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State of New Jersey OFFICE OF ADMINISTRATIVE LAW
- Kenneth Fields
- 3 years ago
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1 State of New Jersey OFFICE OF ADMINISTRATIVE LAW INITIAL DECISION OAL DKT. NO. BDS IN THE MATTER OF THE SUSPENSION OR REVOCATION OF THE LICENSE OF RICHARD A. KAUL, M.D., TO PRACTICE MEDICINE AND SURGERY IN NEW JERSEY. Maureen Hafner, Deputy Attorney General, for complainant Attorney General of the State of New Jersey (John J. Hoffman, Acting Attorney General of New Jersey, attorney) Charles Shaw, Esq., for respondent Richard A. Kaul, M.D. (Law Offices of Charles Shaw, Esq., attorneys) Record Closed: October 31, 2013 Decided: December 13, 2013 BEFORE J. HOWARD SOLOMON, ALJ t/a: STATEMENT OF THE CASE AND PROCEDURAL HISTORY This is a disciplinary proceeding brought by the Attorney General of the State of New Jersey (petitioner) on its complaint filed with the State Board of Medical Examiners (Board) on April 2, 2012, seeking to impose sanctions against Richard A. Kaul, M.D., a board-certified anesthesiologist (respondent), including the suspension or revocation of his medical license. Respondent filed his answer with the Board on April 9, 2012, New Jersey is an Equal Opportunity Employer
2 denying the allegations. The Attorney General filed an amended verified complaint with the Board on June 13, 2012, which then referred the matter to the Office of Administrative Law (OAL), where it was received on June 29, 2012, for hearing as a contested case. Thereafter, petitioner moved to further amend its complaint, which was granted by the undersigned on December 18, The second amended complaint alleged that respondent committed multiple acts of gross neglect, gross malpractice, gross incompetence, in violation of N.J.S.A. 45:1-21(c); repeated acts of negligence, malpractice or incompetence, in violation of N.J.S.A. 45:1-21(d); professional misconduct, in violation of N.J.S.A. 45:1-21(e) and (h), including failure to maintain medical malpractice insurance and/or a letter of credit, in violation of N.J.S.A. 45: and/or N.J.A.C. 13: (b) and (d); failure to maintain good moral character, in violation of N.J.S.A. 45:9-6; failure to obtain hospital privileges or alternative privileges, in violation of N.J.A.C. 13:35-4A.6; professional misconduct, in violation of N.J.S.A. 45:1-21(e) and violation of a Board regulation pursuant to N.J.S.A. 45:1-21(h), including the failure to maintain proper patient records, in violation of N.J.A.C. 13:35-6.5; and misrepresentation of his training and experience in the performance of spinal surgeries, and for his failure to properly bill for his services, both in violation of N.J.S.A. 45:1-21(b). Petitioner further alleged that the above conduct presented a clear and imminent danger to the public health, safety, and welfare, pursuant to N.J.S.A. 45:1-22. Petitioner further alleged that the Board issued investigative subpoenas to respondent and the New Jersey Spine and Rehabilitation Center (NJSR), 1 a one-room outpatient surgical center owned and operated by respondent, for patient records, which was refused by respondent, in violation of N.J.S.A. 45:1-18, and for his failure to cooperate with the Board, in violation of N.J.A.C. 13:45C-1.2 and -1.3(a)(5). 1 Reference will be made herein to another one-room outpatient surgical center known as North Jersey Spine and Rehabilitation Center (NJSR), where respondent worked prior to opening his own center. Any abbreviation of respondent s center, known as the New Jersey Spine and Rehabilitation Center (NJSR), will be underlined to avoid confusion. 2
3 Prior to the commencement of the hearing, the parties filed various discovery motions, which were heard and disposed of prior to hearing. In addition, petitioner filed on short notice a motion for summary decision on its allegations that respondent failed to obtain required hospital privileges and/or alternative privileges (discussed below) and that he failed to maintain required medical malpractice insurance or a letter of credit (also discussed below). The undersigned reserved on the motion pending the conclusion of this matter. After the hearing had commenced, respondent s counsel moved to be relieved as counsel, for reasons heard in camera; the motion was denied. The hearing took place on several dates, commencing on April 9, 2013, and concluding on June 28, Post-hearing briefs and reply briefs were submitted, after extensions were granted to both sides. The last brief was due and received on October 31, 2013, on which date the record closed. FACTUAL DISCUSSION Most of the facts, other than that respondent is a physician licensed to practice medicine and surgery in the state of New Jersey and is the owner and operator of NJSR, were in dispute. In presenting its case, petitioner produced several expert and lay witnesses, starting with Gregory J. Przybylski, M.D. Gregory J. Przybylski, M.D. Gregory J. Przybylski, M.D., is a licensed physician in the state of New Jersey and a board-certified neurosurgeon. He has written extensively about the spine, and has hospital privileges at JFK Medical Center and Jersey Shore Medical Center. After graduating from medical school, he completed several years of training in spinal surgical techniques and has been appointed to faculty positions in neurosurgery. He has never had any negative actions against his license in his seventeen years as a neurosurgeon. Dr. Przybylski has performed an extensive amount of spinal fusions, minimally invasive surgeries, including decompression or fusion or a combination of both, averaging approximately 120 to 150 spinal surgeries a year. Over the past several years, he has 3
4 devoted the majority of his practice to minimally invasive surgeries and percutaneous procedures, which he began around When asked to describe the differences between percutaneous and open surgeries, he responded that percutaneous are needle-based procedures while open surgery exposes the area of the spine to be treated. For open surgery, the training for the physician is significantly different than that for percutaneous procedures. In describing the differences between open spinal and minimally invasive surgeries, he stated that in open surgery, the area to be treated is much more exposed than in minimally invasive surgeries, the latter of which involves the insertion of a tube to conduct the repair. In minimally invasive surgery, the physician s field of vision is limited since the procedure is done through a tube. The physician must decide whether to perform an open or a minimally invasive surgery, after obtaining a cogent medical history and reviewing diagnostic tests. Both such surgeries are done in a hospital setting. During his preliminary testimony, Dr. Przybylski produced a model of the lumbar spine and discussed its physiology, including facet joints and discs. He also demonstrated various surgical techniques, including fusion, designed to limit motion of the spine to advance healing. Then he explained the differences between fusion and fixation. During a fusion, the process is to unite two bones disrupting a joint and pack the area with bone material to limit or prevent mobility. With fixation, wire, screws or rods, or a combination thereof, are used to immobilize the bones to allow for a fusion to occur. Most spinal surgeries involve degenerative disc disorder where the disc dehydrates and becomes less of a shock absorber, resulting in pain. Various diagnostic tests are available, such as CT scans, MRIs and discograms, which assist the surgeon in determining the type of surgery needed. The importance of obtaining a cogent medical history and the use of diagnostic testing were taught in medical school, and became 4
5 heightened during his residencies. He discussed various articles and publications concerning spinal surgeries that he had relied upon in rendering his report. 2 He mentioned that pain-management physicians consist of multidisciplines, such as radiologists, anesthesiologists, and internists trained to do percutaneous procedures (those procedures which are needle-based). After his review of the curriculum vitae of respondent P-109(a), it was his opinion that respondent did not have the requisite training to perform spinal surgeries, either open or minimally invasive. According to respondent s curriculum vitae, he was a surgical intern in at Catholic Medical Center in New York. Dr. Przybylski opined that interns at such a hospital would have had very little responsibility to perform spinal procedures on their own. He also noted that in , respondent was a surgical intern at Nassau County Medical Center in New York, where, again, Dr. Przybylski opined that there was limited training given to interns in performing surgical procedures on their own. Dr. Przybylski noted that in , respondent moved to Booth Memorial Medical Center in New York, a different medical center, where he likely would have had limited surgical experiences because he was newly transferred to that hospital. Respondent did complete a residency in anesthesiology at Albert Einstein Montefiore Medical Center in New York during , during which he would not have had any exposure to spinal surgeries. This residency likely included training in epidurals, discographies, and needle-based procedures. He further noted that in , respondent had a pain fellowship at the Department of Anesthetics at Bristol Royal Infirmary in Bristol, England. Here respondent would have received training in percutaneous procedures, not open or minimally invasive spinal fusion surgery. Respondent also listed in his curriculum vitae his membership in 2006 in the American Society of Interventional Pain Physicians. Dr. Przybylski examined the website for this association and noted that it was open to doctors of different disciplines who 2 See attached appendix for references. 5
6 sought to do interventional pain management, which treatment would have been limited to needle or percutaneous spinal procedures. In his curriculum vitae, respondent also listed the completion of a two-week fellowship in minimally invasive spine surgery at the Wooridul Hospital in Seoul, Korea, in In an excerpt from respondent s testimony before the Board on February 3, 2010 (P-98), respondent confirmed that his training in Korea was only for two weeks, a time period, according to Dr. Przybylski, that was totally insufficient for proper surgical training. Dr. Przybylski added that a typical fellowship for minimally invasive surgery is approximately six to twelve months, which would involve performing procedures and caring for patients under the supervision of a monitor, an experienced physician. During the residency, the physician is eventually weaned from supervision and gradually performs surgeries on his or her own, with the monitor in attendance. Respondent also listed his membership in 2004 in the American Academy of Minimally Invasive Spinal Medicine and Surgery, which Dr. Przybylski mentioned is not recognized by the American Board of Medical Specialties. Membership in this organization is open to various physician disciplines, but membership by itself did not provide expertise in spinal surgery. Respondent also mentioned that he is a diplomate of the American Board of Interventional Pain Management. Dr. Przybylski stated that this membership also involves physicians from various disciplines, such as physiatrists, neurologists and anesthesiologists, which leads to becoming a diplomate in percutaneous procedures, not minimally invasive ones. He further commented that the continuing medical education (CME) courses taken by respondent did not qualify him to perform open or minimally invasive surgeries. Attendance at these courses did not lead to surgical competence, but only satisfied CME requirements for licensure. As to respondent s certificate from the North American Spine Association, Dr. Przybylski commented that this association included a broad spectrum of physicians. Even a non-physician who took the appropriate course or courses offered could obtain a certificate, which only certified attendance. The amount of time and breadth of study 6
7 necessary to train for open or minimally invasive surgeries is much greater than merely attending CME courses. He further opined that given respondent s lack of training, he would not have been granted hospital privileges for either open or minimally invasive surgeries, particularly at JFK Hospital, where Dr. Przybylski sits on a credentialing subcommittee. He would, however, have been given privileges as an anesthesiologist to perform percutaneous procedures. Based upon his review of respondent s curriculum vitae, which illustrated his lack of training in either open or minimally invasive surgeries, Dr. Przybylski opined that respondent s performance of those surgeries constituted a gross deviation from medical standards. Dr. Przybylski testified that there were also several risks associated with this deviation, citing, for example, a patient treated by respondent who underwent multilevel procedures that cannot not be corrected during the patient s life. Dr. Przybylski also noted atrophy in that patient and mentioned other maladies that were likely to develop. Since complications could arise during open or minimally invasive surgeries, these surgeries should be done in a hospital setting or at least at the hospital s outpatient center. If a problem were to occur, the patient could be properly and immediately treated. Therefore, the surgeon must have hospital privileges. However, respondent did not have any hospital privileges. He further opined that since respondent was performing spinal surgeries, it was a gross deviation for him not to have hospital privileges. In the alternative, respondent could have worked with doctors who had hospital privileges, who could then take over the care of the patient, if needed. But no relationship with other doctors was noted in the materials he reviewed. Dr. Przybylski was asked to give his opinion about respondent s treatment of patient R.B. In arriving at his opinion, Dr. Przybylski reviewed respondent s medical records, imaging reports, pre- and post-operative reports, and the consent for surgery. He opined that respondent deviated from the standards of care for treatment of this patient. 7
8 Respondent improperly performed a discogram, for which there should have been a control, or normal, disc. Since that was not done, he concluded that this was a gross deviation. Upon his review of respondent s operative report, he noted that patient R.B. underwent a discectomy of L-3, L-4, and L-5 at the North Jersey Center for Surgery (NJCS) in Newton, New Jersey, an outpatient facility. A fusion was also performed using a mesh cage with allograft. While the patient consented to a discectomy, the operative report showed that, in addition to a discectomy, fusions were performed, which were not contained in the consent. Dr. Przybylski explained that during surgery, other medical concerns might be discovered, which were unknown during the consent process. These new issues could be treated while the patient is under anesthesia, rather than subjecting the patient to a new surgery and further anesthesia. But nothing was noted in the operative report about encountering other problems necessitating expanding the surgery. He considered this to be a gross deviation. Surgery was performed on April 11, 2005, where respondent performed a lumbar discogram at L4-5; lumbar discogram at L3-4; lumbar discectomy at L4-5; lumbar discectomy at L3-4; lumbar interbody fusion at L4-5 with mesh cage; and lumbar interbody fusion at L3-4 with mesh cage. A follow-up MRI on April 22, 2005, disclosed a large disc herniation at L4-5 with nerve impingement, which was the same area where respondent inserted the mesh cage. On April 27, 2005, respondent performed another surgery for the removal of bone fragment using a percutaneous approach. On an MRI dated May 5, 2005, of the L4-5 surgery site, there was still a large disc herniation at that level. According to Dr. Przybylski, this meant that disc material that should have been removed by the prior surgeries was still present. On May 9, 2005, respondent performed another surgery which consisted of a fragmentectomy of disc fragment in the L4-5 neural foraminal space on the left side where 8
9 two grams of fragment were removed. On June 6, 2005, the patient returned to respondent complaining of radiating pain in his left leg and of his inability to return to work. On June 9, 2005, other MRIs were obtained, with and without contrast, of the lumbosacral spine. The imaging showed that at L4-5 there was still the presence of a large disc fragment, notwithstanding the prior surgeries. By then, the patient was reporting weakness and atrophy in his left leg. Respondent planned another surgery to remove the fragment, which was his fourth surgery at the L4-5 disc. This surgery was performed on June 15, An MRI on August 25, 2005, revealed that a stable large disc fragment was present centered in the distal aspect of the left L4 neural foramen, impinging upon the left L4 nerve root, further indicating that a portion of the disc fragment extended into the proximal aspect of the neural foramen. On September 19, 2005, respondent performed a percutaneous procedure endoscopically, but another imaging obtained on October 4, 2005, showed there was no definite interval change from the prior imaging of August 25, Respondent used mesh during surgery, which Dr. Przybylski stated was likely OptiMesh, adding that the use of OptiMesh was improper since it could not withstand the load from body weight as an interbody structural support. He cited the literature prepared by Spineology, the manufacturer of OptiMesh, which contained the following FDA notice in bold and bracketed print: The safety and effectiveness of this device used for fusion of the interbody space has not been established. (P-13.) Dr. Przybylski stated that the proper material should have been Allograft or a PEEK (polyether ether ketone) cage, not mesh. Dr. Przybylski opined the following gross deviations: 1. Performing a discography without a control level. 2. The inconsistency between the consent and the operative report. 3. The performance of multiple surgeries to the same area. 9
10 4. The use of mesh. 5. Respondent s lack of training in performing spinal surgery. Dr. Przybylski noted that patient R.B. ended up with foot weakness and atrophy and developed a foot drop. In addition to the above deviations, the witness was also critical of respondent s repeated use of percutaneous techniques. In all, he opined that respondent grossly deviated from the standards of care in his treatment of patient R.B. Dr. Przybylski was then asked to render his opinion about respondent s treatment of patient G.H. An MRI on November 5, 2011, indicated there were degenerative disc changes at multiple levels with small focal disc herniations at L4-5 and L5-S1. On November 14, 2011, G.H. consulted with respondent. Respondent recommended a lumbar discogram at L2-L3, L3-L4, L4-L5 and L5-S1. On December 3, 2011, respondent performed a discogram, but not at L5-S1 as the operative report initially indicated. On the lumbar discography report of December 3, 2011, respondent reported that L5-S1 was not accessible. On an MRI taken December 3, 2011, grade-four annular tears of L2-L3 through the L5-S1 disc were noted. The patient then consulted with respondent on December 6, 2011, with ongoing complaints of pain in the low back and in both legs. Respondent recommended a lumbar decompression and interbody fusion at the L3-L4, L4-L5, and L5-S1 levels with the use of interbody cages, iliac-crest autograft, bone marrow harvest and GPS autograft. In his operative report dated December 9, 2011, respondent performed a lumbar decompression and interbody fusion with fusion cage at the L3-4, L4-5 and L5-S1 levels. Dr. Przybylski noted that the report described an incision over the iliac crest and a minimally invasive use of a retractor. He opined that this surgery involved an open procedure for Iliac-crest bone grafting, while the remainder consisted of minimally invasive surgery. 10
11 Dr. Przybylski noted that the consent for spinal surgery, which disclosed a lumbar decompression and interbody fusion at L3-L4, L4-L5, and L5-S1, with hardware and with iliac-crest bone harvest, did not contain any signature of either the patient or respondent. According to the anesthesia record, the surgery lasted about six hours. (P-6 thru P- 12, at G.H ) During surgery, respondent used mesh, which Dr. Przybylski concluded was likely OptiMesh. Again he discussed the FDA warning about the safety and effectiveness of this device for interbody structural support. (P-13.) Although a PEEK interbody cage was used at L3-4, respondent used mesh at other intervertebral spaces. Dr. Przybylski opined that respondent deviated from the standards of care: 1. Performing three-level spinal fusions constituted a gross deviation. The guidelines only provide for one- or two-level, not three-level, fusions. 2. The use of OptiMesh at L4-5, L5-S1 constituted a gross deviation. 3. Discography was not necessary since it had already been established that there was pain at two levels. This constituted a deviation between moderate and gross. 4. The history and physical examination undertaken by respondent was without any neurological examination, which constituted a moderate deviation. 5. The consent forms did not have signatures to confirm if the patient had consented to the procedures. 6. Respondent s performance of an open procedure with his lack of training and qualifications constituted a gross deviation. 7. Respondent s lack of hospital privileges or alternative privileges was a gross deviation. 11
12 Dr. Przybylski also opined that the surgeries performed by respondent placed this patient at risk for neurological injury. A three-level spinal fusion could cause stiffness, require further surgeries, and cause the development of stenosis at the L2-3 level. Dr. Przybylski saw this patient on July 24, 2012, and December 10, The patient reported that his leg pain had improved, but not his back pain. He had functional difficulties putting on shoes and socks. In his examination, Dr. Przybylski noted a long incision as well as an iliac-crest incision. Mesh cages were noted at L4-5 and L5-S1. On the follow-up CT scan, it was noted that the L4-5 and L5-S1 level end plates were eroding, which Dr. Przybylski opined was caused by bone destruction. Dr. Przybylski was asked to give his opinion about respondent s treatment of J.J. In arriving at his opinion, Dr. Przybylski reviewed respondent s office records, operative reports and imaging studies. On an MRI performed on June 12, 2004, desiccation (dehydrated disks) was indicated at several levels. Respondent met with J.J. on September 9, 2005, where he planned to perform a discogram at L2-3, L3-4, L4-5 and L5- S1, which was performed on October 3, According to respondent s records, he performed a surgery on October 11, 2005, at the Market Street Surgical Center in Saddle Brook, New Jersey. He performed a discogram at L4-5, L5-S1, discectomy at L4-5, discectomy at L5-S1, lumbar interbody fusion with mesh cage at L4-5, and lumbar interbody fusion with mesh cage at L5-S1, and he inserted a posterior pedicle screw placement at L4, L5, S1 bilaterally with posterior rod placement. (P-12 thru P-18, at J.J ) According to the consent form of Market Street Surgical Center, the patient consented to a lumbar fusion at L5-S1, a single-level fusion. (Id. at J.J ) However, the operative report showed that a fusion was performed that exceeded the consent, namely, at L4-5 in addition to L5-S1. Dr. Przybylski could not find any reason in the operative report for the extra procedure. Furthermore, there was a receipt from Spineology for two OptiMesh devices. (Id. at J.J ) 12
13 When respondent saw J.J. in a follow-up consultation on November 7, 2005, respondent noted mild deficits over the L5 dermatomal distribution of the left lower extremity. (Id. at J.J ) In a neurological examination performed by Comprehensive Neurological Services on November 30, 2005, J.J. complained of left-leg pain all the way down to the dorsum of the foot and the second and third digit of his left foot, which occurred daily with increased pain. The patient mentioned that he had never experienced this before. A follow-up consultation with respondent on December 2, 2005, indicated some mild weakness over the left-knee extensors. In another follow-up consultation, on December 16, 2005, respondent noted that the patient still complained of some left-sided leg pain, which respondent claimed in his notes was improving. (Id. at J.J ) A CT scan obtained on December 22, 2005, disclosed that a left pedicle screw at L5 was medially located within the pedicle and might have breached the cortex of the lateral recess on the left. The radiologist noted high density material within the disc space at L4-5 and extends adjacent subcutaneous tissues and compromises the left neural foramen, and that the left pedicle screw was medially located within the pedicle and may breach the cortex of the lateral recess on the left. (Id. at J.J ) Dr. Przybylski was then referred to a report of a neurosurgical evaluation conducted by Alfred A. Steinberger, M.D., on January 5, This physician noted a history of numbness and paresthesias in the left knee, which the patient described as something new, which was causing him to frequently fall. Dr. Steinberger performed surgery on January 31, 2006, which included a revision of left posterior segmental instrumentation at L4, L5 and S1. His operative notes reflected that the screw-rod construct on the left was not solid and that the nerve roots at the L4-5 foramen and the L5-S1 foramen were found to be severely compressed. This led to decompression at the L4-5 on the left. Dr. Steinberger also found that the nerve root at L4 was densely adherent to the scar. This was also true for the nerve at L5, as well as the nerve root at S1. He also corrected L4-5 by removing disc material and corrected extruding bony material which was previously placed and which compressed the nerve root. (Id. at J.J ) 13
14 care: Dr. Przybylski opined that respondent deviated from the following standards of 1. Performing a fusion constituted a gross deviation. Initial imaging revealed degenerative disc change and an MRI supported that no fusion was necessary. 2. Respondent s lack of proper training in performing a fusion constituted a gross deviation. 3. The L5-S1 cage extended beyond the disc-space footprint, placing the patient at risk of harm to nerves and blood vessels. This was a gross deviation. 4. The use of a mesh cage as an interbody support device constituted a gross deviation. Dr. Przybylski further opined that risks to this patient included failure of fusion, which did occur, and injury to the nervous system. He was asked to give his opinion about respondent s treatment of patient F.K. In forming his opinion, Dr. Przybylski again reviewed respondent s medical records, operative reports and imaging studies. According to respondent s records, on April 4, 2008, he recommended a lumbar discogram at L2-L3, L3-L4, L4-L5 and L5-S1. Based upon an MRI study of the lumbosacral spine on March 10, 2006, the patient had already undergone a discogram on April 7, An MRI study had been done on January 25, 2008, which indicated status post laminectomy at L3 and L4, fixation screws and stabilization rods from the L3 through L5 levels, and a worsening L2-L3 posterior disc herniation, among other findings. On April 19, 2008, respondent performed a provocative lumbar discogram at L2-3 and L3-4. Patient was seen on April 2, 2008, for a follow-up consultation, where respondent planned a lumbar interbody fusion at the L2-L3 and L3-L4 levels with the insertion of hardware for posterior stabilization. There were other follow-up consultations on May 14, 2008, and June 18, 2008, where respondent provided the same treatment plan. 14
15 According to respondent s operative report of July 28, 2008 (P-21 thru P-29, at F.K to 0024), the following surgery was performed: 1. Removal of previous hardware from the L3, L4 and L5 levels; 2. Lumbar interbody fusion with mesh cage and allograft bone at the L2-L3 level; 3. Lumbar interbody fusion with interbody mesh cage and allograft bone at the L3-L4 level; 4. Lumbar interbody fusion with interbody mesh cage and allograft bone at the L4-L5 level; and 5. Insertion of pedicle screws at the L2, L3, and L4 pedicles on the right and at the L3, L4, and L5 pedicles on the left with insertion rods. This surgery was performed at the Bergen/Passaic Ambulatory Surgery Center, an outpatient facility. According to the history taken by respondent on July 28, 2008, this patient was a smoker of one pack of cigarettes a day. Dr. Przybylski also noted some modification to the consent form, where it appeared that the location L4-5 was inserted with a different ink and handwriting. Also noted was a receipt from Spineology for the delivery of three quantities of OptiMesh. From the records, Dr. Przybylski concluded that the surgery started at 13:45 and lasted until 20:25, six hours, forty minutes. (Id. at F.K ) Dr. Przybylski opined the following deviations: 1. The patient already had a two-level fusion and the contemplation to perform another fusion was not supported by the guidelines. Since respondent was not sufficiently trained, it was a gross deviation to perform a surgical procedure in the first place. 15
16 2. A discography was not done with a control level, which constituted a gross deviation. 3. A three-level fusion was not within the training of respondent. Two levels L3-4 and L4-5 had already been fused, and there was no indication to re-fuse, constituting a gross deviation. 4. The use of OptiMesh, which was not proper for an interbody space, constituted a gross deviation. 5. The screw fixation at the L2-3 level was not balanced on both sides. Accordingly, the lack of using screws bilaterally was a gross deviation. 6. Allograft, instead of autograft, was used even though this patient was a smoker, which constituted a gross deviation. 7. Respondent s lack of training in performing a three-level fusion for disc degeneration constituted a gross deviation. Only two levels were indicated within the guidelines. Dr. Przybylski opined that the risk of exposing this patient to surgery, particularly where it was not indicated, was the development of a chronic condition known as reflex sympathetic dystrophy, which he described as swelling and pain to the touch and for which there is no known cure. Dr. Przybylski was then asked to discuss respondent s treatment of patient L.M., where he again opined that respondent deviated from medical standards. He reviewed respondent s records, operative reports and imaging studies. At the initial consultation on May 3, 2011, the patient complained of lumbosacral pain, and numbness and tingling in the right arm and in the right leg. The patient also complained of weakness in the right arm and in the right leg and reported that the pain had been getting worse and was more severe on coughing, sneezing and going to the 16
17 bathroom. In the patient s past surgical history, respondent noted that the patient had undergone an anterior cervical discectomy and fusion at the C5-C6 and C6-C7 levels. (P- 30 thru P-39 at L.M ) Upon review of imaging studies, respondent s plan of treatment included a lumbar decompression and interbody fusion at the L4-L5 level with the use of allograft and autograft bone; the insertion of pedicle screws bilaterally at the L4 and L5 pedicles; and iliac-crest autograft, among other procedures. (Id. at L.M ) An MRI study on April 26, 2011, indicated end-plate changes. Dr. Przybylski noted that this patient had severe disc degeneration, for which it was uncommon to prescribe surgery. He said that there were other treatments available, such as physical therapy, exercise, weight loss and epidural injections. He also found, which he characterized as most unusual, a document entitled Patient Mutual Binding Arbitration Agreement dated May 3, 2011, as part of respondent s records. Surgery was performed at the NJSR Center. According to respondent s operative report dated May 12, 2011, a midline incision was made and a tissue flap was created to the left using Bovie and Metzenbaum scissors. The soft tissues were sharply dissected down to the ilium. (Id. at L.M ) The report further stated that the ilium was opened with a chisel, which Dr. Przybylski opined was an open procedure. The operative report further indicated that a scalpel was used to make a stab incision over the guide wire and blunt dilator, which Dr. Przybylski opined was minimally invasive surgery. An operative report of Sukdeb Datta, M.D., the co-surgeon, was signed on the same date of May 12, 2011, which Dr. Przybylski noted was identical to respondent s report. Both reports noted that once the mesh cage was inserted into the intervertebral space, allograft bone was then packed into the intervertebral space. Dr. Przybylski stated that PEEK, rather than a mesh cage, was the proper device for support. According to the operative report of November 14, 2011, respondent performed a left-sided posterior cervical foraminotomy and decompression at the C3-4 and C4-5 levels. (Id. at L.M ) 17
18 In another operative report, dated January 14, 2012, (Id. at L.M to 0202) respondent reported that he performed a provocative lumbar discogram at L2-3, L3-L4 and, what had already been fused, at L5. When Dr. Przybylski reviewed the discography, he noted that levels L2-3, L3-4, and L5-S1 were asymptomatic. Therefore, the L2-3, L3-4, and L5-S1 levels were not the source of pain. A discogram was performed on February 14, About a month later, the patient had a follow-up consult for neurophysiological testing of the lower extremities since there were ongoing complaints of pain in the lower back and legs. Respondent s treatment plan was for a series of three bilateral lumbar facet injections at the L3-L4, L4-L5 and L5-S1 levels. Respondent s findings, EMG and nerve conduction velocity (NCV), revealed no evidence of lumbar radiculopathy or peripheral neuropathy, which, according to Dr. Przybylski, was a normal study. He added that the testing performed by respondent should have indicated a paraspinal muscle abnormality since the patient had a prior surgery, but none was noted. On March 6, 2012, the patient had a follow-up consultation with respondent where he had complaints of back and leg pain. Respondent s treatment plan was for a lumbar decompression and interbody fusion at the L3-L4 and L5-S1 levels with interbody cages, iliac-crest autograft, and a staged insertion and extension of pedicle screws bilaterally extending from L3 to S1 on the left and right. According to the operative report of March 23, 2012 (Id. at L.M. 0223), respondent performed a lumbar decompression and interbody fusion with fusion cages at the L3-L4 level, use of the iliac-crest bone harvest, use of allograft bone, use of local autograft bone and use of bone-marrow harvest and reconstruction of the ilium using Vitoss (described as an artificial, ceramic-type material). Dr. Przybylski opined that an open procedure was done at the iliac crest. The balance of the surgery involved a minimally invasive procedure. Mesh cages were inserted. The surgery lasted a little less than two hours. On March 30, 2012, respondent performed another surgery, which Dr. Przybylski stated was identical to the previous surgery. He noted that in the details of the procedure 18
19 an incision was made over the crest using Bovie and Metzenbaum scissors, with a dissection carried down to the iliac crest, which he opined was an open procedure. He also opined that the rest of the procedure was minimally invasive for screw fixation. He also found that the description of an L5-S1 fusion noted at the beginning of the operative report was not contained in the body of the report, and found this to be a discrepancy. From the anesthesia record, Dr. Przybylski noted this surgery lasted approximately four hours. In a follow-up consultation on April 10, 2012, the patient reported no improvement in her ability to walk and in her ability to function. Respondent prescribed home rest and for the patient to return in four weeks. The patient was to obtain x-rays of the lumbosacral spine. Rather than return to respondent, the patient consulted with Kenneth Rieger, M.D., an orthopedic surgeon. In his report of May 30, 2012, Dr. Rieger noted that radiographs of the lumbar spine demonstrated an L3-S1 posterior instrumented fusion with anterior interbody prosthesis at L3-L4, L4-L5 and L5-S1. He further indicated, there does not appear to be any bone graft in the post-posterolateral gutters or anywhere for that matter. (Id. at L.M. 473.) He ordered a CT scan of the lumbar spine, which was done on June 6, 2012, and which noted, among other things, that there were end-plate erosion changes at the L3-4 and L5-1 levels. Also foreign-body granuloma was another possibility, which Dr. Przybylski mentioned was an inflammatory process. Dr. Przybylski opined the following deviations committed by respondent: 1. Respondent did not have the training for a fusion at the L4-5 level, which constituted a gross deviation. 2. In respondent s operative report, a PEEK cage was mentioned, but instead a mesh cage was used, which was improper for structural support. The use of a mesh cage as an interbody structural mechanism constituted a gross deviation. 19
20 3. Based upon respondent s lack of training, the performance of posterior C3-4, C4-5 decompressions constituted a gross deviation. 4. A lumbar fusion at L3-4 and L5-S1 was performed, although the discogram of January 14, 2012, and EMG study of February 14, 2012, showed normal findings. Since there were no clinical indications to proceed with fusion, the performance of surgery constituted a gross deviation. 5. Respondent was not qualified to perform an open iliac-crest harvest or a minimally invasive interbody fusion, which was a gross deviation. 6. The screw and mesh were improperly placed, which was a gross deviation in surgical technique. Consequently, a revision surgery was necessitated. 7. Respondent s lack of recognition of a foot drop was also a gross deviation. Although a foot drop could happen as a result of the type of surgery this patient had undergone, the surgery itself was unnecessary. Therefore, the resulting foot drop, the use of mesh cage at the L3-4 and L5-S1 levels, and the performance of three fusions were all gross deviations. Dr. Przybylski opined that the patient was at risk for nerve injury. He also noted that on March 23, 2012, and March 30, 2012, the patient underwent two separate surgeries, one week apart. He opined that there was no indication for either surgery, but performing two surgeries within a week subjected the patient to anesthesia twice and bone-graft harvesting, thus putting the patient at risk unnecessarily. He opined that this was also a gross deviation. patient P.M. Dr. Przybylski was asked to render an opinion about respondent s treatment of 20
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text:
Complete Chinese Vegetarian Cooking Guide
Chinese Vegetarian Cooking Guide
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text:
The Saucony Mirage 3 running shoe is the solution for runners seeking an incredibly lightweight, responsive ride with a touch of guidance. A re-engineered forefoot with deeper, more substantial flex grooves promotes a smooth and nimble ride. FlexFilm technology is welded onto the breathable seamless mesh upper to secure and stabilize the foot, simultaneously reducing layers to the shoe while increasing flexibility. Beveled, decoupled heel encourages a midfoot strike pattern. HydraMAX collar lining offers exceptional moisture management, as well as a great step-in feel. HRC strobel board adds enhanced cushioning and comfort. High-abrasion EVA midsole offers cushioning and durability. Heel ProGrid provides supreme cushioning. TPU Arc supplies increased support. XT-900® carbon rubber outsole delivers exceptional traction and long-lasting wear. Wt. 7.5 oz.
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text:
Johnny One Time - text
Musíš se nejprve přihlásit. Pokud nemáš účet, tak se zaregistruj
Songwriters: Frazier, Dallas; Owens, Sr., Arthur L;
So he told you that you're the dream that he's been searching for
And he told you that he's never met anyone like you before
And I can hear him telling you, your lips taste just like sherry wine
But did he tell you that he's known as Johnny One Time
Did he tell you that your heart will soon become
Another trinket on his bracelet of broken hearts?
Did he tell you that the morning sun will find you
Patching up your shattered pride and searching for the missing parts?
Did he tell you that the special love you're saving
Will disappear in flames of shame like mine?
Did he tell you that he's known as Johnny One Time
So he told you that he'd never lead your heart astray
And he told you that he'd love you forever and a day
And I can hear him telling you that he's the shy and bashful kind
But did he tell you that he's known as Johnny One Time
Did he tell you that your heart will soon become
Another trinket on his bracelet of broken hearts?
And did he tell you that the morning sun will find you
Patching up your shattered pride and searching for the missing parts?
And did he tell you that the special love you're saving
Will disappear in flames of shame like mine?
Did he tell you that he's known as Johnny one time?
Nezařazené v albu
- Afraid
- All In The Name Of Love
- Angel Flying Too Glose To..
- Are There Any More Real C..
- Are You Ever Coming Home
- Are You Sure
- As Time Goes By
- Back Street Affair
- Black Rose
- Blackjack County Chain
- Blue Hotel
- Blue Rock Montana
- Born To Lose
- Bring It On Down To My Ho..
- Cold November Wind
- Columbus Stockade Blues
- Congratulations
- Convict And The Rose
- Corrine Corrina
- Cowboys Are Frequently Se..
- Crazy Old Solider
- Dead Flowers
- Don't Go To Strangers
- Down In The Everglades
- Drivin' Nails In My Coffi..
- Fan It
- Fire And Rain
- Following Me Around
- Forever And Ever Amen
- Forgiving You Was Easy
- Fraulein
- Ghost
- Go On Home
- Goin' Home
- Goin' Steady
- Gold Dust Woman
- Good Timing Man
- Half A Heart
- Hallelujah
- Happiness Lives Next Door
- Have I Stayed Away Too Lo..
- Have I Told You Lately Th..
- Heart Of A Clown
- Heartaches By The Number
- Heartaches Of A Fool
- Heaven Or Hell
- Heenie Jeebie Blues
- Hesitation Blues
- Highwayman
- Homeward Bound
- How Long Have You Been Th..
- Husbands And Wives
- I Ain't Gonna Give Nobody..
- I Am The Forest
- I Been To Georgia On A Fa..
- I Can Cry Again
- I Can See Clearly Now
- I Don't Do Windows
- I Don't Feel Anything
- I Just Don't Understand
- I Just Drove By
- I Love You Because
- I Told A Lie To My Heart
- I Walk Alone
- I'd Trade All Of My Tomor..
- I'll Fly Away
- I'll Keep On Loving You
- I'll Pick Up My Heart And..
- I'll Walk Alone
- I'm A Memory
- I'm Gonna Lose A Lot Of T..
- I'm Looking For Blue Eyes
- I'm Sittin' On Top Of The..
- I'm So Lonesome I Could C..
- I'm Still Not Over You
- I've Got A Wonderful Futu..
- I've Loved You All Over T..
- I've Seen That Look On Me..
- If It's Wrong To Love You
- If You Could See What's G..
- If You Could Touch Her At..
- In God's Eyes
- In The Jailhouse Now
- Invitation To The Blues
- Island In The Sea
- It Will Come To Pass
- It Wouldn't Be The Same W..
- It's My Lazy Day
- It's Not For Me To Unders..
- Jingle Bell Rock
- Johnny One Time
- Just Walkin' Out The Door
- Kneel At The Feet Of Jesu..
- Last Thing On My Mind
- Laying My Burdens Down
- Let's Pretend
- Life Turned Her That Way
- Little Old Fashioned Karm..
- Live Fast Love Hard Die Y..
- Lookin' For A Feeling
- Love Has A Mind Of Its Ow..
- Lovin' Lies
- Loving You Was Easier
- Luckenbach Texas
- Maiden's Prayer
- Make The World Go Away
- Make Way For A Better Man
- Making Believe
- Mama Don't Let Your Babie..
- Mansion On The Hill
- Me And Paul
- Message
- Moonlight Becomes You
- More And More
- Mountain Dew
- My Heroes Have Always Bee..
- My Love For The Rose
- My Mary
- Natural To Be Gone
- No Love Around
- No Love At All
- No Reason To Quit
- Nobody Slides My Friend
- Nobody There But Me
- Old Five And Dimers Like ..
- Old Friends
- On The Road Again
- One Time Too Many
- One With The Sun
- Over You Again
- Pick Up The Tempo
- Please Come Home For Chri..
- Please Don't Talk About M..
- Pancho And Lefty
- Pressure Drop
- River Boy
- Run That By Me One More T..
- Seasons Of My Heart
- Senses
- Sentimental Journey
- Seven Spanish Angels
- Shame On You
- Sister's Coming Home - Do..
- Sky Train
- Slow Dancing
- Slow Movin' Outlaw
- Slowly
- So You Think You're A Cow..
- Some Other World
- Somebody Pick Up My Piece..
- Someday (you'll Want Me T..
- Somewhere In Texas Part 1
- Somewhere Over The Rainbo..
- Sorry Willie
- Still Water Runs The Deep..
- Sweet Dreams
- Sweet Jennie Lee
- Take It To The Limit
- Teach Me To Forget
- Texas On A Saturday Night
- That's Why I Love Her So
- The Troublemaker
- There Is No Easy Way (but..
- There Stands The Glass
- There'll Be No Teardrops ..
- They All Went To Mexico
- Till I Gain Control Again
- To All The Girls I've Lov..
- Today I Started Loving Yo..
- Tougher Than Leather
- Twinkle Twinkle Little St..
- Two Sides To Every Story
- Uncloudy Day
- Walkin'
- Washing The Dishes
- We Had It All
- What Do You Want Me To Do
- What Now My Love
- When A House Is Not A Hom..
- When We Live Again
- Where Do You Stand
- Where's The Show - Let Me..
- Whole Lotta Shakin' Goin'..
- Why Baby Why
- Why Do I Have To Choose
- Wild Side Of Life
- Will You Still Love Me To..
- Within Your Crowd
- Women Who Love Too Much
- Wonderful Future
- Wondering
- Workin' Man Blues
- Would You Lay With Me (in..
- I´m Moovin´On
- Willie nelson in amsterda..
- Willie nelson and dyan ca..
Willie Nelson texty
- 1. Always On My Mind
- 2. On The Road Again
- 3. Blue Eyes Crying In The R..
- 4. To All The Girls I've Lov..
- 5. Highwayman
- 6. Moon River
- 7. She Is Gone
- 8. Good Hearted Woman
- 9. They All Went To Mexico
- 10. Amazing Grace


text:
While pawrusing the 'net for ins'paw'ration, we came across this blog. http://stamping-ground.blogspot.co.uk/ Now this is just our kind of thing, a legitimate reason to make as much mess as possible....
Here is our desk
Here we are midway through making some charity cards. We've had to add a mini fold away table to the left of the picture, to hold blank cards and the previously made toppers box.
On the craft mat is a card in progress, made using our circle and scallop Nestabilities dies and some Prima flowers.
We also have the folder full of alphabets and sentiments lounging up against the silver magazine and ideas file to the back of the desk, and all our pro markers are waiting patiently to be used in colouring white sentiments.
Our Fiskars trimmer and extra blades are almost always taking up space on the desk whenever we're crafting. It's probably our most used tool.
Note the 'here's some we made earlier' cards on the window sill.
I guess it's not too messy really, for bears!
With love from the bears 🐻


text:
Birthday: Mar 4, 1678Website:
Member Favorites: 46
Antonio Lucio Vivaldi (Italian: [anˈtɔːnjo ˈluːtʃo viˈvaldi]; 4 March 1678 – 28 July 1741), nicknamed il Prete Rosso ("The Red Priest") because of his red hair, was an Italian Baroque composer, Catholic priest, and virtuoso violinist, born in Venice.
Recognized as one of the greatest Baroque composers, his influence during his lifetime was widespread over Europe. Vivaldi is known mainly for composing instrumental concertos, especially for the violin, as well as sacred choral works and over forty operas. His best known work is a series of violin concertos known as The Four Seasons.
(Source: Wikipedia)
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text: I was trying to find a good shopping list app for the Droid and thought I would pick the hive mind's brain. I downloaded a few over the weekend to try out, and didn't find one that fit my needs. I really want something that lets me enter aisle information into an item and sort by aisle. The apps I tried over the weekend were: My Shopping Lists OI Shopping List OurGroceries They were OK, but none of them really fit my need. Andy


text:
Dates of Publication in the Orlando Sentinel
Central Florida
Winter Park
Lake County
203(k) renovation loan is a fix for homes that may need repair
By Stef Donev, Interest.Com
A built-in breakfront is the answer to a dining-room storage problem
By Frances Ingraham Heins, Albany Times Union
Some trends of note
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Family's need for insurance shifts with life stages
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Take it easy around the house
By Real Simple Magazine
Single women -- and others -- will appreciate this book
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Bartering likely won't reduce tax
Don't shoulder a fund's load
By Marshall Loeb, MarketWatch.com Inc
DaimlerChrysler stock on steady climb
By Andrew Leckey, Tribune Media Services
Casa calories: Supersize it, please
By Marc Ramirez, the Seattle Times
Can the rant
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Renting storage space can be lesson in itself
By Steve Rosen, the Kansas City Star
Free lunches come with helping of fear
By Humberto and Georgina Cruz, Tribune Media Services
Save the planet and money too
By Nicole Tsong the Seattle Times
Clever and classic designs brighten choices in lighting
By Debbie Travis, King Features Syndicate
Chew on this fact: Termites love wood
By Jay Romano, New York Times Syndicate
If you want your tools to work for you, do some work yourself
By Al and Kelly Carrell, King Features Syndicate
Home Front
Clermont man's aunt finds reverse-mortgage nightmare
By Kenneth R. Harney, Washington Post, Writers Group
A basic model? Hardly
By Ruth Ryon, Los Angeles Times
Your money habits are often inherited
By Carolyn Bigda, Chicago Tribune
Progress Energy Inc.
Rockabye baby with creativity, personal style
By Lisa Boone, Los Angeles Times
Boat's motor baffles local repair shops
By Greg Dawson, Sentinel Columnist
Borrowing from a relative
By Marketwatch
Check out these whiz-bang options for today's home
By Newsday
Finding love in a `Singles' building
By Nicole Tsong,The Seattle Times
10 ways to cottage up your kitchen
Reuse, recycle, remodel
By Nicole Tsong, The Seattle Times
Revive your bathroom surfaces
By Stacy Downs, the Kansas City (Mo.) Star
Condo board needs to fill buyer in on new assessment
By Richard White, Special to the Sentinel
Pitch a party oasis
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High Point's high notes
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What's hip? How about simple, well-crafted items
By Charlyne Varkonyi Schaub South Florida Sun-Sentinel
Your Cost Of Living: Private School For A First-grader In The Southeast
Dyson designer's goal: Perfection in function and form
By Greg Morago, the Hartford Courant
L.A. wants to go vertical on smaller scale
By Janet Eastman, Los Angeles Times
Computer-driven funds gain in popularity
By Marketwatch
Made you look! Curb appeal is all about good impressions
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Green, safe and smart
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Trust allows gifts without all the taxes
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Tipper has taken her shots
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For a particular actor,timing is everything
By Joyce Wadler, New York Times News Service
A home for Eudora Welty's spirit
By Roger Mudd, New York Times Syndicate
Take your garage out of park
By Carrie Alexander, Special to the Sentinel
Transferring title to survivor
By Robert Bruss, Inman News
Home security can be a do-it-yourself project
By Gary Dymski, Newsday
Setting the Scene
Is that drain gunked up? Try baking soda, vinegar
Gardenias can be shy flowers in the garden unless you help them
By Tom Maccubbin, Special to the Sentinel
Backsplashes move to the foreground
By As Told to Laurie Squire Newsday
Colorful and imaginative plates? Must be a majolica design
By Ralph and Terry Kovel, King Features Syndicate
Would teens benefit from career counseling?
They share their lives -- but not their homes
By Jill Brooke, New York Times Syndicate
It will take more than caulk to fix cracked pool deck
Fishing Forecast
By Mark Blythe, Sentinel Staff Writer
Winning defense surprises the Suns
UF's Every receives award
Biffle fights off all contenders with impressive Darlington win
By Ed Hinton, Sentinel Staff Writer
Huggins will elevate K-State
By Mike Huguenin, Sentinel Columnist
To combat breast cancer, baseball looks so pretty in pink
By Jemele Hill, Sentinel Columnist
Devils stay alive with blowout win
James, Varejao rescue Cleveland
By Brian Windhorst, Akron Beacon Journal
Real crime lurks in shadows of this steroids mess
By David Whitley, Sentinel Columnist
Cavaliers, Mavs feel at home
By Deanna Gugel, Sentinel Staff Writer
De Biase gives Rollins a lift
By Jon Malavolti, Special to the Sentinel
Taylor tries to be leader for Jags
By Alan Schmadtke, Sentinel Staff Writer
Pistons hold back James' rise
By Tim Povtak, Sentinel Columnist
Wadkins takes control at Boeing
Nets favored
Jarrett to join Toyota next year
Marlins get 10th win
What we miss: the places
Cubs expect Wood to start Thursday vs. Nationals
Put ridicule on ice
Florida won't make SEC tourney
Hart ensures FSU matters in more than just football
By Mike Bianchi, Sentinel Columnist
Tough Read
By Brian Schmitz, Sentinel Staff Writer
Next On Deck . . .
By Chris Olds, Sentinel Staff Writer
Mauresmo ousted
Liverpool wins FA Cup on kicks over West Ham
Lake Howell adds to area's tradition
Spruce Creek falls short
By Jeff Berlinicke, Special to the Sentinel
Halladay tosses 3-hitter
Great Babe/ Barry debate rages
By Mike Berardino, South Florida Sun-Sentinel
Grow up, Willis
Spanish River turns back Lake Howell in 5 games
By Shannon J. Owens, Sentinel Staff Writer
New Lions looking cowardly
By Chris Harry, Sentinel Columnist
What's hidden in the EADA?
By Alan Schmadtke, Sentinel Staff Writer
The judge, the jury and the murders all figure in a frenzy of escapist fun
By Reviewed By Ann Hellmuth Sentinel Staff Writer
What's Happening
By Marie Blom, Sentinel Staff Writer
Teacher-model to keep job
View worth considering
Focus On Safety: Building Fair Draws Crowd
World-class vision
EPA wants agency to clean debris before its removal
Maybe high gas prices will conserve water
By Bill Cadiz
City helps residents envision future
By Mark Pino, Sentinel Staff Writer
Remembering a writer who took stands
By Mark Pino, Sentinel Columnist
Nepal's government aims to curtail king's powers
Salary boost can help fill county jobs
By Periwinkle
Make new growth pay its way
By Periwinkle
Police say 2 teens bragged online about several blazes
. . . unrelated
My bad housing decision
Art, Authors And Eats: Library Plans Shindig
Making connections . . .
Kristian Beach
By Lori Carter, Special to the Sentinel
Spring Cleaning? Pot Found Along Road
Sometimes, Volusia must go its own way
By John E. Evans, Special to the Sentinel
Puerto Rico decision
Experts seek help counting birds
By From Staff Reports
Iranian president says he's willing to talk about nukes
Police Log
Open minds
By Copper
Polk residents can speak out on growth planning
By Amy L. Edwards, Sentinel Staff Writer
Our kids are flunking . . .
By George Diaz, Sentinel Columnist
Blog to give UK residents a voice
By Kelly Griffith, Southwest Bureau Chief
Cuba crackdowns are a sign of perceived strength
By Paolo Spadoni, Special to the Sentinel
Born to be wild on scooter ride out to grab milk
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Rare candor about budget-busting: Is anyone listening?
By David Broder, Washington Post Writers Group
All safe on Kennedy flight after lightning hits plane
Palestinian prisoners' plan for statehood dismissed
Check executive power
By Sage
Text Enhancement Log
McCain addresses dissent on Iraq war
Corrections & Clarifications
Larger than life
What's Happening
Residents can speak out on subdivisions
Philharmonic's music to float at The Springs
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Suit seeks to keep tiny owl on endangered-species list
New blog will offer UK visitors a voice
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NAACP unhappy about plan to cut Rev. King holiday
Thousands protest moving U.S. bases in South Korea
Politics can mar hospital discussions
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Mudslingers Unite
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Trial to start in deputy's death
Orlando Chorale ready to make `Joyful' noise
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Golf, clambake to benefit marine center, charity
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Canker scare may halt citrus shipments
By Amy C. Rippel and Jerry W. Jackson, Sentinel Staff Writers
Waterford class gives winnings to kids' charity
Campbell rings true
Going To Bat For Needy: Bring Canned Food
Schools need to help
As life calms down, artist finds time for expression
By Sara Sheckler, Special to the Sentinel
Cancer Institute opens treatment center in Clermont
Life's Treasures seeks volunteers
Volunteer Spotlight | Jerry Tautfest
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Mount Dora chamber gears up for summer doldrums
By Rosalind Jennings, Special to the Sentinel
Fatal bird flu wanes in hard-hit nations
By Donald G. Mcneil Jr., the New York Times
best sellers
Break-in try disrupts peace, not humanity
By Kelly Griffith, Sentinel Columnist
Retiree put down roots after years of service in Air Force
By Linda Florea, Sentinel Staff Writer
Workforce to give employer awards
Don't blame mayor for all of Deltona's woes
By Mike Lafferty, Sentinel Columnist
Slaying is sad reflection of times
Polk commissioners to meet with FEMA
Get Back To Nature: Lake Louisa Field Day
Academic All-Star | Daniel Bathke
Senior Spotlight | Lawrence Kehne
By Lori Carter, Special to the Sentinel
Man kills 2 children, then himself in Ohio standoff
Celebration residents can learn about incorporation
Families of mentally ill face dilemma
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Price boost slows use of bio-diesel
5,000 French farmers decry repopulation of bears
Parental alienation gets a day
By Kathleen Parker, Sentinel Columnist
Alzheimer's information
Teacher of the Week | Suzette Lopez
By Joseph Rassel, Sentinel Staff Writer
Battle over dog anti-inflammatory echoes Vioxx debate
By Marc Kaufman the Washington Post
Every morning I notice holes in my lawn and garden. What could it be making them?
By Sherry Boas, Special to the Sentinel
The deft art of being a politician
By Scott Maxwell, Sentinel Columnist
Deaths | Central Florida
Teen's 1883 diary opens up area's sweet past
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Longwood bank readies new building
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Next stop, Kuwait
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Upscale lounge makes Clermont council ultra-careful
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Minneola manager gets graded
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Polk students are dreamers, doers
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Hering not seeking Keller's seat -- in '06
Brevard alters graduation sites after church-state suit
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Advocate puts faith into daily actions
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In The Line Of Duty
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Surveys show drop in rape, sex crimes
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Mother wants public to fight development
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Police Log
Rowdy Friends: Concert Set For May 28
Space rock could make 2036 a killer year
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Winter Park mayor ruffles feathers
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A land to call their own
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Slow down if passing a cop -- it's the law
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Polk hires Carolinian as deputy manager
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Sancho on quest for election reform
By Christopher Sherman, Tallahassee Bureau
Condo conversion vs. sugar cookies
Fishing tourney to help Meals on Wheels
It's hard to detect ovarian cancer
By Richard T. Bosshardt, Special to the Sentinel
Thanks for the roof
A bright spot in `Century Club'
By Lori Carter, Special to the Sentinel
Upscale casual cafe is a drive in right direction
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Scholarships awarded
Cortes the killer, the lover
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Tourist-tax income fails to match take in 2005
By Monica Scandlen, Special to the Sentinel
The gift of a mother's touch
All-nighter 1 last blast of safe fun for seniors
By Rosalind Jennings, Special to the Sentinel
Water lines
Kids, teens steeped in the outdoors life
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Teacher of the Week | Anne-Margret Strudgeon
Officials find gator that killed Davie student
By Brian Haas South Florida Sun-Sentinel
Army keeps troubled soldiers in ranks, investigation finds
By Lisa Chedekel and Matthew Kauffman, the Hartford (Conn.) Courant
Bilingual ballots? Unnecessary
Sandoval is top lifter
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Harris leads lifters
By Joe Williams, Sentinel Staff Writer
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By Debbie Barr, Special to the Sentinel
Good eating, fine art
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All For Charity: It's A Challenge
Friends try to go with the cash flow
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By Steven D. Barnes, Special to the Sentinel
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By Eleanor Foerste, Special to the Sentinel
Middle class struggles to buy homes
By April Hunt and Jerry W. Jackson, Sentinel Staff Writers
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Mr. Abstract Random
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Toni Jennings makes it clear -- no plans to seek another office
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By Tammie Wersinger, Sentinel Staff Writer
Seattle exhibit juxtaposes masterworks
Kid-friendly capital: Hit the heights
Get the big picture before you take off
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Traveling picture shows
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Nat King Cole documentary is almost forgettable
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HOUSTON - A Denver-based company has purchased close to 200,000 sf of industrial space in Houston as part of a larger deal spanning across Texas, Kentucky and Oklahoma.
Industrial Property Trust purchased the building at 302 West Rd., near the convergence of Beltway eight and I-45, for $59.9 million, the Houston Chronicle reports.
The 190,565-sf building is fully leased to Victory Packaging, a Houston-based packaging services and distribution company.The deal will boost Industrial Property Trust's Houston presence significantly.
Before the deal, it had grown its portfolio in the city to 1.7 million sf, according to the Chronicle.
In addition to the Houston property, Industrial Property Trust scooped up four other industrial buildings occupied by Victory Packaging, according to Fort Worth Business. The five buildings total more than 1 million sf:• a 247,861-sf building at 1610 Cornerway Blvd. in San Antonio• a 327,733-sf building at 15101 Grand River Rd. in Fort Worth• a 150,000-sf building at 7400 Trade Port Dr. in Louisville• a 80,400-sf building at 4949 Southwest 20th St. in Oklahoma City
Our twice-weekly e-newsletter provides a quick overview of Texas real estate markets. Because your time is valuable.


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Seeing as how this topic is bound to come up again in this blog – and maybe end up becoming a major theme (although I hope not) – I figured I'd start it now… We're looking for health insurance. In the USA. And it's not looking great.
Before we left for our adventures we were covered through the school district. Since I worked as a teacher I was able to cover the whole family for a very reasonable amount. It was decent coverage. Life was good.
Once we left the USA, we converted to a high-deductible policy through IMG that was designed for expats and long-term travelers. We've never had reason to file a claim so I have no idea if they are any good or not (have heard good reports from other travelers), but knowing that we have a policy has given me tremendous peace of mind over the years. (I've written about health insurance here)
Now we're back in the USA and hoping to stay here. IMG stipulates that we be out of the country for at least six months each year in order to continue coverage, so we had hoped to find something else. So far, my (admittedly very basic) search has led me nowhere.
Seeing as how we are covered until January 1, 2012 I haven't spent a lot of time on this issue yet, but I have to say I'm stunned. Truly blown away. Yes – I've read loads of articles about how unaffordable health insurance is in the USA, but I didn't "get it" – until now.
Right now we are living on the income generated by rental properties we own and the small amount this website is generating. Our needs are basic and we live frugally. We're currently living on about half of what I used to make as a teacher – but I'm not complaining. At this point in time, we prefer the freedom of this life to the constraints of a classroom.
A quick check of health insurance policies floored me – if we were to switch to another policy, we would be paying every penny we have coming in for insurance. EVERY PENNY! JUST FOR HEALTH INSURANCE! That would leave nothing to buy food, nothing to pay electricity, not a single red cent for clothes or bike parts or – God forbid – to see a doctor. Every dollar we bring in would go for paying the health insurance.
Seeing as how we aren't bringing in a lot, I wondered if maybe we would qualify for low-income health insurance. Holy Mother of God!! We would have to be living on less than $382 for a family of four to qualify! That's just downright insane. NOBODY can live for less than $382/month for four people in the USA! You just can't do it.
At this point we don't know what we will do come January. Our hope is that we'll find some sort of affordable policy out there. Maybe one of us will try and find a job with benefits just so we can get health insurance. Maybe we'll leave the country and hit the road again.
I don't know, but it makes me very, very angry that we may have to leave the United States of America – our own country – because we can't afford health insurance here. I can't believe that is a very real possibility in our lives.
Maybe we'll go back to Nicaragua where they have great, free medical care. But dang – I had hoped to live happily ever after in the US of A.
One of the ways you can help us out is by clicking through our site to these vendors if you need something from them. Your shopping experience won't be any different but they somehow track that you arrived at them from our site and we'll get a few pennies from every purchase you make. If you need anything from any of these stores, we would hugely appreciate it if you click from our site! We've got a special page set up here with all the ads.


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STEM camp fosters learning
Fifteen middle-schoolers gathered at the breakwall in Two Harbors Friday morning for the culmination of a week-long STEM camp.
Science teachers Penny Juenemann and Mark Schlangen, shop teacher Kyle Chalupsky and math teacher Brian Rauvola collaborated on the project, which was a hit with all the students.
Eighth-grader Sam Knight, said he enrolled in the camp because he wants to be an engineer.
"We call him Einstein," said his classmate, Nathan Campbell. Campbell said he's unsure of what he will pursue after high school, but the course "definitely increased" his interest in engineering.
Jake Wilmott, another eighth-grader, said he was amazed by what the group was able to build in just a week.
"I'm especially surprised we got the canoes done so fast," he said.
Emily Sweatt, also in eighth-grade, wants to study English or literature after high school, but still found the STEM camp interesting.
"I thought it would be fun and my friend said she would sign up with me," Sweatt said of her reasons for attending.
As for what she learned in the week-long course, many things came to mind — biology, soldering, physics — plus a lesson the class learned the hard way.
"We learned that epoxy is spontaneously combustible," she said, sharing the story of the moment their epoxied canoes almost turned into firewood. Despite the close call, the boats survived and floated. The underwater vehicles performed well, too, and the students even found a bicycle that had been sent to a watery grave, resting near the breakwall's edge.
"Things really came together nicely," Rauvola said.