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Paulsen v. Illinois Department of Professional Regulation

November 1, 2000


Appeal from the Circuit Court of the 10th Judicial Circuit, Peoria County, Illinois, No. 98--MR--9 Honorable Richard E. Grawey, Judge, Presiding.

The opinion of the court was delivered by: Justice Slater

The Illinois Department of Professional Regulation (the Department) placed John Paulsen's license to practice medicine on probationary status for two years on the ground that he had committed gross negligence in the practice of medicine (225 ILCS 60/22(A)(4) (West 1992)). The circuit court affirmed this decision in an administrative review proceeding. On appeal, Paulsen contends that the Department's decision is arbitrary and capricious and against the manifest weight of the evidence. For the reasons that follow, we affirm.

In 1989, Paulsen treated John Clauser for two abdominal hernias. An abdominal hernia is a protrusion of internal tissue through a defect in the abdominal wall. While treating the hernias, it was discovered that Clauser suffered from a gall stone, cirrhosis of the liver, portal hypertension, and hypersplenism. Portal hypertension is an increase in blood pressure in the portal vein, the primary blood vessel bringing blood to the liver for removal of toxins. The condition is often symptomatic of cirrhotic liver and may cause increased blood pressure in, and dilation of, other collateral blood vessels. Hypersplenism is a malady of the spleen whereby, among other things, elements of the blood necessary to coagulation, such as platelets, are consumed by the spleen resulting in coagulation disorders collectively known as "coagulopathy."

In addition to repairing the hernias, Paulsen removed Clauser's spleen and gall bladder. Paulsen accomplished these tasks by means of a laparotomy, i.e., a direct incision into the affected area of the abdomen. In his notes, Paulsen observed that the operation had gone well despite Clauser's cirrhosis and "severe" portal hypertension.

In August 1991, another physician treated Clauser for pancreatitis (inflammation of the pancreas) and peritonitis (inflammation of the peritoneum). The peritoneum is a membrane located between the inner abdominal wall and the outer surfaces of the abdominal organs.

At discharge, the treating physician stated that Clauser's prognosis was "somewhat dismal" because he had "hepatic [liver] insufficiency, marked esophageal varices, and will most probably develop further complications in the future." A varix is a dilated blood vessel. An esophageal varix is a dilated blood vessel of the esophagus.

On June 21, 1993, Clauser was admitted to the hospital after experiencing acute abdominal pain. Paulsen determined that Clauser was suffering from a one-to-two-centimeter abdominal, ventral hernia. A portion of Clauser's peritoneum was protruding through his abdominal wall. After discussing the matter with Paulsen, Clauser elected to undergo a laparoscopic repair of the hernia. In a laparoscopy, the surgeon inserts tubes, or "trocars," into the abdomen through which he introduces an endoscope to observe the interior of the abdomen and surgical tools to repair defects in the abdominal wall.

On July 6, 1993, despite the fact that he had not reviewed the records of Clauser's 1991 treatment, Paulsen began to repair Clauser's hernia laparoscopically. Upon inserting four 10-to-12-millimeter trocars into Clauser's abdomen, Paulsen observed several adhesions of the peritoneum to the abdominal wall. In order to conduct a search for other hernias, it was necessary to remove the adhesions by separating the adhering sections of the peritoneum from the abdominal wall. After accomplishing this task, Paulsen discovered what might have been another small ventral hernia near the targeted hernia. It is unclear from the record whether Paulsen ever definitively identified this apparent defect as a secondary hernia or undertook any efforts to repair it.

During the operation, Clauser began experiencing more bleeding than Paulsen had anticipated. Paulsen converted the laparoscopy into a conventional laparotomy to gain sufficient access to Clauser's abdomen so that he could properly ligate any hemorrhaging blood vessels. Paulsen ligated several blood vessels, placed a surgical patch over the area of the repaired hernia, and concluded the operation. Clauser lost 2,000 cubic centimeters of blood during the operation. Clauser's normal blood volume was 6,000 cubic centimeters.

During the morning of July 7, after Clauser had received several blood transfusions, it became evident that he was still bleeding internally. Paulsen undertook another surgery to stop the internal hemorrhaging. After Paulsen ligated several more blood vessels, the bleeding appeared to cease.

Subsequently, however, Clauser developed a condition known as disseminated intravascular coagulation (DIC). DIC is a blood coagulation disorder characterized by a reduction in the elements necessary to blood clotting due to their use within blood vessels. In the late stages of DIC, hemorrhaging is profuse and widespread. The development of DIC is a risk for patients with hepatic cirrhosis. Latent DIC is sometimes activated by the trauma associated with surgery.

Clauser's condition stabilized. However, by that time, Clauser had developed adult respiratory distress syndrome. On July 20, Clauser died of pulmonary failure.

In March 1996, the Department filed its complaint alleging that Paulsen had committed gross negligence in the practice of medicine (225 ILCS 60/22(a)(4) (West 1992)). In particular, the Department alleged that the following acts or omissions, among others, were evidence of Paulsen's recklessness or carelessness: (1) failing to do preoperative blood clotting studies; (2) failing to obtain a complete preoperative evaluation; and (3) performing a laparoscopic repair rather than a conventional laparotomy.

The matter proceeded to a hearing. At the hearing, Paulsen testified that he had completed 150 hours of continuing medical education (CME) concerning laparoscopic techniques by the time of Clauser's surgery. He had employed laparoscopy to perform approximately 250 cholecystectomies (gall bladder removals), 30 to 40 repairs of inguinal hernias (hernias in the groin region), 3 repairs of ventral hernias, and an appendectomy. Paulsen recalled that he had performed his first laparoscopic ventral hernia repair in March ...

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