of her nipples after the implant exchange is as a result of substandard care by Dr. Rex.
Patient A feels that the new implants are too large, but a review of Dr. Rex's office notes indicates that Patient A requested and agreed to larger implants as a way to remove the wrinkling. Dr. Rex explained to Patient A prior to surgery the disadvantages of large implants. (Findings 20, 23, 26)
There is no evidence that Patient A's dissatisfaction with the appearance of her breasts is as the result of substandard care provided by Dr. Rex.
Documentation of implant size
Dr. Rex dictated his operative note four months after Patient A's surgery. He incorrectly stated that he used 700cc implants overfilled to 840cc when he in fact used 630cc implants overfilled to 840cc.
Dr. Slavin testified that the standard of care requires that notations in a chart should be "as accurate as possible." (Tr. V, 461.) He did not testify that Dr. Rex's care of Patient A was substandard as a result of this error in the operative note. There is no evidence that Patient A was in any way harmed by this error.
I cannot conclude that Dr. Rex's error in his operative note rises to the level of substandard care.
Overfilling the implants
Dr. Rex used implants with a nominal fill volume of 630cc and a maximum fill volume of 750cc. He overfilled the implants to 840cc. He overfilled the implants by 90cc which is 12% of 750cc. (90 divided by 750 = .12 = 12%)
Dr. Marshall testified that overfill in measured in relation to the maximum fill leve. (Tr. IX, 937.)
Dr. Slavin opined that overfilling breast implants is not a deviation of the standard of care, and that in general "we overfill ten percent and when there is some ambiguity here, up to twenty percent is considered pretty much the maximum." (Tr. V, 463.) Dr. Slavin opined, "although we've been taught that ten percent is correct, there is a gray zone of a few extra percent." (Tr. V, 558.)
I conclude that Dr. Rex did not breach the standard of care by overfilling Patient A's implants by 12%.
Failure to dictate operative note for four months
I found as fact that Dr. Rex did not dictate his operative note until four months after Patient A's surgery based on Dr. Rex's letter of January 4, 2005 to the Board in which he wrote, "The operative note was not dictated on the date of surgery which is my standard." (Ex. 55.)
Dr. Marshall opined that an operative note should be dictated within 24 hours, and that dictating an operative note four months after surgery is not "good practice." (Tr. XI, 1177.)
Dr. Slavin opined that it is not within the standard of care to dictate an operative note four months after surgery. (Tr. V, 462.)
I conclude that Dr. Rex deviated from the standard of care by failing to dictate his operative note until four months after Patient A's surgery.
I recommend that the Board impose appropriate discipline.
Maria A. Imparato
Administrative Magistrate


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Browsing Department of Geosciences by Author "Douglas, Scott W., 1986-"
Now showing items 1-1 of 1
The Jurassic Norphlet Formation of the deep-water Eastern Gulf of Mexico : a sedimentologic investigation of aeolian facies, their reservoir characteristics, and their depositional history. Douglas, Scott W., 1986- (2011-01-05)This study defined the sedimentary facies, reservoir architecture, and depositional history of the Jurassic aeolian Norphlet Formation in the deep-water Eastern Gulf of Mexico. Seven depositional facies were identified ...


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Jesuit communities around the world have been asked to make their buildings more energy efficient, help farmers use sustainable agricultural practices and launch programs in their universities that promote both theological reflection and scientific research on protecting the environment. A 68-page special report on ecology, "Healing a Broken World," published in Rome in mid-September by the headquarters of the Society of Jesus, calls on Jesuits and their collaborators to confront their own inner resistance and "cast a grateful look on creation, letting our heart be touched by its wounded reality and making a strong personal and communal commitment to healing it."
The report calls for biblical and spiritual reflection on the gift of creation and an understanding of environmental protection as a justice issue, since it is the poor who suffer first and most severely from the destruction of environment. "Creation, the life-giving gift of God, has become material, extractable and marketable," the document said. According to "Healing," people have allowed technology and rationality to dominate the way they look at the physical world, "blunting our sensitivity to the mystery, diversity and vastness of life and the universe."
The overuse of fossil fuels and the creation of greenhouse gases, the waste or pollution of waters, deforestation, polluting the ground with chemicals and the growing pressure put on the environment by increasing populations are issues that must be dealt with from a position of faith, personal responsibility and science, it said. "It is the very dream of God as creator that is threatened. It is the entire world, the one God put in the hands of humankind to keep and preserve, which is in real danger of destruction."
Restoring a right or just relationship with God, with creation and with other people is not simply a matter of personal prayer and appreciation. It requires a real change in the way one lives, the report concludes. Religious communities may not have the technical know-how and resources to reverse pollution, but they do espouse the moral values that are needed to promote new relationships with the world God created and with the poor, who experience hunger, drought, landslides and flooding because of environmental destruction, the Jesuits said.
In practical terms, the report asks Jesuits worldwide to: conduct assessments of their energy use and consumption patterns, taking their vow of poverty seriously to reduce their own negative impact on the environment; consider the huge impact the environmental crisis is having on the poor and commit themselves to advocacy work on behalf of the poor; promote sustainable agriculture practices; look for ways to explain and promote the spiritual and practical motivations for environmental concern.
"Healing" asks Jesuit schools, universities, theology faculties and research institutes to immerse their students in "real-world environmental issues"; promote an "environmental ethic" on campuses by supporting recycling and energy savings; and develop courses in business, science, ethics and theology that include environmental responsibility and reflection. The report suggests that Jesuits living in environmentally vulnerable parts of the world develop projects bringing together social and pastoral work, advocacy and scientific research to help the local people.


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We offer what you need to achieve success. Come explore and find out why so many students have decided to call one of the colleges in the Alamo Colleges District the pathway to their future.
Not sure where to start? Our Career Assessment Tool can help.
Alamo Colleges Education Services is a secure portal connecting Faculty, Staff & Students to Academic Resources, Email, and other Online Resources.
Support Contacts Helpdesk (210) 485-0555 Weather Line (210) 485-0189
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Alamo Colleges Online
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The Alamo Colleges is pleased to announce the release of Alamo GPS, a web-based tool to help students and advisors monitor a student's progress toward degree completion.
Alamo GPS combines the Alamo College's degree requirements and the coursework completed into an easy-to-read worksheet that helps see how courses completed count toward degree requirements and what courses and requirements still need to be completed. This system is designed to aid and facilitate academic advising, but is not intended to replace face-to-face advising sessions.
Alamo GPS is available to students who were admitted to the Alamo Colleges since Fall 2009, and students pursuing a degree/major through the Fall 2010 or later catalog. Students will continue to meet with their academic advisor concerning degree progression. Alamo GPS may be accessed through ACES; no additional username or password is needed. For students, a current audit will load automatically once Alamo GPS is accessed. Advisors must enter the student's Banner ID number.
The degree audits produced by Alamo GPS are dependent on a student's major/concentration. Data is extracted from the Banner System into Alamo GPS. Any request to change degree program information (majors/concentrations) or a student's catalog term will not be reflected in Alamo GPS until the request is completed by enrollment services.Anyone with the Alamo GPS advisor role can use the Refresh button at any time to update a student's audit once the requested change is completed.
Students following a catalog prior to Fall 2010 may use the "What-If option" and select a major from the drop-down list, to view a full degree audit.These students may also use the Planner and GPA Calculator functions.
Review the FAQs, Help and Tutorials available on the left hand links of this site or the instructions available under the Help tab on each page in Alamo GPS. If further assistance is needed, see an advisor or enrollment services on your campus.
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Kate Bosworth: Charlie Chaplin Oscar Anniversary!
Kate Bosworth arrives at a celebration for the 40th anniversary of Charlie Chaplin's honorary Academy Award on Tuesday (February 21) at Chateau Marmont in Los Angeles.
The 29-year-old actress, wearing a Stella McCartney dress with Miu Miu heels, hit the carpet with beau Michael Polish before heading inside the party.
Earlier in the afternoon, Kate and Michael arrived at LAX Airport after jetting in from England.
The two had checked out Burberry's Fall/Winter 2012 collection during London Fashion Week.
FYI: Kate is carrying a JewelMint clutch.
15+ pictures inside of Kate Bosworth and Michael Polish at the Charlie Chaplin anniversary celebration…


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Find a clinic near me
Hearing Aids in West Bend, WI
1755 W Paradise Dr, Ste 103
West Bend, WI
Toll Free: 1-888-426-6632
Tel: (262) 299-3170
Call the West Bend Connect Hearing clinic to schedule your no-cost hearing screening -- or visit us today! This short screening will confirm your hearing health. If it reveals you will benefit from hearing technology, your highly qualified hearing care professional will guide you through the solutions that best fit your lifestyle and budget.
About Connect Hearing - West Bend, WI
We are dedicated to providing outstanding patient care and finding customized hearing care solutions that perfectly match each patient's individual needs, lifestyle and budget.
Join us today and receive:
- FREE, 2-Week Hearing Aid Trials*
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This location accepts the following healthcare plans:
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** The 3 year warranty is valid starting from the date of invoice. This limited warranty covers manufacturing and material defects in the hearing aid itself, but not accessories such as batteries, tubes, ear modules, external receivers. The warranty includes 3 year loss and damage coverage that can be redeemed ONE TIME and requires a deductible of $450.
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May 01, 2017
May is Better Hearing Month! To celebrate, Connect Hearing is offering nearly 300 free hearing… Read more »


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Men's Wax Lace-Up Leather Shoes in Black
€350€105 (70%)
- Pure calf leather in a worn waxed finish
- Vegetable-tanned
- Two part construction
- Overlapping upper
- Round toe silhouette
- Raw-edged detailing
- Lace-up fastening
- Flat leather laces
- Stacked leather sole
- Made in Spain
100% calf leather. Sole: 100% calf leather
Conscious Note:
'Petrucha footwear is crafted from leathers dyed using vegetable and natural extract tannins, oils and waxes, free from chromium, solvents and heavy metals. With these boundaries we can avoid many dangers to the environment and those that work with our collections. We work with recycled rubbers, water based dyes and glues and natural corks - all of the components that we use are from certified suppliers. The majority of our shoes have no backstitching, are torn by hand and placed directly on the last and each heel's layer is crafted by hand. Choosing to not sell by seasons or traditional collections we are able to work more sustainably, improving the value chain of our product and reducing environmental impact in the process. Recycling as much as we can in our factory, reusing what we can, where we can. Petrucha produces shoes that are far removed from collections, seasons and trends. They are continuity items that never lose their value. Our aim is to achieve good quality shoes that last for a long time.' -- Anaid Cano and Josep Vila
Founders Anaid Cano and Josep Vila started Petrucha in 2014 with the intention of creating a sustainable footwear brand that wasn't just a label, but a vehicle for change. With a small team of designers, leather craftsman and art directors, all the work is carried out in Petrucha's workshop in Alicante, Spain. Committed to sustainability and ethical production, Petrucha follows a criteria that makes its cycle as circular as possible, not adhering to collections, seasons or trends. All leathers are naturally treated, only using vegetable dyes whilst designs feature raw-edges and hand-stitched detailing. With a minimal and natural aesthetic, the brand creates transcendental biodegradable objects which pay incredible attention to detail resulting in handcrafted, high-quality leather shoes that never lose their value.
We offer Standard and Express Shipping
All purchased items can be returned free of charge – including reduced items.
We are happy to refund any purchases* within 14 business days from receipt. All returns must be sent via registered mail in their original condition.
*Excludes underwear, fragrance and cosmetic items which are non-returnable.
All orders are shipped worldwide via our affiliate DHL.
As soon as we have shipped your order you will receive an email stating the tracking number. You can check the status of your order one to two hours after receiving the email via the link provided.
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Standard - EUR 15 - 2/4 BD
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Exhale the Locusts Lyrics
I tried to bleed out, bleed out the sickness with synthetic remorse, like tempests they assail from the sky. (Haunting me, killing me.) Will I remain?...and I'm sorry for all I've done to you in my hour of shame, twisting, turning blind, deaf. Waif-like and thinning. Go. Run away. Don't look back until your eyes bear the strain of new light. Exhale all of the sorrow I've brought unto you. Exhale the locusts, better off unfeeling numb and motionless. Frozen like a sleeping death, cold mother You're gone. All I'm left with is my hate. No, with my blood opiate entwines her poison lips on mine. I'm better off in the lye, for I've got nothing anymore. Locusts... The sun you've always known, a bleeding heart. Your Achilles heel, the sun you've always known. We fade away.


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This is how I feel for hours, after eating raw onions. Dragon breath!
Sunday, October 07, 2012
MoFo 7: Pad Thai Salad with Tofu
This is how I feel for hours, after eating raw onions. Dragon breath!
11 comments:
Yummy, I haven't tried either of those recipes & I love AFR.ReplyDelete
both of these look seriously delicious! and i agree about raw onions, totally not my thing! i feel like my boyfriend is a onion dragon because i always give him all my onions too!ReplyDelete
I just discovered your blog thanks to Sunday's VeganMOFO round up, and I was so excited to see your drawings! I decided to do drawings as my MOFO theme this year, and I'm happy I'm not alone. Yours are far more professional, but I'm still glad to see another sketcher. (Your oil paintings are amazing too -- what a powerful message.)ReplyDelete
I have this book from the library, so I'll have to look into the Pad Thai Salad, but I agree with you about the onions. I like a little and beyond that I'm afraid to talk to anyone in person for awhile...ReplyDelete
I have almost made that salad so many times but never have. Actually I think it's the ONLY salad in AFR I haven't made even once. Your post is making me wonder why!ReplyDelete
And I agree on raw onion! It's one of the only foods I don't like, in part 'cuz of the fire breath.


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LOS ANGELES (AP) — California cities hoping to promote community gardens and small-scale farms in urban areas are getting a boost from a new state law recently signed by Gov. Jerry Brown.
The measure lets municipalities lower the assessed value — and property taxes — on plots of three acres or less if owners dedicate them to growing food for at least five years, the Los Angeles Times reported (http://lat.ms/1a0LzPc ).
The voluntary program makes it easier for cities to create "urban agriculture incentive zones" that don't rely on public land or heavy philanthropic support.
The legislation authored by Democratic San Francisco Assemblyman Phil Ting aims to make it easier for owners to transform eyesore parcels such as empty lots into farmable land.
"It's a huge step for urban agriculture," said Caitlyn Galloway, 32, a San Francisco famer who grows salad greens and flowers for local restaurants in what was once a weedy vacant lot.
The bill passed the Senate unanimously and garnered just six no votes in the Assembly.
Sole opposition came from the California Assessors' Association, which cited potential for abuse by corporate property owners who might cut deals with local government. The bill was later amended to curtail lot size, the Times said.
The concept for the incentive zones is a hybrid of the Williamson Act, which offers tax subsidies to owners of rural land maintained for agricultural purposes, and the Mills Act, under which cities may enter into contracts with private owners who receive subsidies in exchange for restoring and preserving historic buildings.
Community organizations in Los Angeles County, Oakland, East Palo Alto and San Diego have expressed support for the program.
Sacramento city officials supported the bill and have expressed interest in participating, as has San Francisco Supervisor David Chiu, who is moving forward to seek local approval.
"We simply want to create the impetus and awareness for property owners that this is a viable and productive use of land," Chiu told the Times. "This is an option many communities are excited about."
Information from: Los Angeles Times, http://www.latimes.com