BEFORE THE ARIZONA VETERINARY MEDICAL EXAMINING BOARD
IN THE MATTER OF: Case Nos.: 15-77, 15-103, 18-26, 18-54 | and 18-57 REFAAT ISHAK, DVM, AMENDMENT TO CONSENT ‘ Holder of License No. 4666 AGREEMENT,
FINDINGS OF FACT, CONCLUSIONS OF LAW, AND ORDER FOR PROBATION
For the practice of Veterinary Medicine in the State of Arizona,
Respondeni.
Respondent Refaat Ishak, DVM, and fhe Arizona Veterinary Medical Examining Board hereby agree thai provision Number 3 of the Order contained in the attached Consent Agreement signed by Respondent on December 10 / 2018, in Case Nos. 15-77, 15-103, 18-26, 18-56 and 18-57 shall be amended as
follows,
3. Respondent must refer clients fo another licensed veterinarian if
resulis from anytesis are positive/abnormal.
All other Recitals, Findings of Fact, Conclusions of Law, and Order provisions contained in the attached Consent Agreement remainine same and
in effect.
DATED this 22 day of December 2018.
YY
eetadk ae DVM
fo ; ISSUED THIS _f’7”_ DAY OF ee 2018.
FOR THE BOARD: ARIZONA STATE VETERINARY MEDICAL EXAMINING BOARD
JIM LOUGHEAD-Chairperson
(/ ie By i pAatir— eee
Original of the foregoing filed this_/7* day of _ddezmher 2018 with:
Arizona State Veterinary Medical Examining Board 1740 W Adams St Phoenix, AZ 85007
Copy of the foregoing mailed by certified U.S. mail. this /7 “day of _abeceméer _, 2018 to:
Refaat Ishak, DVM ADDRESS ON FILE Respondent
David L. Stoll
Beaugureau, Hancock, Stoll and Schwariz, P.C. 302 East Coronado Road
Phoenix, AZ 85004
Attorney for Respondent
Larry Cohen
The Cohen Law Firm P.O, Box 10056
Phoenix, AZ 85012 Attorney for Respondent
By: ft onine Board Staff
BEFORE THE ARIZONA VETERINARY MEDICAL EXAMINING BOARD
Case Nos.: 15-77, 15-103, 18-26, 18-56 and 18-57
CONSENT AGREEMENT, FINDINGS OF FACT, CONCLUSIONS OF LAW, AND ORDER FOR PROBATION
IN THE MATTER OF:
REFAAT ISHAK, DVM,
Holder of License No. 4666
- For the practice of Veterinary Medicine in the State of Arizona,
Respondent.
Consistent with the public's interest, statutory requirements and responsibilities of the Arizona State Veterinary Medical Examining Board (“Board”), and pursuant to A.R.S. §§ 32-2201 ef. seq., A.R.S. § 32-2234(E), and A.R.S. § 41-1092.07(F}(5}), Refaat Ishak, DVM, (“Respondent”) and the Board enter into this Consent Agreement, Findings of Fact, Conclusions of Law and Order for Probation as a final disposition of Case Roe 15-77, 15-103, 18-26, 18-56, and 18-57.
RECITALS
Respondent understands and agrees that:
if Any record prepared in this matter, all investigative materials prepared or received by the Board concerning the allegations, and all related materials and exhibits may be retained in the Board's file pertaining to this matter.
Zz. While Respondent has the right to a formal administrative Reding at which Respondent can present evidence and cross examine the State's wiinesses, Respondent agrees to the issuance of the attached Order and
Respondent hereby irrevocably waives his right to such a formal hearing
concerning these allegations and irrevocably waives his right to any rehearing or judicial review relating to the allegations contained in this Consent Agreement. Respondent further waives any and all claims or causes of action, whether known or unknown, that Resoondent may have against the State of Arizona, the Board, its members, offices, employees and/or agents sasnecut of this matter.
3. Respondent understands that he has the right to consult with an attorney prior to entering into this Consent Agreement and such consultation has either been obtained or is waived.
4, Respondent acknowledges and agrees that upon. signing this Consent Agreement and returning it to the Board's Executive Director, Respondent may not revoke his acceptance of this Consent Agreement or make any modifications to it. Any modifications of this original documeni are ineffective ena void unless mutually approved by the parties in writing.
5: The findings contained in the Findings of Fact portion of this Consent Agreement are conclusive evidence of the facts stated herein and may be used for purposes of determining sanctions in any future disciplinary matter.
6. This Consent Agreement is subject to the Board’s approval and will be effective only when the Board accepts if. In the event the Board, in its discretion, does not approve this Consent Agreement, this Consent Agreement is withdrawn and shall be of no evidentiary value, nor shall it be relied Upon or introduced in any disciplinary action or judicial action by any party hereto, except that Respondent agiees that should the Board reject this Consent
Agreement and this case proceeds to hearing, Respondent shall assert no claim
that the Board was prejudiced by its review and discussion of this document or of any records relating thereto. |
is Respondent understands that once the Board approves and signs this Consent Agreement, it is a public record that may be publicly disseminated as a formal action of the Board.
8, lf any part of the Consent Agreement is later deciared void or otherwise unenforceable, the remainder of the Order in its entirety shall remain in full force and effect.
9. Respondent acknowledges that any violation of this Consent Agreement constitutes unprofessional conduct pursuant fo A.R.S, § 32-2232 and may result in disciplinary action pursuant fo A.R.S. § 32-2234.
10. Respondent admits to the following Findings of Fact, Conclusions of Law and Order.
11. Respondent and the Board also enter into this Consent Agreement as a final disposition of Respondent's pending appeal of the Board's Order in Case Nos. 15-77 and 15-103 pursuant to Ishak v. Arizona Veterinary Medical Examining Board, Arizona Court of Appeals Case No, 1 CA-CV 17-0682. Respondent agrees to the attached Order and agrees to immediately withdraw his pending appeal. Respondent waives his rights to .any further
judicial review of any of these actions.
DATED this_%f) day of ae Ce pee. 2018.
Refaat Ishak, DVM ss
Based on the evidence before it, the Board issues the following Findings of Fact, Conclusions of Law and Order:
FINDINGS OF FACT |
1. The Board is the duly constituted authority for the regulation and control of the practice of veterinary medicine in the State of Arizona. |
2 Respondent holds license number 4666 for the practice of veterinary medicine in the State of Arizona.
Se On May 14, 2016, after an administrative hearing was held before the Board in Case Numbers 15-77 and 15-103, the Board issued an Order to Dr. Ishak for a sixemonth suspension under a stayed revocation, followed by five years of probation under a stayed suspension, subject to various terms and conditions, including a practice restriction from all surgeries indefinitely. A copy of the Order is attached as Exhibit “1” and is incorporated herein by reference.
4, Thereafter, on October 3, 2017, in Case No. 18-26, the Board received a new complaint that Respondent overmedicated a dog, performed diagnostics without medical justification, inappropriately prescribed hydromorphone for pain control, and that pain medication was noi dispensed at discharge. A copy of the Board's Investigative Commitiee Report in Case No. 18-26 is attached as Exhibit Wg”
on On January 25, 2018, in Case No. 18-56, the Board eeeved fe second complaint that Respondent violated his Board Order in Case Nos. 15-77 and 15-103 by extracting teeth and/or performing surgery during two anesthetic procedures involving a dog and a cat. A copy of the Board's Investigative
Committee Report in Case No. 18-56 is attached as Exhibit “3”.
6. On January 26, 2018, in Case No. 18-57, the Board received a third complaint that Respondent failed to recognize a dog's paresis upon discharge, failed to provide copies of medical records in 10 days, and failed to ebiaih signed authorization from the pet owner before euthanasia was performed. A copy of the Board's Investigative Committee Report in Case No. 18-57 is _ attached as Exhibit “4”, |
fe Respondent admits to the Findings of Fact.
CONCLUSIONS OF LAW Case No. 18-26:
1, The conduct and circumstances described in Findings of Fact No. 4 constitutes a violation of A.R.S. § 32-2232(22) Medical Incompetence in the practice of veterinary medicine for performing. diagnostics without medical justification indicating that Respondent lacked sufficient knowledge; inappropriate use of hydromorphone for pain control where the method of administration left large windows of pain present; and pain medication was not dispensed at discharge in or around August 21, 2017.
Case No. 18-56:
2. The conduct and circumstances described in Findings of Fact No. 5 constitutes a violation of A.R.S. § 32-2232(18) for Violating the Board’s Order in Case Nos. 15-77 and 15-103 by extracting teeth and/or performing surgery during two anesthetic procedures involving a dog and a cat on December 18, 2017, and December 29, 2017, respectively, where the Board's Order restricted Respondent from performing any and all surgeries indefinitely including soft
tissue, orthopedic, and oral surgeries, including dental extractions.
Case No. 18-57: |
<i The conduct and circumstances described in Findings of Fact No. 6 constitutes a violation of A.R.S. § 32-2232(12) as it relates to A.A.C. R3-11-501(1) for failure to provide professionally acceptable procedures for not recognizing the dog's paresis on discharge on December 21, 2017, and again on December 22, 2017, when dropped off for euthanasia where medical records stated dog was ambulatory; A.R.S. § 32-2232(12) as it relates to A.A.C. R3-11-501(8) for failing to provide copies of medical records within 10 days of the pet owners request; and A.R.S. § 32-2232(21) as it relates to A.A.C. R3-11-502(F) for failure to
obtain signed authorization from the pet owner before euthanasia was
performed. 4, Respondent admits to the Conclusions of Law. 5. The conduct and circumstances described in the Findings of Fact
constitute sufficient cause pursuant to A.R.S. §§ 32-2201 ef. seq., A.RS. §32- 2234(E), and A.R.S. § 41-1092.07(F)(5) to take disciplinary action against Respondent's license to practice as a doctor of veterinary medicine in the State
of Arizona.
ORDER
Based upon the foregoing Findings of Fact and Conclusions of Law, IT IS ORDERED that Respondent's license be placed on PROBATION for a minimum period of ten (10) years subject to the following practice restrictions:
1s Respondent is prohibited from performing any veterinary services
with the exception of the following:
a. Euthanasia procedures that are not based upon his diagnosis but rather on a diagnosis made by another veterinarian or at an owner's request.
b. Pre-vaccination examinations; vaccinations; blood draws related to heartworm, FIV/FeLV tests and other Snap tests that are performed in-house; microchipping; nail - trims; anal gland expressions; and providing/dispensing heartworm preventive care if appropriate testing had occurred and/or medical records from another provider indicate the medication is appropriate.
c. Write prescriptions and/or dispense heart worm prevention and flea and tick contro! medications and may send out fecal exam tests to external labs, with the understanding that the owner must be instructed to follow up with their regular veterinarian in connection with any abnormal findings or results.
on Respondent may conduct his practice from a fixed facility or from a mobile unit. |
3 Respondent must refer clients to a full-service veterinary practice if results from any test are positive/abnormal.
4, These practice restrictions shall remain in place for a minimum of ten (10) years. Respondent may petition the Board for modification annually.
D: Respondent is prohibited from performing any veterinary services beyond those authorized under this Consent Agreemeni. ee, ee bid
ISSUED THIS _/7 M DAY OF Abeer 2018.
FOR THE BOARD: ARIZONA STATE VETERINARY MEDICAL EXAMINING BOARD
JIM LOUSHEADS -Chairpeyson
€
By V cetabe Whidadots. Victoria Whitmore, Executive Director
Original of the foregging filed this_/77~_ day of Wecemébt~ 2018 with:
Arizona State Veterinary Medical Examining Board 1740 W Adams St Phoenix, AZ 85007
Copy of the foregoing mailed by certified U.S. mail. this_ /7* day of _Mezndee __, 2018 to:
~ Refaat Isnak, DVM
Adaress on file Respondent
David L. Stoll
Beaugureau, Hancock, Stoll and Schwariz, P.C. 302 East Coronado Road
Phoenix, AZ 85004
Attorney for Respondent
Larry Cohen
The Cohen Law Firm P.O. Box 10056 Phoenix, AZ 85012
Attorney oe eel
‘Boar Statt DOC#7516216
EXHIBIT |
BEFORE THE ARIZONA STATE VETERINARY MEDICAL EXAMINING BOARD
IN THE MATTER OF: Case Nos.: 15-77 and 15-103
) REFAAT ISHAK, DVM : FINDINGS OF FACT, CONCLUSIONS OF LAW Holder of License No. 4666 \ AND ORDER } }
For the practice of Veterinary Medicine in the State of Arizona,
Respondeni.
On March 16, 2016, the Arizona State Veterinary Medical Examining Board (“Board") conducted a Formal Hearing regarding Refaat Ishak, DVM (“Respondent”). The proceedings in this matter are governed by A.R.S. § 32- 2234 {A}. Respondent was advised of his right to legal counsel by letter, appeared, and participated in the Formal Hearing and was represented by his attorney, David Stoll. The Board reviewed all documents submitted regarding this matter, took testimony from: {1} Ms. Tracy Riendeau, Senior Medical Investigator of the Arizona State Veterinary Medical Examining Board; (2) Brian Sidaway, DVM, expert witness; and (3) Kathleen Rowe-Guthrie, DVM. The Board proceeded as is permitted by A.R.S. § 32-2234 (A). |
Following the Formal Hearing and the Board's discussion of the information and documents submitted, the Board determined that Respondent's conduct constituted unprofessional conduct pursuant to:
A.R.S. § 32-2232 {11} Gross incompetence; A.R.S. § 32-2232 (12) as it relates to R3-11-501 (3); A.R.S. § 32-2232 (22) Medical incompetence in the practice of
veterinary medicine; and administrative violation of A.R.S. § 32-2233 (B}(3).
15-77 & 15-103, Refaat Ishak, DVM
he
15-103:
A.R.S. § 32-2232 (11) Malpractice, gross negligence and gross incompetence and A.R.S. § 32-2232 (22) Medical incompetence in the practice of veterinary medicine. After considering all of the information and testimony, the Board
issues the following Findings of Fact, Conclusions of Law and Order, (“Order”).
FINDINGS OF FACT 1. Respondent is the holder of License No, 4666 issued on January 17, 2008, and is therefore auiheried to practice the profession of veterinary medicine in the State of Arizona. Case No. 15-77: 2. On November 14, 2014, "Ledge," a 4-year-old male German Shepherd dog was presented to Respondent with a possible anal gland abscess. Upon
exam, the dog had a weight = 92 pounds, a temperature = 100.1 degrees, a
heart rate = 124b pm, and a respiration rate = 3lrom. Respondent alleged he
could not perform a rectal due to the dog's temperament caused by pain in that area. The anal gland area was swollen with severe dermatitis and painful when tail was raised, Respondent recommended cold laser therapy along with medical treatment to control the swelling and inflammation. Complainant declined the laser therapy and the dog was discharged with the following:
-a. Rimadyl 100mg,-.20 tablets; give one tablet orally every 12 hours
as needed for pain; and b, Baytil 186mg, 20 tablets; give two tablets orally every 24 hours
until gone.
15-77 & 15-103, Refaat Ishak, DVM
No
3, According to Complainant, Respondent did not recommend an Elizabethan collar, but she elected to purchase one to ensure the dog was not
licking the area.
4. On November 25, 2014, the dog was presented to Respondent for a
recheck. Complainant reported that the area was not improving, The dog had a weight = 97.8 pounds; no temperature, heart rate, or respiration rate was recorded. Respondent noted that both anal glands were ruptured with purulent hemorrhagic discharge. Respondent advised that they could do laser therapy and see how the area responds; surgery was also an option to clean the area and remove the anal glands, however, it was recommended to control the infection before performing surgery. Respondent gave a poor to guarded prognosis and advised Complainant to expect long term management. Respondent documented that he recommended referral to a dermatologist; Complainant denies a referral was offered at any fime. According to Respondent, he recommended sedation to perform a rectal exam; Complainant declined and wanted to wait fo see how the dog responded to the medical treatment. The dog was discharged with Simplicef 200mg, 20 tablets with instructions to give two tablets orally every 24 hours until gone. |
5. On November 26, 2014, a follow-up call was made to check on the dog. There were no other calls placed to Complainant to check on the dog.
6. On January 13, 2015, the dog was presented to Respondent for evaluation of the anal area. Upon exam, the dog had a weight = 93 pounds, a heart rate = 130bpm and a respiration rate = 60rpm; no temperature noted. Respondent stated that the dog had been licking the area and that was the
reason why the dog was not improving and was worse. Complainant contends
15-77 & 15-103, Refaat Ishak, DVM
Gd)
that the dog was not licking and had been wearing an Elizabethan Collar the entire time. Respondent documented that he observed that that the anal ared was very swollen and inflamed, that there were several skin injuries, holes, infection and mucopurulent discharge mixed with blood, and bilateral anal gland abscesses.
7. Respondent documented that he advised Complainant that they needed to sedate the dog to examine, clean, and debride the area, Respondent contended that it would be best for the anal glands to be healed
and intact but the area needed to be explored and cleaned and ihe wounds
|| closed, The anal glands were ruptured and Respondent would remove the
portions of the anal glands, if located. The dog was discharged with the following: qa. Amoxicillin 500mg, 14 tablets; give one tablet orally every 12 hours; b. Deramaxx 75mg, 10 tablets; give one tablet orally once daily to control pain and inflammation; c, EnteDerm ointment 7.5mL; apply to inflamed area three times ad day until healed; d. Schedule surgery for next Tuesday: and — @, Recheck in 7 days. 8. On January 16, 2015, the dog was presenied to Respondent for an anal sacculectomy. Upon exam the dog had a weight = 93 pounds, a temperature = 101.6 degrees, a heart rate = 130bpm, and a respiration rate = AOrom. Respondent noted that the anal glands were swollen and had discharge. Respondent claims that it was Complainant who elected ies do the
surgery sooner as the medication was not helping and that it was Respondent
15-77 & 15-103, Refaat Ishak, DVM
io
who stated that it would be best to perform surgery when the glands were healed however he would explore the area and remove the ruptured anal glands if he could locate them. | 9, According to Complainant, it was Respondent who recommended surgery to remove the anal glands and to stop the dog from licking. Complainant stated however that the dog had not been licking because he was wearing the Elizabethan collar during this time. She was concerned because Respondent previously told her that they could not do surgery until the sores were Under control: the sores were not under control — they appeared WOTSE. Respondent's recommendation was to continue with the surgery. — ~ 10, Blood work was performed and Respondent proceeded with SUrGery. An |V catheter was placed and the dog was started on Lactated Ringer's Solution. The dog was pre-anesthetized with Torbugesic, induced with Ketamine and Valium and maintained on isoflurane and oxygen. The anal area was clioped and scrubbed; there was mucopurulent discharge mixed with blood, there was damaged, inflamed skin on the right dorsal lateral aspect of the anus
and on the ventral right anal gland. There were several holes, fistulas and both
| anal glands were ruptured. Respondent lanced the anal glands and debrided
the wound; the area was flushed, the holes and fistulas were explored and parts of the anal sacs were found aha removed. Both anal gland necks were flushed and removed, Respondent injected and applied to the wound — gentamycin 100mg, dexamethasone 2mg and triamcinolone 5mq. The SQ tissue was sutured with 3 — 0 PDS and skin was closed with 2 — 0 PDS. The dog was administered Ketoprofen 100mg/mL 0.82mLs SQ, The dog was discharged later that day with Orbax 68mg, 30 tablets: give three tablets orally every 24
hours until gone.
15-77 & 15-103, Refaat Ishak, DVM
an
11. The surgical monitoring sheet indicates the surgical procedure was
started at 10:45am and ended at 11:45am (one hour). However, the surgical
|| monitoring itself indicates the dog was under anesthesia for one (1) hour and 45
minutes. The surgical anesthetic form is inadequate/ not properly documented.
12. Complainant stated that the morning after surgery there was a gap
at the surgery site that was draining brown discharge. She contacted the
premise and sent pictures of the surgical site - she stated that she was advised that the dog was fine and to continue to monitor the dog. A few days later more sutures came out, According to Complainant, the dog was not moving or
licking - he was contained and wearing the Elizabethan collar.
13. On January 21, 2015, Complainant reported that the dog was not
doing well and needed to be seen. Upon exam, the dog had a weight = 88.8 pounds, a temperature = 100.8 degrees, a heart rate = 140bpm and a respiration rate = 60rom. Complainant reported that the dog was having diarrhea, was still on Orbax, but she had discontinued the topical ointment. Respondent documented that the dog was not wearing the Elizabethan collar and was licking the incision. He told Complainant that the licking will delay healing and make the situation worse, as the dog had already removed some of the sutures. Complainani contends that the dog wore the Elizabethan Collar the entire time. Respondent recommended laser therapy for wound management and probiotic for the diarrhea. The dog's prognosis was guarded. Complainant approved the laser therapy and declined the probiotic.
14, The wound was cleaned with chlorhexadine scrub and normal saline. Laser therapy was performed and the dog was-discharged with instructions to
care for the wound with diluted betadine 2 —-3 times a day.
15-77 & 15-103, Refaat Ishak, DVM
15. The dog underwent 6 laser therapy treatments — one treatment
approximately every other day.
16. On February 9, 2015, the dog was presented to Respondent due to not doing well and being in pain. Complainant reported that the dog has diarrhea, suture is hanging from rectum and there is bloody discharge. The dog was in pain and no longer taking pain medication or antibiotics. Upon exam, the dog had a weight = 90.2 pounds; no temperature, pulse or respiration was recorded. Respondent documented that the incision was inflamed and the dog is self-mutilating by scooting and licking incision site. Respondent removed the suture and told Complainant to make sure the dog is wearing the Elizabethan collar. Complainant stated that they keep the collar on the dog ai all times. Respondent documented that he allegedly discussed referral to a dermatologist or surgeon for more intensive work-up, possible biopsy and culture and sensitivity. The dog was discharged with the following:
a. Tramadol 50mg, 90 tablets; give three tablets orally every 8
hours as needed for pain;
b, DiaGel dog 5mLs; give ImL orally every 24 hours as needed for
diarrhea; c. Metronidazole 500mg, 30 tablets; give 2 tablets orally every 8 hours for 5 days; and d. Silver Sulfadiazine Cream 1%, 50gms; apply to the area 1 - 2 times a day until healed. 17. On February 10, 2015, Complainant reported that the dog's diarrhea had stopped and seemed to be doing well with the pain. 18. On February:11, 2015, the dog was presented to Respondent for laser
therapy. Upon exam, the dog had a weight = 90 pounds, a temperature = 102
15-77 & 15-103, Refaat Ishak, DVM
~l
degrees, a heart rate = 100bpm and a respiration rate = 42rom. Respondent noted that the area seemed to be healing; pet was still painful. According to
Respondent, the dog came in with no Elizabethan collar and was licking the
‘wound. Respondent reminded Complainant to keep the collar on.
19, On February 13, 2015, the dog was presented to Respondent for laser therapy. No weight, temperature, heart rate or respiration rate documented.
20. On March 24, 2015, the dog was presented to Dr, Metcalf at Casa Grande Animal Hospital for a second opinion. Complainant reported that the dog had anal gland surgery two months ago, the sutures fell out shortly after surgery, and she had been hot soaking and Beanine for the past two months.
21. Dr. Metcalf stated in his narrative that the area was a giganiic, infected mess that reminded him of a possible non-healing sequelae to anal gland removal and/or furunuclosis, Blood work was performed, an IV catheter was set and the dog was anesthetized. Under anesthesia, the area was clipped and extensively soaked — an impression smear revecied a lot of different sized rods and cocci. The anatomy around the rectal area was unrecognizable. The anus was barely palpable and looked as though recessed or overgrown by nasty looking, friable, gray, granulation tissue. No evidence of mucocutaneous junction was discernable. The dog also had sores where the Elizabethan collar rested.
22, The clean-up and soaking took approximately three hours. A culture and sensitivity was submitted to Idexx, the dog was administered 4mLs of Depo- Medcrol for extreme irritation and topical application of Panalog for anti- inflammatory/anti-bacterial activity. The dog was also started on Clavamox.
23, On March 25, 2015, the dog was seen by Dr. Metcalf’s associate and
given Vetericyn to apply topically and laser treatment.
15-77 & 15-103, Refaat Ishak, DVM
foe)
24. On March 27, 2015, the dog was presented fo Dr. Metcalf and owen possible improvement but siill looked "atrocious", There was brown discharge present and Dr. Metcalf thought this could be due to anal gland remnants. He gave Complainant the results of the culture and sensitivity. Due to the possibility of perianal fistulae/furunculosis present, the dog was put on Cyclosporine and Ketoconazole. Laser therapy was continued.
25. Dr. Metcalf stated that he advised Complainant that under the best circumstances the dog would need continual care, additional procedures including reconstructive surgery, skin grafting and exploratory for anal gland remnanis if indicated as well as a possible biopsy. He did not feel the dog was in pain; he recommended proceeding cautiously and suggested euthanasia was an option due to the circumstances. | Case No. 15-103:
26. On March 16, 2015, “Onyx," a 10-year-old male domestic long hair cat was presented to Dr. Vick at Small Animal Clinic due to frequent trips to the litter box and only producing small amounts of urine. Dr. Vick examined the cat and noted some urine at the penile opening on the fur, the bladder did not paloate hard, and the cat was apparently not straining. Radiographs were taken and revealed three (3) uroliths in the urinary bladder and several other stones were viewed in the urethra; no stones were noted in the kidneys. Dr. Vick recommended surgery — retropulsion and cystotomy. She also discussed the risk of blockage if surgery was not performed. An estimate for surgery from Small Animal Clinic and from the Emergency Animal Clinic was provided to the pet
owner. Blood and urine were collected and the cat was discharged with the
following:
15-77 & 15-103, Refaat Ishak, DVM
Se;
a. Prednisolone 5mg, 6 tablets; give % tablet orally twice a day for 3 days; and
B piessen Img, 30 tablets; give 2 tablets orally every 8 — 12 hours for urethral soasms.
27. On March 17, 2015, the cat was presented to Respondent for a second opinion and possible surgery. Upon exam, the cat had a weight = 10.3 pounds, a temperature =, 101.1 degrees, a heart rate = 140bpm, and a respiration rate = 24rom. Respondent repeated abdominal radiographs which revealed two (2) stones in the urinary bladder, approximately 7 - 10 in the proximal urethra and one at the tip of the penis.
28. An IV catheter was placed and Lactated Ringer’s Solution was administered at 20mL/hr (total of 40mL). The cat was administered torbutrol 2mg IM (0.2 of 10mg/ml), ketamine 50mg IV and isoflurane and oxygen. Respondent attempted to insert a 3.5 Fr open end catheter while injecting normal saline. He was Unable to insert the catheter more than approximately lcm and the saline never went through the catheter. Respondent attempted several times to gently retropulse but the saline bubbled in the perineal area which made Respondent think the urethra was possibly ruptured.
29, Respondent contacted the pet owner to advise that he could not insert the urinary catheter, therefore, could not move the stones back into the bladder. He further relayed that it was possible there was a urethral rupture at the perineum. The pet owner commented that the cat urinated and vocalized loudly during the exam, suggesting that is possibly when the rupture secuned: Respondent recommended ips poet owner take the cat to a specialist for surgery; the pet owner declined, asking Respondent to do what he felt was
best,
15-77 & 15-103, Refaat Ishak, DVM
a Oo
24
25
30. Respondent clipped and prepped the perineum and a 1-inch incision was made on the midline paieen the penis and the anus, which was deepened until free-floating stones were located. Respondent removed the stones and located the urethra; the urethra was sutured to the skin with 4-0 PDS. Respondent placed an 8 Fr urinary catheter, sutured it to the skin and bandaged to the cat's tail. At this point the cat's temperature appeared to be getting low (medical records simply stated "90" and surgical report shows cat's temperature = 92 degrees at its lowest but was increasing); therefore, Respondent elected to postpone removing the cat's penis.
31. Respondent contacted the pet owner to explain what had transpired and recommended hospitalizing the cat for three (3) days at the premise or at a 24 hour facility; the pet owner declined and elected to take the cat home. The cat was administered and discharged with the following:
a. Fentanyl 25mcg transdermal patch;
b. Conveniad injection 80mg/mL — 0.45mL SQ;
c. Hydromorphone 2mg/mL ~0.5mL SQ;
d. Cefazolin 333mag/mL, 0.30 mL (route unknown);
e. Onsior 6mg, 3 tablets; give 1 tablet orally every 24 hours for 3 days;
f. Laser therapy;
g. Stone analysis; and
h. Recheck daily.
32, On March 18, 2015, the cat was presented to Respondent for a recheck. Upon exam the cat had a weight = 10.5 pounds, a heart rate = 120bpm, and a respiration rate = 40roem. The pet owner reported that the cat
removed his Elizabethan collar during the night and removed the urinary
15-77 & 15-103, Refaat Ishak, DVM
| od el
catheter. Respondent noted that the incision site was inflamed from the cat licking. The cat remained at the premise for a few hours for observation; it was determined that the cat was urinating on his own. Laser therapy was performed and the cat was discharged later that day, Respondent elected not to replace the urinary catheter due to the cat urinating on his own. |
33, On March 19, 2015, the cat was presented to Respondent for not urinating. The pet owner reported that the cat had vomited the previous day and had not had a bowel movement since the surgery. Upon exam, the cat had a weight = 10.2 pounds, a temperature = 101.6 degrees, a pulse rate = 130bpom, and a respiration rate = 15rpm. Respondent noted that the surgical area was inflamed and the bladder was moderately full and EOReReO easily. The cat was masked down and maintained on isoflurane. Respondent found several stones on the tip of the urethra, which were removed, and a 12 Fr catheter was placed after cutting the tip. The catheter was sutured to the perineum and to the tail with 3 —- 0 PDS, An enema was also performed due to the pet owner stating the cat had not had a bowel movement since the
surgery. 34, Stone analysis revealed calcium oxdlate dnd SO food was
recommended.
35. On March 20, 2015, Respondent spoke with the pet owner who stated the cat was doing better, had passed diarrhea, and vomited a hairball. The cat was scheduled to be seen the following day for laser treatment.
36. On March 21, 2015, the cat was presented to Ist Pet Veterinary Centers due to not urinating. The pet owner Updated hospital staff on the cat's current blockage and inne concerns. The cat presented with a 12 Fr red
rubber catheter that was placed below the anus dnd above the urethra. The
15-77 & 15-103, Refaat Ishak, DVM
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red rubber catheter had clumping litter in the opening and the left rear paw
| was swollen from a vet wrap bandage on the leg with a fentanyl patch which
Respondent had placed.
37. Dr. North examined the cat and noted the soiled vet wrap on the left hind limb with a fentanyl patch underneath. The bandage had been in place since March 17th. There was a large bore red rubber catheter sutured in place between the anus and the penis. There were feces present around the insertion and cat litter inside the distal end of the catheter. There was edema oresent on the ventral abdomen and down the hind limbs — leff worse than right. The pet owner reported that some of that was normal but the skin folds appeared to be distended beyond what would be normal. |
38, Due to the unusual placement of the catheter, Dr. North performed radiographs which revealed the catheter did not terminate in the bladder and seemed to be cut at an angle, potentially overlying the colon. There appeared to be fluid distention of the retroperitoneal space, possible small amount of free air and effusion in the abdomen. There were five (5) visible uroliths in the urethra caudal to the pelvis and one urolith that appeared to still be in the bladder. It was not visible in the VD view, so Dr. North could not rule out bladder rupture. Dr. North documented that she felt these were very concerning conditions that would need prompt surgical intervention and that a boarded surgeon would most likely need to perform an abdominal exploratory to repair any damage and a proper perineal urethrostomy surgery. Blood work was performed and was within normal limits.
39, Dr. North stated in her narrative that a contrast study was recommended prior to surgery. Due to the premise being out of contrast, a
surgeon not being available until later that evening, and due to the Unusual
15-77 & 15-103, Refaat Ishak, DVM
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placement of the red rubber catheter, Dr. North recommended transferring the cat to another emergency facility that could address the cat's immediate needs. The pet owner agreed fo transfer the cat.
AQ. Later that day, the cat was presented to Dr. Garcia at Emergency Animal Clinic for continued treatment and possible surgery. Dr. Garcia examined the cat and reviewed the case. Her assessment was oneumoperitoneum, 5 days post-op perineal urethrostomy, fever and heart murmur. Diagnosis; pneumoperitoneum, 5 days post-op perineal urethrostomy, fever — perineal bacterial infection, septic peritonitis, urinary tract infection, inflammation; and heart murmur — cardiac structure disease, dynamic flow murmur. Dr. Garcia gave a guarded prognosis — surgical and medical management would be needed to try to achieve resolution and a good quality of life but options could be limited.
41, An IV catheter was placed and the cat was hospitalized for IV
|| therapy and treatment. After a lengthy discussion with the pet owner regarding
the cat's heart murmur and current serious condition, the pet owner approved the estimate minus the echocardiogram. A contrast study was performed by
removing the red rubber catheter and placing a sterile 8 Fr red rubber catheter
into the space and administering sterile Omniopaque contrast and retracting |
the red rubber tube. Contrast entered into the abdomen and retroperitoneal space and the red rubber catheter was removed.
42. Boarded surgeon, Dr. Rowe-Guthrie arrived to evaluate the cat and perform surgery. Pursuant to Dr. Rowe-Guthrie's submitted narrative along with medical records, she noted that the cat had an orifice created just ventral to the anus, with the scrotum and penis still in place (noting this was very atypical
for a perineal urethrostomy}. From the imaging and exam performed at
15-77 & 15-103, Refaat Ishak, DVM
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Emergency Animal Clinic, Dr. Rowe-Guthrie stated that if was clear that the urethra cranial fo the new orifice was ruptured, leading to uro and oneumoperitoneum. At surgery, she confirmed pneumoperitoneum and uroperitoneum (found bladder stone free in abdomen). Dr. Rowe-Guithrie also confirmed urethral rupture by catheterizing the urethrostomy site and seeing
the catheter tip within the abdomen. While in the abdomen, the urethrostomy
site was explored and the urethrostomy site had been created cranial to where |.
a typical perineal urethrostomy (PU) site would be — at the bulbourethral glands. The rupture of the urethra was cranial to that. Because the urethra was not long enough, the PU could not be salvaged and a pre-pubic urethrostomy was performed.
43, The cat was discharged the following day and follow up care was
through Southwest Veterinary Surgical Service.
44, At the December 16, 2015 Informal Interview, Respondent submitted a diagram to show the Board a depiction of ihe surgery he performed on the
cat. The diagram he submitted was of a dog, not a caf.
CONCLUSIONS OF LAW 45. The Arizona State Veterinary Medical Examining Board has jurisdiction over this matter pursuant to A.R.S. § 32-2201, ei seq, 15-77: 46, The conduct and circumstances as described above constitute UNPROFESSIONAL CONDUCT as defined in A.R.S. § 32-2232 (11) Gross
incompetence for:
e Misdiagnosis of the dog's condition (no documentation in medical
record that dog had perianal fistulas);
15-77 & 15-103, Refaat Ishak, DVM
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e improper treatment regime for the dog's condition, worsening condition;
e Unwarranted surgical procedure;
e Failure to perform culture and sensitivity to determine proper antibiotics; |
e Antibiotics dispensed were used indiscriminately and for only short duration of time for chronic condition;
e Administration of ketoprofen, dexamethasone and triamcinolone to dog on day of surgery when dog was currenily on deramaxx (NSAID},
47, The conduct and circumstances as described above constitute UNPROFESSIONAL CONDUCT as defined in A.R.S. § 32-2232 (12) as if relates to R3-11-501 (3) for failure to refer Complainant to a qualified veterinarian to enhance the animal's care.
48. The conduct and circumstances as described above constitute UNPROFESSIONAL CONDUCT as defined in A.R.S. § 32-2232 (22) Medical incompetence in the practice of veterinary medicine.
49, The conduct and circumstances as described above constitute an
ADMINISTRATIVE VIOLATION as defined in A.R.S. § 32-2233 (B) (3) failure to
adequately document anesthesia monitoring of the dog on January 16, 2015] ©
and R3-11-502 (L) (4) for failure to document in the animal's medical record a temperature, pulse and respiration on November 25, 2014, February 9, 2015; and February 13, 2015, respectively. 15-103:
50. The conduct and circumstances as described above constitute
UNPROFESSIONAL CONDUCT as defined in A.R.S. § 32-2232 (11) Malpractice —
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Respondent's treatment caused injurious results and the suffering of the cat; gross incompetence - lack of professional skill in the performance of professional practice; and gross negligence — treatment of a patient or practice of veterinary medicine resulting in injury and unnecessary suffering.
51. The conduct and circumstances as described above. constitute UNPROFESSIONAL CONDUCT as defined in A.R.S. § 32-2232 (22) Medical incompetence — lacking sufficient medical knowledge or skills, or both, to a
degree likely to endanger the health of patients.
ORDER ~ SUSPENSION ~ SIX MONTHS li Based upon the foregoing Findings of Fact and Conclusions of Law 17 is ORDERED that Respondent's License, No. 4666 be placed on SUSPENSION status for a period of six (4)-months. Respondent may not practice veterinary medicine in any way during this period. 2. During the six (4)-month Suspension period, Respondent shall take and
pass the National Board of Veterinary Medical Examiners (NBVME)’s
Companion Animal Species Specific Examination. Respondent shall make
arrangements with the Board's Executive Director to take this exam. Respondent will have two (2) attempts to pass the exam during the Suspension period. If Respondent fails to pass the exam after these two attempts, or if he
has not taken the exam at all, the Stayed Revocation in the Order shall be
lifted.
STAYED REVOCATION — DURING SIX-MONTH SUSPENSION PERIOD
3, IT IS ORDERED, during the ‘initial six months while the Order is in effect,
the Respondent's license shall be revoked. However, the revocation shall be
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stayed and Respondent's license shall be placed on Suspension status. During
the stayed revocation portion of the Order, if Respondent is noncompliant with
the terms of the Order in any way, the stay of the revocation shall be lifted and
Respondent's license shall be automatically revoked as set forth above. If Respondent contests the lifting of the stay, Respondent shall request in writing, within 10 days of being notified of the automatic revocation of licensure, that the matter be placed on the Board agenda for the Board fo review and determine if the qutomatic revocation of Respondent's license was supported by the evidence. If the written request is received within 10 days of a regularly scheduled Board meeting, the request will not be heard at that meeting, but will be heard at the next regularly scheduled Board meeting. Pending the Board's review, Respondent's license shall be noted as-revoked - under review. Respondent may not work in any capacity as a licensed veterinarian in Arizona pending the Board's review. The Board's Order shall not be subject to further review dnd Respondent shall comply with all of the terms of the Order before
Respondent is eligible to be released from the Order.
ORDER — PROBATION — FIVE YEARS 4, Based upon the foregoing Findings of Fact and Conclusions of Law it Is ORDERED, following the six-month SUSPENSION period and if the Respondent has passed the NBVME exam, Respondent's license will be placed on PROBATION for a period of five (5) years subject to the following terms and conditions that shall be completed within the Probationary period, These
requirements include practice restrictions, practice monitoring, notification
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pay ie)
requirements, completion of one hundred (100) total hours of continuing education (CE}, and a civil penalty-detailed below: PRACTICE RESTRICTIONS
5. IT IS ORDERED THAT Respondent shall be restricted from performing any
and all surgeries indefinitely. This restriction includes soft tissue, orthopedic, and
oral surgeries, including dental extractions. Prior fo any modification or
termination of the practice restriction, Respondent must submit a written
request to the Board for release or modification of the practice restrictions
outlined in the Order. When submitting such a request, Respondent shall
weve the Board with evidence establishing that he has appropriately
addressed the issues that resulted in the practice restrictions and that he can
safely and competently perform surgical procedures.
PRACTICE MONITORING 6. IT IS ORDERED THAT Respondent shall provide fifteen (15) sets of medical records to the Board on a quarterly basis during the first year of the Probationary period. These medical records shall be from St. Mark's Animal Hospital and/or any other premise where Respondent is employed as d veterinarian during the first year of the Probationary period. The first set of records shall be submitted by Respondent within sixty (60) days from the date
the Probationary period begins.
NOTICE TO ASSOCIATE/RELIEF/RESPONSIBLE VETERINARIAN
7. IT IS ORDERED THAT if Respondent employs an associate or relief
veterinarian at his premise, Respondent shall provide a copy of this Order to
15-77 & 15-103, Refaat Ishak, DVM
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those individuals within seven (7) days of the effective date of this Order (if currently employed at premise) or within seven (7) days of the individuals’ first date(s) of employment at Respondent's premise (if become employed in the future). Those individuals shall read the Order and submit a written notice fo the Board that he/she understands the terms within ten (10) days of receiving the Order,
8. If Respondent is employed by any other veterinary premise(s) besides St. Mark's Animal Hospital or any other premise he owns, Respondent shall provide a copy of this Order to the Responsible Veterinarian of that premise prior to Respondent's first date of employment. The Responsible Veterinarian shall read the Order and submit a written notice to the Board that he/she Understands the terms within ten (10) days of receiving a copy of the Order
from the Respondent.
CONTINUING EDUCATION
9. IT I$ ORDERED THAT Respondent shall provide written proof satisfactory to the Board that he has completed one hundred (100) hours of continuing education (CE}; hours earned in compliance with this order shall not be used for licensure renewal. Respondent shall satisfy these 100 hours by attending CE in the areas of: |
° Anatomy and physiology;
e Surgery; and
e Diagnostics.
Fifty {50} of the 100 hours of continuing education shall be obtained by attending wet labs, with thirty-five (35) of those 50 hours being obtained in soft
15-77 & 15-103, Refaat Ishak, DVM
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tissue and/or orthopedic surgeries. Respondent shall submit written verification
of attendance to the Board for approval and if a CE provider/institution
requires a test to demonstrate course competency, Respondent shall pass that}.
test based on the provider or institution's grading system.
10. All continuing education to be completed for this Order shall be pre- approved by the Board. Respondent shall submit to the Board a written outline (i.e. “CE Plan”) regarding how he plans to satisfy these CE requirements.
e Within the first six (4) months of the effective date of the Order, Respondent shall submit a CE plan than includes at least twenty (20) CE hours. Plans for more than 20 CE hours may be submitted for consideration at that time.
_e After the Board approves the first CE plan, Respondent shall submit a CE plan(s) to the Board for approval, which contains at least 20 hours, each year of the Probationary period until all 100 hours are approved.
11. The CE Plan(s) shall include CE course details including: course name, provider, date(s), hours of CE to be earned, a brief course summary, and
notation to explain if the course is a wet lab, an online course, or course that Is
attended in person.
CIVIL PENALTY 12. IT 1S FURTHER ORDERED THAT in addition to the statutory requiremenis, Respondent shall pay a civil penalty of three thousand dollars ($3000) — ($500
for each of the six violations). Civil penalty shall be made payable to the
| Arizona State Veterinary Medical Examining Board and is to be paid by
15-77 & 15-103, Refaat Ishak, DVM
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cashier’s check or money order, Civil penalty is due on or before the end of the
Probationary period.
OTHER TERMS
13. Respondent shall obey all federal, state and local laws/rules governing the practice of veterinary medicine in this state.
14. Respondent shall bear all costs of complying with this Order.
15. This Order is conclusive evidence of the matters described and may be considered by the Board in determining an appropriate sanction in the event a subsequent violation occurs. In the event Respondent violates any term of this Order, the Board may, after opportunity for Informal Interview or Formal Hearing, take any other appropriate disciplinary action authorized by
law, including suspension or revocation of Respondent's license.
STAYED SUSPENSION — DURING FIVE-YEAR PROBATION PERIOD
16. ITIS ORDERED, Respondent's license shall be suspended, However, the suspension shall be stayed and Respondent's license shall be placed on Probation status. During the stayed suspension portion of the Order, if Respondent is noncompliant with the practice restrictions outlined in the Order in any way, the stay of the suspension shall be lifted and Respondent's license shall be automatically suspended as set forth above. If Respondent contests the lifting of the stay, Respondent shall request in writing, within 10 days of being notified of the automatic suspension, that the matter be placed on the Board agenda for the Board to review and determine if the automatic suspension of
Respondent's license was supported by the evidence. If the written request is
15-77 & 15-103, Refaat Ishak, DVM
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received within 10 days of a regularly scheduled Board meeting, the request
|i will not be heard at that meeting, but will be heard at the next regularly
scheduled Board meeting. Pending the Board's review, Respondent's license shall be noted as suspended - under review. Respondent may not work in any capacity as a licensed veterinarian in Arizona pending the Board's review. The Board's Order shall not be subject to further review and Respondent shall comply with all of the terms of the Order before Respondent is eligible to be
released from the Order.
REHEARING/APPEAL RIGHTS
Respondent has the right to petition for a rehearing or review a this Order, Pursuant to A.R.S. § 32-2234 (H) and § 41-1092.09 the petition must be filed with the Board within thirty-five (35) days from the date of mailing if the Order was served via certified mail. Pursuant to A.A.C. R3-11-904 (C), the petition must set forth legally sufficient reasons for granting the rehearing or review. The filing of a petition for rehearing or review is required to preserve any rights of appeal to the Superior Court that the party may wish to pursue.
This Order shall be effective and in force upon the expiration of the above time period for filing a motion for rehearing or review with the Board. However,
the timely filing of a motion for rehearing or review shall stay the enforcement
lof the Board's Order, unless, pursuant to A.A.C. R3-11-904 (F), the Board has
expressly found good cause to believe that this Order shall be effectively
immediately upon the issuance and has so stated in this Order.
Dated this [¢ day of (Daye, 26
np wW
15-77 & 15-103, Refaat Ishak, DVM
Arizona State Veterinary Medical Examining Board Jim Lougheaad Chairman
Original of the foregoing filed this _/ ys day ot Wn , 2016 with the:
Arizona State Veterinary
Medical Examining Board
9535 E. Doubletree Ranch Rd, Ste. 100 Scottsdale, Arizona 85258
Copy ov the foregoing sent by certified, return receipt mail
this _/_ day of The 2016 to:
Refaat Ishak, DVM Adaress on file Respondent
Copy of yen foregoing sent by U.S. regular mail this _/4** day of = , 2016 to:
David L. Stoll, Esq.
Beaugureau, Hancock, Stoll & Schwariz, PC 302 E, Coronddo Rd.
Phoenix, Arizona 85004
Board Staff
15-77 & 15-103, Refaat Ishak, DVM
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EXHIBIT 2
VICTORIA WHITMORE » EXECUTIVE DIRECTOR «
IDOUGLAS A. DUCEY - GOVERNOR «
ARIZONA STATE VETERINARY MEDICAL EXAMINING BOARD 9535 E, DOUBLETREE RANCH RD, STE, 100, SCOTTSDALE, ARIZONA 85258 PHONE (GO2) 364-1-PET (1738) * FAX (602) 364-1039
VETBOARD.AZ.GOV ©
INVESTIGATIVE COMMITTEE REPORT
TO: Arizona State Veterinary Medical Examining Board
FROM: PM Investigative Committee: Robert Kritsberg, D.V.M. - Chair Donald Noah, D.V.M. Adam Almaraz Amrit Rai, D.V.M., Tamara Murphy
STAFF PRESENT: Tracy A. Riencdeau, CVT, Investigations Sunita Krishna; Assistant Attorney General
RE: Case: 18-26 Complainani(s): Ann Cangiano Respondent(s}: Refaat Ishak, DVM {License: 4666)
SUMMARY: APPLICABLE STATUTES AND RULES: Complaint Received at Board Office: 10/3/17 Laws ds Amended July 2014 - Committee Discussion: = 12/12/17 (Salmon}; Rules as Revised September Board IIR: 2/21/18 2013 (Yellow)
On August 18, 2017, “Lexi,” a 9-year-old female Border Terrier was presenied to Respondent with a history of not eating or drinking for 24 hours. Pancreatitis was suspected and the dog was hospitalized.
When Complainant visited the dog the following day, she was concerned that the dog was over-medicated as she could not lift her head. The dog remained hospitalized and Complainant picked up the dog on August 21, 2017.
Complainant contends Respondent was negligent in the care of the dog.
Complainant was noticed and appeared. Witness, Larry Sinclair, appeared, Respondent was noticed and appeared with counsel, David Sfoll. The Committee reviewed medical records, testimony, and other documentation as described below:
e Complainani(s) narrative: Anne Cangiano e Respondent(s) narrative/medical record: Refaat Ishak, DVM e Witness(es} narrative: Kathryn Seelye ~ Complainant’s daughter
18-26, REFAAT ISHAK, DVM
PROPOSED ‘FINDINGS of FACT’:
1. On August 18, 2017, the dog was presented to Respondent due fo not eating or drinking for 24 hours, Complainant thought the dog could have goiten into something, possibly aq cough drop; the dog does eat table food along with her regular diet. She further reported that the dog had a history of inappetence and seizure like activity. Uoon exam, the dog had a weight = 13.40 pounds, a temperature = 101.3 degrees, a heart rate = 135bpm and a respiration rate = 60rom. Respondent noted the dog had discomfort with palpation of the spine at the lumbar region. The dog was 7% dehydrated and had a history of ataxia.
2. Respondent relayed to Complainant that he suspected pancreatitis and recommended in- house diagnostics including blood work and radiographs. The CPL snap test was abnormal, ALP
= 17, Phos = 2.1. Radiographs revealed compressed disc space, calcified disc material and spondylosis in a variety of locations of the spine from 17 to L7. The dog had vomited prior to radiographs.
3. Respondent relayed his findings to Complainant and offered a referral to adn emergency facility for better working of the spinal issue and treatment of the pancreatitis, Complainant declined. Respondent recommended hospitalization —|V fluids, anti-emetic, pain medication and antibiotics - aodominal ultrasound, having the radiographs reviewed by a radiologist and sending blood and urine to an outside lab for evaluation — Valley Fever, Tick Fever, thyroid, CBC and cardiopet screen, Complainant approved all recommendations.
4, The dog was hospitalized; an IV catheter was placed and Lactated Ringers Solution was started — 200mLs bolus then 25mL/hr. The following medications were administered:
Baytril 10Omag/mL — 0.6mL IV; :
Famotidine 10mg/mL 0,6mL SQ;
Cerenia 1Omg/mL 0.6mL SQ;
d. Hydromorphone 2mg/mL 0.6mL SQ: and
e. Sucralfate 500mg PO.
OO 2
5. That evening the dog received his medications and was still panting with abdominal tension.
6. On August 19, 2017, the dog’s vitals were obtained, fluid line was twisted and changed, and food was offered — no interest. It was noted that the dbdomen was less painful and tense. A glucose = 99mg/dl, and Respondent elected to add mirtazapine to stimulate the dog's appetite. Medications were administered:
a. Baytril }OOmag/mL —0.6mL IV;
b. Famotidine 10mg/mL 0.6mL SQ;
c. Cerenia 1Omg/mL 0.6mL SQ;
d. Hydromorphone 2mg/mL 0.6mL SQ;
e, Sucralfate 500mg PO; and
f. Mirtazapine 15mgq/tab — % tablet PO.
7. Ms. Seelye, Complainant's daughter contacted Respondent to check on the dog. Respondent explained that his two main concerns were Addison's disease or gastric ulcer, He wanted to perform an ACTH stim test and an ultrasound. Respondent stated that Complainant
18-26, REFAAT ISHAK, DVM
coulda visit the dog to see if the dog would eat for her.
8. Complainant visited the dog and was told that if she ate, she could be released to go home. When the dog was presented to her, she appeared overmedicated due to the fact she could not pick uo her head or recognize Complainant. Complainant kept the dog hospitalized.
9. That day, the ACTH stim test was performed as well as the abdominal ultrasound which was sent to PetRays. That evening the dog was medicated ~ still no interest in food or water — and the Baytril was switched to penicillin 300,000U/mL —0.6mL SQ, Respondent noted that the ulirasound report indicated that the dog had pancrealiitis and degenerative changes in the kidneys. The abdomen palpated less painful.
10. On August 20, 2017, Respondent evaluated the dog and noted that she was less painful and brighter. She licked canned food offered but did not eat, Respondent decreased hydromorphone dose and the following was administered:
. Penicillin 300,000u/mL - 0.6mL SQ;
b. Famotidine 10mg/mlL 0.6mL SQ;
c. Cerenia 10mgd/mL 0.6mL SQ;
d. Hydromorphone 2mg/mL 0.3mL SQ;
e
f.
Q
. Sucralfate 500mg PO; and Mirtazapine l5mg/tab — % tablet PO.
11. That evening, the dog was interested in eating and ate 1/8 can of Recovery diet. Lab revealed a normal CPL result. Medications were administered,
12. On August 21, 2017, the dog had eaten and ate additional food given to him. She was doing well and could go home with the appetite stimulant and famotidine. Medications were administered: | . Penicillin 300,000uU/mL — 0.46mL SQ; . Famotidine 10mg/mL 0.46mL SQ; . Cerenia 1Omg/mL 0.46mL SQ; . Hydromorphone 2mg/mL 0.3mL SQ; . Sucralfate 500mg PO; and Mirtazapine 1limg/tab —% tablet PO.
oD (Oe)
13. Respondent contacted the lab fo discuss the normal CPL test versus the in-house abnormal CPL test. He was advised that it was not uncommon to get conflicting results. Additionally, the lab did not feel the Vitamin D test was necessary therefore if was cancelled. The Valley Fever and Tick Fever tests were negative and the T4 was normal.
14, Complainant returned to the premise that day and Respondeni reviewed the dog's case with her. He recommended following up in a week for gd recheck exam or sooner if symptoms return. According to Respondent, the dog was bright, alert and responsive at discharge. Mirtazapine and Famotidine were dispensed. |
15. According to Complainant, when the dog was brought out to her to take home, she was too drugged to walk. She expressed concerns that the dog was overmedicated.
erences, Page 3
18-26, REFAAT ISHAK, DVM
COMMITTEE DISCUSSION:
The Committee discussed that Respondent performed unnecessary diagnostics, improperly used pain medication while hospitalized and did not send pain medications home with an animal that was suspected fo be in pain.
The Committee discussed that diagnostic testing need to be medically justified. Diagnostics were performed/requested without any medical reasoning or sufficient knowledge. An ACTH test in this case was not medically necessary and appeared to be a revenue generator. Additionally, hydromorphone can be used for pain; however, based on the symptoms of the dog and the need for pain medication, a potent, shorf-acting pain medication was used fo regulate pain, instead of a pain medication that would relieve the dog’s pain consistently. .
The Committee felt that the medical records did not match the dog's appearance. According to the records, it dopears the dog was improved and walked out of the premise aft the time of discharge. According to Complainant, the dog was too sedated to walk requiring the dog to be carried, which would be accurate since the dog had received a dose of hydromorphone shortly before discharge. |
COMMITTEE'S PROPOSED CONCLUSIONS of LAW: The Committee concluded that possible violations of the Veferinary Practice Act occurred, COMMITTEE'S RECOMMENDED DISPOSITION: |
Motion: It was moved and seconded the Board fina:
ARS § 32-2232 {22} Medical incompetence in the practice of veterinary medicine for: e Performing diagnostics without medical justification indicating that Respondent lacked sufficient knowledge; | e {nappropriate use of hydromorphone for controlling pain — method of administration left large windows of pain present; and e Pain medication was not dispensed at discharge.
Voie: The motion was approved with a voie of 5 to 0. The information contained in this report was obtained from the case file, which includes fhe
complaint, the respondent's response, any consulting veterinarian or witness input, and any other sources used to gather information for the investigation.
Tracy A. Riendeau, CVT Investigative Division
EXHIBIT 3
DOUGLAS A. DUCEY - GOVERNOR «
VICTORIA WHITMORE - EXECUTIVE DIRECTOR «
ARIZONA STATE VETERINARY MEDICAL EXAMINING BOARD 9535 E. DOUBLETREE RANCH RD, STE. 100, SCOTTSDALE, ARIZONA 85258 PHONE (602) 364+1-PET (1738) ¢ FAX (GO2) 364-1039
VETBOARD.AZ,.GOV
INVESTIGATIVE DIVISION REPORT
TO: Arizona State Veterinary Medical Examining Board FROM: Investigative Division RE: Case: 18-56
Complainant(s); Rontasia Scurlock Respondent(s): Refaat Ishak, D.V.M. (License: 4666)
SUMMARY: APPLICABLE STATUTES AND RULES: Complaint Received at Board Office: 1/25/18 Laws as Amended July 2014 Board Discussion: 3/21/18 Salmon); Rules as Revised
september 2013 (Yellow)
Complainant was employed by Respondent from August 2017 to January 2018. She alleges Respondent violated Board Order 15-77/15-103 by extracting teeth and/or performing surgery during two dnesihetic procedures.
Complainant further claims Respondent is practicing under a name that is not on his veterinary license.
18-56, REFAAT ISHAK, DVM
PROPOSED ‘FINDINGS of FACT’:
1. According to Complainant, Respondent was extracting teeth/performing surgery while he was under a Board Order restricting him to do so, She submitted information regarding two clients that she states Respondent extracted teeth/performed surgery on.
“Isabella” Miller a a 9-year-old female Yorkshire Terrier:
2. Complainant submitted a screen shot of the dog's record from December 18, 2017 showing there was an $80 fee for tooth extraction — minor, amount 4.
3. According to Respondent, his Board Order does not restrict him from performing routine denial work.
4,On December 16, 2017, fhe dog was presented to Respondent for an oral evaluation. The dog had a foul order coming from the mouth. Respondent examined the dog and noted grade 2 periodontal disease with gingivitis. He recommended dental work and prescribed metacam for pain and administered the dog convenia. | _
5, On December 18, 2017, the dog was presented to Respondent for a dental cleaning. Blood work was performed, an lV catheter was placed and fluids were started. The dog was pre- medicated with hydromorphone, anesthetized with ketamine and valium, intubated and maintained on isoflurane and oxygen. Respondent stated that the upper incisors were Covered by tartar and fell out during the scaling process due to being very loose; the gums were flushed and cleaned. A class 4 laser was applied with dental setting on a small area.
“Sissy” Haggard — a 7-year-old female domestic medium hair cat:
6, On December 14, 2017, the cat was presented to Respondent with a swollen face, watery eyes and lethargy. The pet owner reported that they noticed a lump on the cat's face a couple months earlier: believes the cat was bitten and drooling was noted. Upon exam, Respondent found a facial mass on the left upper jaw — it appeared non-painful and bleeding inside the mouth — it was difficult to open the mouth to evaluate and there was blood tinged saliva.
7. Respondent discussed his findings with the pet owner and suggested the cat may have a tumor, inflammation or infection of the bone or soft tissue; Respondent recommended referral to di specialist which was declined. Respondent further recommended radiographs and lab work — et owner agreed to in-house testing and radiographs. Radiographs revealed an osteolytic lesion on the face which was possibly mixed with soft tissue swelling and discharge. Metastasis was not noted and a cytology of the saliva showed rods and some cocci mixed with blood cells. He advised the pet owner that he would dispense antibiotics to help with infection/inflammation but it would not helo with the tumor. The cat was ddministered ketoprofen and convenia SQ; Orbax suspension was dispensed and the cat was discharged,
8. On December 21, 2017, the cat was presented to Respondent for a recheck. The pet owner reported that the medication was helping as the cat was no longer drooling and had become
ye
{ 8-56, REFAAT ISHAK, DVM
more responsive. Upon exam, Respondent noted that the mass was still present on the jaw but the swelling had decreased. The pet owner declined referral therefore Respondent recommended a dental with biopsy and evaluate the mouth under anesthesia, which was approved,
9. On December 29, 2017, the cat was presented to Respondent for a dental. An IV catheter was placed and fluids were initiated. The cat was pre-medicated with hycromorphone, induced with ketamine and mask isoflurane; the cat was then intubated and maintained on isoflurane and oxygen. Resoondent documented that the teeth were scaled and polished — there were no teeth on the left maxilla, the mass was examined and a biopsy was collected — the mass appeared to be soft tissue vs osseous. The biopsy site was closed with 3-0 PDS.
10. Respondent stated that he discussed his findings with the pet owner. They declined histopathology until the son gave permission, Respondent referred them to a specialist and administered convenia and depo-medrol to the cat prior to discharge.
11. On the screen shot Complainant submitted of the cat's account, there is an item line that states “tooth extraction.” There is also a screen shot of a dental chart that is marked with tooth 101 as being extracted. There is no patient identifying marks, only a hand-written note that indicates the dental chart belongs to Patient ID ~ 8437.
Claim Respondent is not practicing under licensed name:
12. Complainant claims that Respondent is practicing under the name “Reed Ishak” and his veterinary license is under ‘Refaat Ishak,”
13. Respondent stated that his full name is Refaat Reed Ishak and clients find it easier to call him Reed due fo the difficulty pronouncing Refaat.
14. The name on Respondent's veterinary license application is Refaat Reed Ishak. The ‘information contained in this report was obtained from the case file, which includes the
complaint, the respondent's response, any consulting veterinarian or witness input, and any other SOUICE used to gather information for the investigation.
Tracy A. Riendeau, CVT Investigative Division
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EXHIBIT 4
VICTORIA WHITMORE - EXECUTIVE DIRECTOR «
DOUGLAS A. DUCEY » GOVERNOR -
ARIZONA STATE VETERINARY MEDICAL EXAMINING BOARD 174.0 W. ADAMS STREET, STE. 4600, PHOENIX, ARIZONA 85007 PHONE (602) 364-1-PET (1738) * FAX (602) 364-1039 VETBOARD.AZ.GOV
INVESTIGATIVE COMMITTEE REPORT
TO: Arizona State Veterinary Medical Examining Board
FROM: PM Investigative Committee: Donald Noah, D.V.M., - Chair Amrit Rai, D.V.M. Adam Almaraz Christine Butkiewicz, D.V.M. Tamara Murphy
STAFF PRESENT: Tracy A. Riendeau, CVT — Investigations Victoria Whitmore, Executive Director Sunita Krishna, Assistant Attorney General PY
RE: Case: 18-57 Complainant(s): Charles Orr Respondent(s}: Refaat Ishak, DVM (License: 4666)
SUMMARY: APPLICABLE STATUTES AND RULES: Complaint Received at Board Office: 1/26/18 Laws as Amended July 2014 Committee Discussion: 4/3/18 (Salmon); Rules as Revised September
Board IIR: 4/18/18 2013 (Yellow)
On December 13, 2017, “Sadie,” a 6-year-old female Chihuahua was presented to Respondent for anal glad expression. Respondent diagnosed the dog with infected anal glands and treated with convenia and metacam,
On December 21, 2017, the dog was presented for a recheck and bloody urine. Radiographs and blood work were performed and the dog was discharged with Augmentin.
The following day, Complainant elected to humanely euthanize the dog.
Complainant contends Respondent was negligent in the care of the dog.
Compiainant was noticed and appeared. Respondent was noticed and appeared.
The Committee reviewed medical records, testimony, and other documentation as described below: ® Complainant(s) narrative: Charles Orr e Respondent(s) narrative/medical record: Refaat Ishak, DVM
18-57, REFAAT ISHAK, DVM
PROPOSED ‘FINDINGS of FACT’:
1, On December 13, 2017, the dog was presented to Resoondent for an anal gland expression due to the dog excessively scooting. Upon exam, the dog had a weight = 7.40 pounds, a temperature = 101.5 degrees, a heart rate = 108bpm and respiration rate = 72rom. Respondent diagnosed the dog with an anal gland infection and administered the dog convenia 80mg.mL, 0.34mLs SQ and dispensed metacam 1.5mg/mL, 10 doses; give 0.5mL every 24 hours.
2, On December 20, 2017, the dog was presented to Respondent for a recheck, Complainant reported that the dog was improved and had stopped licking the area. He further reported that he had noticed blood in the dog's stool but none was present at the time of exam. Respondent examined the dog dnd explained that the blood in the stool could have been a side effect of the convenia but has resolved,
3, On December 21, 2017, the dog was presented to Respondent for possibly passing bloody stool. Upon exam, the dog had a weight = 7.6 pounds, a temperature = 100.1 degrees, a heart rate = 130bpm and a respiration rate = 28rom. Respondent determined that dog had hematuria cind recommended blood work, a urinalysis and radiographs; Complainant approved. — Radiographs revealed a moderately distended bladder, with one visible stone in the right kidney and mineralization in the left kidney. Nothing significant was noted on blood work and urinalysis revealed blood in urine and calcium oxalate crystals. The dog was discharged with Augmentin drops 40/5.7mg/mlL, 15mLs; give ImL every 12 hours and instructions to return the following day for an ultrasound and go over lab results. Respondent stated that he also offered referral to a specialist.
4, The following day, Complainant dropped off the dog for euthanasia, Complainant stated that the dog could not get up on her hind legs and/or walk after Respondent had obtained samples for the lab. Respondent called Complainant to explain that at this point the dog had crystaluria and they could try a special dief and consult with a specialist regarding the kidney stones. Complainant declined and wanted the dog euthanized, Respondent humanely euthanized the dog as requested by Complainant. Respondent's exam documented in the medical record shows the dog was ambulatory; he did not ask why Complainant wanted the dog euthanized.
COMMITTEE DISCUSSION:
The Committee discussed that Respondent's medical records were prepopulated and were jhe same on each exam. After discussion with Respondent and Complainant, the Committee found Complainant's account more credible. Committee expressed concerns that Respondent did not identify the dog's paresis on December 22nd when the dog was dropped off for euthanasia making the Committee believe the dog was not examined on that day.
The Committee was concerned about what caused the dog's hind end paresis and felt it could have been related to Respondent's exam and manipulation of the dog. Respondent expressed the dog’s dnal glands, performed radiographs, and collected urine and blood from the dog. Complainant reported that he carried the dog out and she could not walk when they retuned home, which was supported by a witness statement.
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The Committee was also concerned that Complainant had to request copies of the dog's medical records several times before receiving a copy almost 30 days later.
COMMITTEE'S PROPOSED CONCLUSIONS of LAW: The Committee concluded that possible violations of the Veterinary Practice Aci occutred. COMMITTEE’S RECOMMENDED DISPOSITION: Motion: |i was moved and seconded the Board find: ARS § 32-2232 (12) as It relates to AAC R3-11-501 (1) failure to provide professionally acceptable procedures for not recognizing the dog's paresis on discharge on December 21, 2017 and again on December 22, 2017 when dropped off for euthanasia; medical
records stafe the dog was ambulatory;
ARS § 32-2232 {12) as it relates to AAC R3-11-501 (8) failure to provide copies of medical records within 10 days of the pet owners request; and
ARS § 32-2232 (21) as it relates to AAC R3-11-502 (F) failure to obtain signed authorization from the pet owner before euthanasia was performed,
Vote: The motion was approved with a vote of 5 fo 0. The information contained in this report was obtained from the case file, which includes the
complaint, the respondent's response, any consulting veterinarian or witness input, and any other pee eG to gather information for the investigation.
Tracy A. Riendeau, CVT Investigative Division
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