BEFORE THE ARIZONA MEDICAL BOARD

In the Matter of
Board Case No. 
DAVID L. GREENE, M.D.,
FINDINGS OF FACT,

CONCLUSIONS OF LAW AND ORDER

(License Revocation)

Holder of License No. 32747
For the Practice of Allopathic Medicine
In the State of Arizona.

 

 

 

 

On August 6. 2008. this matter came before the Arizona Medical Board ("Board")
for oral argument and consideration of the Adminishative Law Judge (ALJ) Diane
Mihalsky?s proposed Findings of Fact and Conclusions of Law and Recommended Order.
David Greene M.D., (?Respondent?) appeared before the Board with legal counsel Paul
Giancola, Assistant Attorney General Dean E. Breldte represented the State. Chris
Munns. Assistant Attorney General with the Solicitor Generals Section of the attorney
General's Of?ceI was present and available to provide independent legal advice'to the
Board.

The Board, having considered the decision and the entire record in this

matter, hereby issues the following Findings of Fact. Conclusions of Law and Order.


1. The Arizona Medical Board ("the Board') is the duly constituted authority for the
regulation and control of the practice of allopalitic medicine in the State of Arizona.

2. Respondent David L. Greene. MD. graduated from the University of Virginia
School of Medicine in 199?. Between 1997 and 1998, Dr. Greene completed a-general
surgery internship at Man'copa Medical Center and. between 1 998 and 2000. he started an
orthopaedic surgery residency at Marioopa Medical Center in Phoenix. Afterthe residency
program at Maioopa Medical Genterwas placed on probation. between 2000 and 2003.

 

Dr. Greene completed an orthopaedic surgery residency in the Brown University
Orthopaedic Residency Program in Providence, Rhode Island.

3. In 2003 and 2004, Dr. Greene completed a fellowship in orthopaedic spine
surgery at Beth Israel Spine Institute in New York City, New 

4. ?1:2 Board issued License No. 32747 for the practice of altopathic medicine to
Dr. Greene-

5. Between the time when Dr. Greene completed his spine fellewship in 2004 and
February 2006. he worked at Sonoran Spine Center (?Saharan?) in Phoenix. Arizona.
Between April 2006 and August 2007. Dr. Greene worked at the Center for Orthopaedic
Research and Education in Sun City, Arizona. He primarily performed
orthopaedic spinal surgeries at both jobs. According to Dr. Greene. he ?has performed
approximately 563 surgical spine cases.?2

6.- The Board received a complaint regarding Dr. Greene's care and treatment of
L0. daughter, who was a nurse, ?led a complaint and also informed the Board that
she was aware of other poo-r patient outcomes. The Board opened an investigation and
assigned Case No. to the initial complaint and ?ve other cases.

7. The Board referred thesix cases in Case No. lntemal Medical
Consultant Gerald G. MD. for review. Dr. prepared and strmeth
a report to the Board.

8. On August 9, 2007, the Board conducted a formal interview of Dr. Greene under
A.R.S- During the intenriew, in responseto Board mernbers' direct question.
Dr. Greene represented to the Board that, during the preceding year and a halt(Dr. Greene's curriculum vitae}.

3 Dr. Greene?s ctcsing statement at 1.

 

had any other major technical complications in his surgeries. such as vessel injuries, bowel
injuries, nerve root injuries, paraplegia, or quad?plegia.?

The Board subsequently unanimously voted to ?nd that, in Dr. Greene's care of
live of the six patients that comprised Case No. MD-06-1043A. Dr. Greene had committed
?unprofessional conduct . . . for faiure to appropriately deal with surgical complications. for
displaying poor clinical judgment in selection of patients for surgery, and for overly
aggressive surgical treatment resulting in signi?cant neu rologic and vascular injuries.?

10. Based on Dr. Greene?s representation that he had not experienced any other
major technical complications in the preceding year and a half, the Board-voted to issue a
decree of censure against Dr. Greene and to place him on probation for two years, with
close monitoring."1

. 11. On Augtst 16, 2007, based on the Board's vote atthe August 7. 2007 meeting,
the Board's Exeoulitre Director on behalf of the Board issued Findings of Fact, Conclusions
of Law, and Order in Case No. issuing a decree ofoensure against Dr.
Greene and placing his license on probation for two years.

12. In the Findings of Fact, Conclusions of Law, and Order in Case No. 
1043A, the Board concluded that Dr. Greene had committed unprofessional conduct in ?ve
ofihe six patient ?les reviewed, in reievant part as follows:

12.1 On January 29, 2005, Dr. Greene had performed T12-L1 and 
laminectomyldiscectomy with a posterior spinal fusion T10 to L1 with pedicle screw ?xation
on PH. Dr. Greene?s operative report noted no compli?ions and that PH's blood pressure
remained stable. PH died on Januarj,r 31, 2005. A February 2, 2005 pathology report

 

See Ex; UU (transcript of formal interview proceedings) at 10, II. 22-23; 64-66, II. 134-
Ex. UU at 105?06, ll- 20-1 (mo?tion): 100, ll. 3~14tvote).
5 Ex. UU at 110?11, II. 224 (Dr. Goidtarb); 112, 15-19 (Dr. Pelaelin}.

 

noted a laceration of abdominal aorta and retroperitoneal hernatorna. The Board
concluded that Dr. Greene had deviated from the standard of care by failing to diagnose
and manage the iatrogenic laceration of aorta, which eventuallyr caused her death.
despite continued need for transfusions and a large retroperitoneal bleed.

12.2 On February 2, 2005, Dr. Greene performed transforarninal lumbar interbody
fusion of L5-S1 with posterior pedicle screw ?xation on RD, a 51-year?old male patient who
had been referred by another physician for a second opinion on treatment of back pain.
After Dr. Greene's surgery, RD had developed severe right leg pain with foot drop. The
Board concluded that Dr. Greene had deviated from the standard of care byfailing to use
intlaoperative fluoroscopy to document the position oflhe right 3-1 pedicie screw to
prevent nerve or dural injury.

12.3 Between April and June 2005, Dr. Greene evaiuated JD, a 35-year-old male,
who presented with a history of mid?back pain following a motor vehicle accident several
years earlier. tit-rays and an MRI demonstrated an old compression fracture ofT~8.- On"
July 25, 2005. Dr. Greene performed a Percutaneous Kyphoplasty at T-B and T-Q with
and fluoroscopy control- Dr- Greene reported that placement of his dilator and
working cannula at T-B was dif?cult and required three atte'npts. 0n awakening, JD had
no sensation below T-9. The Board concluded that Dr. Greene had departed from the
standard of re. which required a physician to perform a kyphoplasty for osteoporo?c
compression fractures or haumatic compression fractures with rehtively recent history, by
performing surgery on a 35~year?old patient who had neither. As a result of the spinal
injury that occurred during Dr. Greene?s surgery, JD had been rendered a paraplegic.

12.4 L0 was a 77-yearuold female patient who complained of back and lower
extremity pain. On January 6. 2006. Dr. Greene placed pedicie screws from 
performed a Iaminectomy at L3L4 and an interbody cage at After more than four

 

?emu-irehours of surgery, after Dr. Greene encountered signi?cant bleeding, he removed the 
pedicle screws. then obtained a vascular surgery consult The vascular surgeon found a
retroperitoneal hemorrhage from an inferior vena cava injury. Although resuscitative
attempts were made. L0 died. The autopsy report on L0 noted an abdominal aorta
laceration at L2-L3, the area where Dr. Greene had performed surgery. The Board opined
that the standards of care required Dr. Greene to identify excessive bleeding intra-
operatively with a decreased blood pressure as a possble vascular Injury and to terminate
the procedure and obtain a vascular surgery consult and to consider a patients age,
evaluation, prior treatment faiures, co-morbidities, and the extent of planned surgery
before proceeding with an extensive elective surgery. The Board concluded that Dr.
Greene had deviated from ?d'rese standards (1) by removing the pedicle screws prior to
closure and turning L0 for abdominal exploration and (2) by showing poor surgical
judgment in deciding to proceed .LO's-aggresshre elective surgery knowing that L0
was 77 years old and had a documented history of rdiac disease and pro-operative
anemia.

12.5 so was al73?year?old male who had a history of chronic back pain who
reported relief with a spinal cord stimuhtor, which had out working. On June 13, 2006. Dr.
Greene removed old hardware and implanted a new spinal cord stimulator and created a
new battery pocket. Altar 66 had problems with delayed healing, on June 26, 2006. Dr.
Greene performed surgery to create a new battery pocket in (56?s buttock, cultured the
wound, washed the battery and leads with Betadine and re-implanted them. Over the next
four months, Dr. Greene documented continued drainage from the battery pocket, noted
that the battery had failed to charge, and prescribed Cipro. On November 10, 2006,
another physician removed the stimulator and debrided the upper and lower back wounds.

 

The Board concluded that Dr. Greene had deviated from the standard of care. which
reduired that hardware not be re?implanted after it was been removed due to "lifection.

13. Dr. Greene did not appeal the Board's Findings of Fact. Conclusions of Law.
and Order in Case No. moce1o43mo superior court and they became ?nal.

14. After the Board entered its order in Case No. MD-05-1043A. it received
complaints involving care that Dr. Greene had rendered to patients DE and patient OK in
May 2007. DE had died atter an extensive procedure that Dr. Greene had performed. DK
had had an interbody cage migrate into the spinal canal.

15. The Board felt that both and cases involved technical complications
that Dr. Greene should have reported to the Board.

16. The Board contacted Dr. Greene's former employers Sonoran and CORE to
request that they identify Dr. Greene?s patients who had experienced surgical
complications. .Sonoran or CORE identi?ed four of Dr. Greene?s patients who had 
experienced serious surgiml complications. which cases the Board added to Case No. 
moor?0723a. 

17. As a result of the new complaints, on August 20, 2007, on Case No. 
0728A, the Board summarily suspended Dr. Greene's license to practice allopalhic
medicine in Arizona and refen'ed the complaints to the Of?ce of Administrative Hearings for
hearing. The summary suspension was reported in the media.

13. On-August 31, 2007, the Board issued an initial complaint in Cece No. 
0728A. involving the care that Dr. Greene rendered to patients DE and DK. The Board
referred the complaints involving DE and DK to Dr. for investigation.

19. The Board received seven additional complaints made by Dr. Greene's former
patients or their families. which the Board designated with new case numbers.

20. The Board referred the new complaints to Dr. for investigation.

 

March 11. 2003. the Board issued a second amended complaint. which
charged that Dr. Greene had committed unprotes'sional conduct in his owe of patients DE(Case No. DC (Case No. RW
(Case No. AZ (Case No. RJ (Cm No. Mo?omrsan), DC
(a second patient havin the sane initials. designated Case No. CD (Case
No. MM7-0857A), and SN (Case No. MD-0740936A).

22. An administrative hearing was held on April 9, 10, 11, 16. and 2008 and
June '11. 2008. The record was held open until June 23. 2003 to allow both parties to ?le
closing memoranda.

2-3. At the hearin, the Board presented the testimony of Dr. and had
admitted into evidence 52 exhibits. Dr. Greene testi?ed on his own behalf, presented the
Mmony of Paul Saiz, M.D., and Willem A. Norcross. MD. and had admitted into
evidence 145 etdiibits.

menous
Dr. ?mid

24. Dr. maintains a private practice and has spent on average 20 hours
per week consulting for the Board for the past two years. In 1969. he graduated from
medical school at the University of Illinois and. in 1974, completed a four-year orthopaedic
residency. For the next two years, he was the chief of orthopaedic surgery at the us.
Naval Hospital at Guantanamo Bay in Cuba. He began practicing in Arizona in 1976. He
is board-certi?ed in orthopaedic surgery. There is no separate certi?cation for orthopaedic
spinal surgery. At the time he completed his orthopaedic training, there were no
fellowships in spinal surgery.

25. Dr. testi?ed that one of his mentors during his residency was Ron
DeWald. one of the fathers of orthopaedic spinal surgery. He performed multiple spinal

 

WNisurgeries during his residency. Over the years. he has seen many patients who required
spine surgery. Although recently he has not been actively involved in a surgical practice.
he has assisted on the cases he has referred to other surgeons. He has worked with
doctors at Barrows, including Volker Sonntag, Tim Harrington, and Bill White.

26. Dr. has not recently personally performed orthopaedic spinal
Surgery on which he was the primary surgeon-

27. Because the Bord was concerned about Dr. Greene's safety to practice, it
asked Dr. to perform an emedited reviewofthe 13 newcases itassigned to
him.

$15.31!

28. Dr. Sat: graduated from the Baylor College of Medicine in 1995.. He
completed his residency in Orthopaedic Surgery at the Phoenix Orthopaedic Ridency
Program in 2000. He completed a fellowship in spine surgery at the Sonoran Spine Genter
in 2001 followed by a fellowship in Musculosketetal Oncology and Reconstruction at Rush
Presbyterian-St. Luke?s in 2002.

29. Dr. Sat: presently performs elective spinal surgery in Las Cmoes, New Mexico.
He is board-certi?ed in orthopaedic surgery. a member of the North American Spite
Society. has published and presented on spine surgery, and is the Spine Team physician
for New Mexico State University.

30. Dr. Saiz was Dr. Greme?s partner at Sonoran. Dr. Saiz left Sonoran in
February 2007 to move to New Mexico. He was therefore implicated in the cases that Dr.
Greene performed While he worked for Sonoran.

31. In 2006, the Board issued a letter of reprimand to Dr. Saiz.

Dr. Noroross

 

10
11
12

1.32. William Arthur Norcross, MD. graduated from Duke University School of
Medicine in 1974. Behrreen June 1974 and June 1977, he completed a residency in family
medicine at the University of Califomia at San Diego l-tehas been licensed as a
medical doctor since September 1975.5

33. Since 1977, Dr. Norcross has been an or professor of family
medicine at various Institutions.

34. Since 2007, Dr. Norcross has been a clinical professor offa'nily medicine at
the UCSD School of Medicine- -

35. Since 1996. Dr. Norcross has been the Director of the UCSD Physician
Assessment and Clinical Education program. Dr. Norcross testified that the
California Medical Board and Arizona Medil Board have referred many physicians to the
PACE program for evaluation of their knovriedge and skills. 

Muirements- for than Testimony

36. Dr. Greene had admitted into evidence the Standards of Professionalism for
Orthopaedic Expert Witness Testimony from the American Association of Orthopaedic
Surgeons?r Dr. Greene atmtted Dr. as failing to meet the mandatory standard
that ?[aln orthopaedic expert witness shall provide evidence or testify only in matters in
which he or she has relevant clinical experience and knowledge in the areas of medicine
that are the subject of the proceeding.?

The mandatory standards also required an expert to review ?all pert'ment
medical records pertaining to a particular patient prior to' rendering an opinion on the
medical or surgical management of the patient" and to "provide opinions andr'or factual

testimony in a fair and impartial manner.?

 

'5 Dr. Nercross? curriculum vitae ls Greene Ex. 143.
Greene Ex. 123.

 

33. Dr. Saiz admitted that he had not reviewed all patient records. Dr. Saiz was
also Dr. Greene's former partner and had cared for some of the patients for wl?rom Dr.
Greene?s care was at issue in these comptaints. Dr. argued that Dr. Sat:
therefore did not meet the Standards of Professionalism for Orthopaedic Expert Witness
Testimony.

EVIDENCE REGARDING DR. CARE DFTHE 13 
Case No. HEW-0723A.


39. DE was 72-year-old female patient who had been diagnosed with Hepatitis
0. Dr. Greene diagnosed her with degenerative scoliosis, degenerative ?at back
rotary lumbar listhesis. and lumbar spinal stencsis. Dr. Greene testi?ed that he
had discussed the h'gh risk of surgery, including death, with DE, but metal-re had elected
to proceed with the surgery because she had no mality of life due to her spinal condition
and was suicidal. i

40. Du May 10, 2007, Dr. Greene performed the anterior surgery on DE with a
vascular surgeon in attendance, performing an anterior lumbar reiease with anterior
lumbar interbody fusions and buttress plating. Dr. Greene estimated bloodless
during the May 10. 2007 anterior procedure to have been 800 so.

41. Post-surgery, DE was monitored in the hospital, transfused and given epogen-
Her hemoglobin increased from 9.3 on May 12, 2007 to 1 1.2 on May 14, 2007. DE's
coagulopalhy studies were within normal limits with a PT of 12.0 and an INR of 1-0- DE's
liver studies showed on ly mildly elevated AST.

42- On l'lr'layrr 15, 2007. Dr. Greene retumed DE to surgery forthe second stage of
her procedure. His only assistant was a surgical assistant. Dr. Greene's operative report

10

 

cameranoted that he performed a posterior instrumented fusion from with Smith-Peterson
Osteotcmies at L3-L4, L5-S1. T6-T7, and T1D-T11 .

43.
more than usual during the lumbar portion of the procedure, which he characterized as
?oozing.? after he had placed bilateral screws from the sacrum up to L2. Dr. Greene placed

In his operative report for May 15, 2007, Dr. Greene described DE as bleeding

some tamponade sponges and continued with the procedure.

44- During the procedure. DE received seven liters of Mo units of fresh
frozen plasma, 17GB cc's of cell saver. and eleven units of packed cells. Dr. 
testi?ed that DE was given a total of almost 13,000 cc's- of fluid which is more than twice
her total blood volumes Dr. testi?ed that the documented ?uid replacement
suggests a more serious condition than the ?oozing? that Dr. Greene's operative report
described-

45. Dr. Greene expedited the normally 8-hour procedure to 5% hours and
emergency proceeded to the?reccvery room. Upon arrival in' the recovery room. staff
documented that DE was mottled, had a bruised tense abdomen' and was pulseless.

46. Within one minute of arriving in the recovery room DE coded and was
resuscitated with a return of pulse and electrical activity. DE received an additional four
units of packed red blood cells and four unis of fresh frozen plasma. but continued to bleed
from multiple. areas ncse. eyes. IV sites. and wound. Coagulation studies were drawn
and the results were drastilly different from those drawn before DE's surgery, which
demonstrated that clotting ability was severely compromised. with a- PT of 61. INR of
17, platelets of 21. and ?brinogen below 60. abdomen was distended. Dr. Greene

 

T. 37'atll. 4.5.

11

 

consulted a vascularsurgeon, who did not think DE would sunrise an exploratory
laparotcmy.

47. DE died less than an hour after she arrived in the recovery room. In his
discharge smnmar?y of June 12. 2007 and on the death certi?cate. Dr. Greene attributed
death to disseminated intravascular coagulopathy liver failure. and scoliosis
surgery with general anesthesia. No post-operative CT scan or autopsy was perfon'ned to
determine the actual cause of death.

48. lateral x?rays show an anterior protrusion of a screw through the anterior
cortex of 5-1. Dr. opined that either the screw or the instruments that Dr.
Greene had used to insert the screw into the sacrum had. caused a vascular injury. The
end of the screw was near the vena cava. Dr. testi?ed that the inns-operative
?uid replacement showed that DE had suffered a huge blood loss.

49. Dr. Greene suggested that such a'vascular injury would have been
catastrophic and would have been noticed immediately.

50. Dr. pointed out that DE was face-down on the operating table for
the posterior portion of the procedure. with her belly hanging free. This position would
have allowed blood to accumulate in the abdomen, causing the ?bmised tanse abdomen"
noted in the recovery room. From his prior experience with patient PH. for whom an
autopsy had con?rmed a vasmlar injury, Dr. Greene would. have known that not all
vascular injuries resutt in catastrophic bleeding.

51- Dr. Greene and Dr. Sat: suggested that DE's coagutopathy was caused by
liver failure from her chronic Hepatitis C. 

52. Dr. noted that Hepatitis is a slowly progressing disease and that
DE had been cleared for surgery.

12

 

72-year-old femaie in whom Dr. Greene had performed a T1 
posterior instrumented fusion with Smith Peterson osteotomies at L3-L4. L4-L5. and L5-S1
with interbody fusions of L3-L4 and L5-S1 on May 17_, 2007.

54- On July 9, 2007, Dr. Greene readmitted DK to the hospital for infection. An x?
ray showed that an interbody ge was migrating into the spinal canal. On July 10, 2007.
Dr. Greene subsequently performed sumery on DK for a debridement, removal of the
interbody go. and administration of antibiotics.

55. Although Dr. had initially faulted Dr. Greene for failing to provide
adequate medical records for  after additional records were produced. Dr. 
withdrew this criticism.-

56. A [octet?surgeryr infected lumbar spine woundand interbody migration are
surgical complications that in case required further surgical intervention. Dr.
opined that Dr. Greene managed both complications appropriately, as well as
an iatrogenic tear that occurred during the second surgery.

Dr. testi?ed that Dr. Greene should have reported the surgl
complications that occurred in case on July 10. 2007 in response to the Board?s
question less than a month later, at the meeting on August 9, 2007.

. 

58. MB was a 15?year-old female with a congenital scoliotic curve.

59. On March 24, 2005, Dr. Greene performed a posterior instrumented fusion
from T1 O?Stfor spinal stenosis. Dr. Greene's operative report documented his posterior
fusion and correction of scoliosis from T3 to L2 using C?Ann ?uoroscopy.

13

 

acumen

60. Dr. Greene reported in a progressnote on April 14. 2005 that his screw
placement was excellent witl'r no migration of screws-

61. Dr. Greene entered a or an of MB. which was taken on November 115.
2005. His report noted that the T-10 screw was not in the pedicie and the T-11 screw went
through the ccstovertebral joint. On December 7, 2005, Dr. Greene noted the
malposiioned screws, but called them ?acceptable.?

62. Dr. Greene testi?ed and had admitted into evidence at the hearing medical
literature that stated that screw placement in the costovertebral joint is suboptimal but
acceptable.?

63. When Dr. Greene?s partner at Sonoran. Denn Crandall. M.D., assumed 
care and ordered another CT scan in March 2006. he noted the malpositioned screws and
took MB to surgery on April 19, 2006 for removal of spinal instrumentation and repair of a
pseudoarthrosis with posterior fusion Dr. Grendel noted preoperatively that he

. was concerned about the danger posed by Dr. Greene?s placement of the screws:

I reviewed all of the images on the CT scan with the family
present. There are two screws of concern. The ?rst is on the
right atTB. This is lateral to the pedicle indenting the suit
tissues of the lung- The second is on the left at T11 in the
costoirrertebral junction and extending up to and undemeath the
aorta.

Dr. Crandall had also reported to the Board MB's case as a surgical complication of Dr.
Graene?s.

64. When Dr. Saiz was shown Dr. Crandall's records and an image of Ma?s
screws, he admitted on cross-examination that ?what screw is not within the bone and it is

 

9 Greene Ex. 2am; T. s1a-szo; 325: 52?. in. 10-20; 329-330; Ex. 150; T. 608-610.
1? Greene Ex. 54. 55.
Board's Ex. Tab 19.

14

 

lateral. That to me would be a cause of ccncem. . . . Clearly [the screw] is indenting the
pleural'sae'f2

65. Dr. Greene agreed that, in retrospect. he should have informed MB's family of
?the acceptable but suboptiml screw placement he was aware of at T1 But he
insisted that MB was not harmed by screw placement near her lung and eerie and that
there was only a theoretical risk of harm to adjacent structures.14 He insisted that the
primary reason for Dr. Crandll?s surgery was the pseudoarthrosis-



66. MO was a TD?year-old female who had been diagnosed with back pain
secondary to degenerative scoliosis, lumbar spinal stenosis and lumbar spondylosis.

07. On June 30, 2005. MC had a two-stage surgical procedure of the spine in
which a vascular surgeon performed the anterior approach and Dr. Greene performed the
postenor approach. The anterior approach was accomplished in approximately-4.5hours,
wihoul: incident. 

68. At 1300 hours. or 1:00 the anesthesiologist noti?ed Dr. Greene that MC
was developing acidos.15 

69. M1309 hours. or 1:09 Dr. Greene started the posterior portion of the 2-
stage surgery on Dr. Greene noted that MC had a dural tear and metabolic
acidosis."

7U. Ai?rough the aneslhesiclogist reported persistent blood pressure problems at
approximately 3:30 the surgery continued for three more hours.18

 

 

 

1: T. 115, II. 10-14.

T. 327-323. 868.
T. see-so, 513.

1: Greene. Ex. 59.

17 Greene Ex. 59.
Greene Ex. 56.

15

 

arterial blood gases were measured at 7.43 at 10:59 am.
7.33 at 12:16 pm, 7.32 at 3:13 pm. and 7.17 at 5:19 pm.19 Dr. Greene testi?ed that the
normal range was 7.35 to 37.45.?

72. Dr. Greene testi?ed that, initially. the anes?'resictogist told him that MC's
acidosis was resolving and that he could continue with the posterior surgery.21 After the
anestl'iesiolog'et informed him that the acidosis had returned. Dr. Greene testi?ed that the
anesthesiologist did not tail him to terminate the procedure but, instead. advised him to
expedite it.22 Dr. Greene then called in his partner, Dr. Crandall. to expedite the surgery.

73. Dr. testi?ed that the surgeon. not the anesthesiologist, is
responsible for making the decision whether to proceed with or terminate a surgery.

74. Dr. Greene and Dr. Saiz both testi?ed that the decision to continue MC's
posterior surgery was a I"judgment call? that was up to the surgeon and, in light of the
alleged advice item the anesthesiologist, defensible.

75. Dr. testi?ed that anestl'resia records documented ?uid reptacement
at 17,500 ode.ii He testi?ed that blood loss with rroiume replacement reduces a patient?s
ability to clot and causes acidosis.

T6. MC was taken post-surgery tor an emergency heart catherization and was
given a dose of Heparin. Her hemoglobin dropped from 15.3 (normal) at 1345 hours to 4.4
at 2215 hours-? The physician who performed the camerization reported that it

 

'3 Greene Err- 57-
?9 Greene Ear. 58.
at 9845, I. 21-
T. 533?534. II. 1-15, 53? II. 1-1

2211531.3. 11. 1945; 537. ll. 1?23.
?3 See Greene Ex. W.
i? T. 540. 542. eds-4?; Greene Ex. 132).

16

 

demonstrated no coronary occlusion and attributed MC's myocardial injuryr to hypotension.
He also noted that MC had lactic acidosis.

77. Dr. Saiz admitted that a CT scan of MC taken one day post-surgery
demonstrated a sacral protruding However, Dr. Saiz opined that bi-
cortical purchase at St was an acceptable screw placement that likely would not have
caused any vascular damage because there are fewer vascular structures at that level
than at the thoracic ierrels.26

73- Dr. Greene testi?ed thatthe administration of Heparin caused MC to bleed
generally with blood accumuiating intraperitoneal and retoperitoneal.?

79. MC's condition continued to deteriorate and, on July 22, 2005, she died- Dr.
Greene's discharge summary did not report that MC had developed acidosis before he
started the anterior portion of her surgery.? .

80. Dr. Greene testi?ed that, since MC's surgery; he no longer attempts to do the

anterior and posterior stages of multi=level aduit deformity surgery-on the same day, but

instead performs the two stages at least two days apart29

01. WR was a 65-year-old male whom Dr. Greene initially evaluated in the hospital
on August 5, 2005 and diagnosed with a vertebral cstecmyelitis and psoas abscess.
82. WR returned to the hospitai on August 29, 2005, complaining of dif?culty

walking.

 

717.1.25.

T. r13. 1. 3-17?.
2? T. 547, ll. 4?20; 551-552}.
2" Greene Ex. 61.

291984, ll. 5-21.



 

September 1, 2005, Dr. Greene performed an anterior surgical
debridement and reconstruction on WR, with the assistance of a vascular surgeon to
Iolize the blood vessels.?

84. During the dissection, Dr. Greene iacerated vena cava, which was
repaired by the vascular surgeon. WR required a blood transfusion.

85. Dr. Greene presented medical literature. which indicated that there is a greater
than 15% vascular complication rate for the type of surgery that he performed on WR. This
is why he had a vascular surgeon present and participating in the surgery.

06. Dr. Sat: called the type of surgery that Dr. Greene performed in WR "a
mine?eld? and testi?ed that ?[ilt?s only a matter of time before you have a vessel injury. So
having a vessel in'pry in this scenario is completely within an expected complication and
his treatment was-within the standard of ref?



37. TB was a 63-year-old male w?h a history of? numerous prior-spine surgeries-
Dr. Greene evaluated TB for complaints of chronic back pain in March 2005.

88. TB also had a history of a coronary bypass in 1995 and cardiac catheterization
in 2002 and was underthe care of Tit-City Cardiology Consultants.32

89. Dr. Greene requested rdiac clearance for TB. Tri-City Cardiology
Consultants administered a stress test to TB on March 9, 2005 and, after discussing the
?small to moderate risk of surgery from cardc standpoint,? issued a note ciearing'TB for

spinal surgery.?

 

3" Greene Ex. T13.
3? T. 423427; Greene Ex. 129, 34. 35; T. 610-620.
32 Greene Ex. 63.

3" Greene Ex 64. 65.

18

 

March 22, 2005, Dr. Greene performed a posterior fusion on TB for
lumbar stenosis and degenerative disease.?

91. TB suffered a dural tear, which Dr. Greene did not recognize during the
surgery. The day after the ?rst surgery, TB showed classic synaptoms of a dural tear and
Dr. Greene performed a second surgery to repair it.

92. Dr. Greene and Dr. Saiz tesli?ed that the risk of dural tears increases in
revision surgeries, from 5% in initial surgeries to 18% in? revision surgeries.- due to the
presence of scar tissue from the prior promdures.35 Dural tears are notorious for not been
seen initially and for being difficulttc repair.??6

93. Although Dr. Greene interpreted a CT scan report to demonstrate excellent
position otthe screws, post-surgery. TB had a foot drop on the right. which is a permanent
injury that requires TB to vvear a foot brace.

94- Dr. Greene testi?ed that the risk of a foot de?cit from this type of surgery is' -
approximately 3 to Dr. Saiz testi?ed that, when the patient endiihits a nerve injury post? 
opera?vely, an error by the surgeon cannot by inferred:

The three factors lh'at come [to mind are, number one, scar
tissue. mobilization of the nerves as well as straightening out
the general scolbsis in all predispose nerves to change post-

Op.

This was a tEChnically dif?cuit case and there was nothing in
[Dr. Greene?s] technique that caused the patients change
aside from the main purpose of the surgery which was
deformity correction.

 

if; Greene Ex. 56.
T. rr1-rr2; 624-625.
a? T. 625. 7?5.

19

 

95. Dr. had testi?ed that nerve injury is a complication of the surgil
procedure that can happen ?usually either due to manipulation or hection on a nerve or in
cases of hardware being utilized. either a marl-positioned sciew or some piece if
hardware'm But Dr. Meezvnsid admitted on owes-examination that TB's foot drop, or
increased neurologic de?cit. was ?not due to any identifible deviation from the standard of
care by Dr. Greene."33

DC [Case No. 

96. DC was a 67?year-old female who had had a Kiiphoplasty'i"a for a compression
fracture of the spine at Ll performed by a surgeon in the State of Washington on August 8.
2005. She had returned to Arizona.

On Septemher15. 2005, Dr. Greene evaluated DC. He documented that she
had tow back pain and right lower extremity numbness and weakness. DC ambuhted with
the aid'of a walker and had right leg weakness or iliopsoas, L4 nerve root strength had numbness at and intact sensation at 15-31. Dr.
Greene noted that imaging studies demonstrated cement in the spinal rial. Dr. Greene
recommended a and cement removal due to motor weakness.

98- 00?s ore-operative EMG was reported as normal.

99. On September 22. 2005, Dr. Greene performed a laminectomy ofT1 2-1.2,
medial facetectomy on the right T1242, and removal of intradural and extradural cement
with mass e??ect and repair. His operative repoit states that noticed that there were
some signi?cant rootlets that had been probath severed during the procedure. but had not
su??ered any damage from my removal.?

 

3" T. 35. ll. 4-9.

3" T. 241?42, I. 23-1.

is a minimally invasive procedure that utilizes liquid bone glue within the vertebrae.
Greene Ex. 100.

20

 

 

100. A September 23. 20:35 post-surgical progress note-documented an
unchanged sensory examination but decreased motor strength of the right lower extremity.
A September 24. 2005 post-surgical progress nete documented an unchanged right lower
exhemity. 

101- A right foot drop was noted on September 25 and 26, 2005. post-
surgical progress showed a continuing right foot drop that was not present prior to Dr.
Greene?s surgery.

102- Dr. questioned Dr. Greene's decision to operate on DC. despite a
normal EMG.

103. Dr. also testi?ed that a neurologist assisting at the surgery may
have bene?ted the DG'soutcome.

104. Dr. Greene testi?ed that, before he operated on US, he presented her case-to
his partners. All of his partners agreed that surgery should?be performed and that. he, as

an' orthopaedic spinal surgeon, was competent to periorrn the surgery. There issigni?cant

overtap between the areas of expertise of spinal surgeons and neurologists.
RW [Case No. 

105. RW was a 47?year-old male who had a history of chronic back pain. Alter a
back surgery in 1997, he was prescn'bed large doses of Vicodin. Oxycontin, and Morphine.
When he Was refened to Sonoran. he provided a note stating that he had ?an incredible
tolerance for narooiics.?41 Dr. Greene?s October 4. 2005 report of his initial examination of
RW notes that has tried all narcotics. but says he is basically immune to them all-?

 

?1 Greene Ex 7'7.

21

 

LIJMH

106. Dr. Greene performed surgery on aw on December 15, 2005,1m1h an initial
anterior approach and fusion of and L5-S1 with anterior buttress plates and BMP,
and then a posterior fusion of L4-L5 and with screw and rod ?xation.

107. A progress note dated December 2005 documented that RW was intact
to motor and sensoryr examination and his abdomen was soft and distended. The" plan was
for pain control.

108. Dr. Greene's partner, Dr. Saiz, saw RW on December 18. 2005. Dr. Saiz
noted that RW appeared comfortable and was started on oral medications.

109. Nursing notes dated December 19, 2005 documented that Reras using IV
Diiaudid for pain relief.

Rw was discharged from the hospital on December 19, 2005. Dr. Greene?s
discharge note documents that RW was doing better with pain control, had intact MN, and
was voiding well. RWs diet was advanced, IV Dilaudid discontinued. and RW was
discharged. Dr. Greene prescribed Contin 30 mg BID and oral Dilaudid 4 to 8 mg -
every 3 hours to RN.

111- The only medication instructions that are documented as having been given
to RW are the hospital's standard ?general infon?nation of medication use."42 These
instructions cautioned patients not to hire more or less of prescribed medications.

112. was readmitted to the hospital on December 20, 2005, with abdominal
pain and distention. An x?ray demonstrated a high grade partial ileus. The initil
ccnsuiting physician noted that, after Dr. Greene's surgery, RW had been placed on a
liquid diet but had passed no tialus post surgery prior to dismarge when his diet 1was
advanced. He recommended an MS tube and N?uids.

 

?GreeneEx.85.

22

 

10
11

12

13'

31-4513. Dr. Greene testi?ed that he did not own a stethoscope. He did not remember
whether he had borrowed a stethoscope to listen for bowel sounds. Instead he relied
on nurses? which documented bowel sounds and ?atsz on Deoemba 16, 17, 18,
and re, 2005 and a bowel movement on December zoos.?is

114. Dr. Greene testi?ed that he routiner asked patients whether they are passing
gas, have had a bowel movement. or are experiencing nausea or-tromiting before
discha'ging them.?

115. Dr. testi?ed that a physician should personally listen for bowel
sounds before discharging a patient. especially aftera surgery such as Dr. Greene had
performed on Rw and administration of Dilaudid. Dr. Greene's reliance on nurses and
statement that he did not own a stethoscope was ?arrogant.?

116. Dr. Sat: agreed that our probably had an ileus Iwhen Dr. Greene discharged
him. 3' 

117. Another. physician discharged RW on December 24, 2005. after-he was.
tolerating oral intake and passing gas. The discharging physicim prescribed 
every six hours.

113. On December 29, 2005. RW died from a drug overdose. The autopsy report
showed that aw had takenbetween and 3 times the dosage of MS Contin that Dr.
Greene had prescribed, in addition to much lower doses of prescription that he had
not prescribed.

119. Dr. testi?ed that MS Contin was a time-release pain medication
thatwas indicated for chronic pain control. It was not recommended for acute post-surgical
pain control. The danger of prescribing a time-release medication for acute pain was that

 

?3 T. 492-497] 502; Greene Ex. 79. SD. and tabbed nurse?s notes tor12118r'05 and 12(191'05 in the Board's
EX. U.

23

 

the patient would not experience expected relief nd would take more of the medication.
Patients need to be advised that they should nottake MS Contin with cthersedative
medications.

120. Dr. Greene testi?ed a timerelease medication like MS Contin is a more
humane altemative to immediate relief medications because it provides a more consistent

md email}; relief.
AZ [cm No. 
121. AZ was a 24?year-old male with a three?year history of low back pain and

numbness in his right leg and foot from a motor vehicle accident in 2001.

122. On September 23. 2065. Dr. Greene performed surgery. His report
documents transforaminal lumbar interbody fusion of interbody cage placement at
L4-L5 and posterior instrumentation aid fusion wilh pedicle screw ?xation.

123. According to Dr. report-45 on September 24, 2005, a Dr. Singh
evaluated AZ in the hospital fora complaint of headache. Dr. .Singh?s note of the
consultation indicates ?mig raine 

124. A2 was discharged from the hospital on? September 26. 2005.

125. In a progress note dated October 13. 2005, Dr. Greene documented that AZ
had increasing pain in his lower back and serous drainage.? There was some redness
around the incision. AZ reported that he had taken a neighbo?e Cipro for a. ten days. Dr.
Greene continued AZ on Cipro because ?[a]ny time you have signi?cant drainage it can

increase the risk of infection. . . 

 

T. 493.

24

 

10
ll

12.

13-

?14126. In a progress note dated November 8, 2005, Dr. Greene dowmented thatAZ
had increasing back pain, fever at night. nausea and vomiting.? Dr; Greene
recommended surgil drainage-

127. Dr. Greene perton'ned surgery on A2 on November 10. 2005. He
documented irrigation and debridement of the lure bar spine around With closure over a
drain.?? Dr. Greene noted no purulenoe but did note an intense amount of drainage from
the ?sewers.? AZ was discharged on November 12. 2005.

123.

lumbar spirre. which Dr. Greene continued to atln'bme to the seroma rather than infection.

AZ was continued on antibiotics and continued to experience pain in his

In a progress note dated November 22. 2005, Dr. Greene noted thatAZ was ?going to try
to go back to work fairly soon.'5? 

129.
AZ probably had a cerebral spinal fluid close)- Iealr.? or. Greene stared-thaw did not

In the next progress note, dated December 20. 2005,.Dr. Greene homo that

have a CSF leak during my surgery but the pab?ent did have only preoperativer after his
IDET procedure. He had a success?ri blood patch because of this by Dr. Wolff and I think
maybe he has a recurrence of this dural leak. Why it would happen at this time frarne i
have no idea but it looks like it is.?

130. AZ had undergone surgery on March 11. 2005 by Michael Wolff. MIL, for an
intedaminar epidural injection and blood patch to repair a CSF at Lei-L5.52
131. On December 22. 2005, Dr. Greene performed surgery on A2 for blood

patches and dural repair. Dr. Greene?s operative report documented tie Iunioar

 

?in
1'?Greene Ex. 116.
5"Greene Ex.115.
51rd-
?ereene Ex. 111.

25

 

 taminectorny for a dural leak: at L4-L5 with soar revision and dural repreir.53 He noted ?rst
he could not lolize an anterior dural tear but placed Duragen and ?brin glue around the
dura.

132. On December 20. 2005. another physician evaluated AZ for headaches and
noted thatAZ had post-surgical meningitis improving with antibiotics and recommended
transfer to a neurologist.

133. On December 30, 2005. neurologist Arnold B. Calica, MD. evaluated AZ and
noted that his lumbar pundure showed evidence of bacterial meningitis.? Dr. Calico
reviewed a December 29, 2005 myelogram aid noted a left paramedian CSF leak or
psemtomeningocoele. A CT seen from the same day;' reported that there was left posterior

paramedian theoal sat: dehisoenoe. Dr. Calica noted screw tract medial to the sorevv site

used on the left and recommended neurosurgioal exploration.

134. AZvvae returned to surgery for dual repair on January 13, 2006  Dr.
Theodore. Dn Theodore?s operative report documents his Iaminectomy at with'e -
porcine collagen patdr repair of a large posterior dural defect and placement of a drain- He
noted that after a complete lamineetomyir there was ligamentum flava adherent to the dura?
and, after removal, he found a large posterior dural defect.

135. Subsequent medical records indicate that, through 2007. AZ required
continued pain management with tentanyl patches and Percocet. A recent MRI in 2007
showed post-operative changes of taminectomy and fusion and interpedicutar screws at
Lat-L5, clumping of the roots from L3 through L5 and extensive scarring at 

 

53 Greene Ex. 1111
?Greene Ex. 11?.

26

 

136. Dr. Greens testi?ed at hearing that the incidence of a dural tear during spinal
surgery is between 6 and His incidence was around despite doing a lot of
revision surgery.?i

137. Dr. Sat: testi?ed that. after Dr. Greene's fret surgery, AZ's were
consistent with an infection and that AZ did not have signs and of a dural tesr
through Dr- Greene's second surgery.55 Dr. Saiz testi?ed that the December 2, 2005 ids:57
showed no fluid collection. which 1would have been expected ifAZ had an undiagnosed
dural tear.? Dr. Saiz testi?ed that, when AZ did not improve, a second surgery' was
performed by two spinal surgeons, Dr. Greene and his partner Dr. Appel, and that they
appropriately treated the suspected leak even though they could not?nd 159

RJ {Case No. MEN-DWI

1138. RJ was a 45-year-old male who was referred to Dr. Greene for complaints of
chronic cervical pain- He had undergone spinal surgery in 2005.?

139." Dr: Greene ?rst saw RJ on July 24, zoos.B1 Dr. Greene noted that RJ
complained of left and right upper extremity pain. Dr. Greene?s examination noted
weakness of le? arm with no upper motor neuron signs. Dr. Greene did not thinkthat
RJ was a ndidate for surgery and recommended a spinal cord stimulator. 

 

5? 765.
5? ear-555.
5" Greene Ex. 133.

T. ass.
T. 659-
:Greene Ex. 102.
Greene Ex. 103.

27

 

2-5

 

 

140. On August 16. 2006. Dr. Greene performed surgery to place a spinal cord
stint ulster.? He documented a laminectomy at C3-C4 with placement of a spinal cord
stimulator.

141. In a progress note dated Aunst 28, 2005, Dr. Greene noted that RJ was
?getting excellent left arm pain relief right now, but states that his right arm is absolutely
'kiiling him.?63 Dr. Greene noted than nut-ray showed that the spinal cord stimulator lead
was a ?little bit off to the right in the upper cervical spine.? Because ?lead placement should
be excellent.? Dr. Greene had arranged to meet with the stimulator?s mamfacturer. Dr.
Greene noted that RJ's neurological examination was the same.

142- On September 1. 20:16, Dr. Greene performed a second surgery for revision
of the spinal cord stimulatorlg?l He noted that he attempted to position the lead on the
stimulator at least 30 times and that subsequently the paddle lead broke. Dr. Greene
attributed his dif?culty in piecing the stimulator to a defect in the paddle.

141- Dr. Sat: testi?ed that 30 attempts to position the lead on the stimulator was 
excessi'lre.85 But he testi?ed that it was quite common for a surgeon to experience dif?culty
in placing the paddle-and possible for a surgeon to make 30 Dr. Greene noted
that RJ was neurologically intact upon awakening.

144- A progress note by a med! assistant dated September 2, 2006. noted that
RJ was intact neurologilly and ooutd be discharged.

 

?2 Greene E1 104.
?3 Greene Ex. 103.
5? Greene Ex. 105.

?5 T. 734, ll. 
it"T. see. ll. 1e12, 2042.

28

 

145. Dr. Greene testi?ed at the bee?ng that he had positioned me spinal cord
stimulator over oervil dura at 03. C4 to mask RJ's 

146. In an of?ce note from CORE dated September 1. 2006, Dr. Greene noted
that he ?had to reposition the stimulator because it was a little too close to his right cervical
nerve root 03 and No neurolog examination was recorded.

147- Dr. Greene?s subsequent office note from CORE dated September 13. 2006,
noted that RJ's wound was healing well, the paddle was in excellent position, and 
right arm pain was slowly Dr. Greene placed RJ on Medrol Dosepaok for the
residual right arm No neurological examination was recorded.

148. On October 23. 2006. Dr. Greene noted that Ed had increased pain since he
had started physical therapy.? Dr. Greene advised RJ to stop the physical merapy. Dr.
Greene noted that RJ was Heuroiogically intact except fornumbness of the right hand. Dr.
Greene noted RJ's previous dianosis (if-carpal tunnel expressed concern
about a double crush and pissed-M?s right arm in a splint.

149. On or about November 2, 2006. Dr. Greene?s partner at CORE. Dr. Apps-l.
saw Dr. Appel documented that RJ had more pain with the spinal oord stimulator on
than off and appeared niyelopathic with a Hcflinan?s sign of the right upper extremity. 3
beats of ohnus in the lower  and weakness of the right upper extrenity. Dr.
Appel recommended an MRI scan and removal of the spinal cord stimulator.

 

5? T. 837-841.

29

 

tutor150. On November 20. 2006, Dr. Greene removed the spinal cord stimulator that
he had previoust implanted in Rd."2 0n the ore-surgical physical, he recorded no nerve
de?cits. Dr. Greene documented his removal of the spinal cord stirriulator and noted that.
as he pulled it, some ofthe titanium sensors came off. Dr. Greene accounted for ?nding 15
of the 16 titanium beads.

151. An MRI of RJ dated December 12, 2006 recorded a signal alteration in the
posterior cord at 03?04 and 04-05 with a somewhat cystic appearance at 04-05. It was
noted that thiswas not seen in prior studies and may have indimted a myelomalacia. Also
noted was the central disc protrusion at 03-04 and a right paracentral disc protrusion at
04-05, which appeared unchanged.

152. Dr. Greene transferred RJ to his partner Dr. Appel. who on December 15,
2006 noted that RJ had signi?cant pain of the right upper extremity with some gait
abnonnalities and clumsinms of the right upper extremity: Dr. Appei noted MRI scan
evidenced myelomaiacia at 03-04 and and recommended a surgical
decompression.

153. On December 27, 2006. Dr. Porter consulted on RJ's case. Dr. Porter
recommended an anterior diskectomy at 03-04, 044:5. and plate removal at 05-06 for
cenrical spondyiosiswnh cord compression and a myelopathy at 03-04 and 04?05. This
was completed on Fehnrary 22, 2007.

154. RJ was seen by neurologist Dr. Kahlon on May 22, 2007. Dr. Kahlcn
diagnosed RJ with chronic pain and cervical radiculopathy post cervical spine
surgery. RJ has been under the care of a physician for pain management since March
2007.

 

 

 

7? Greene Ex. 106.

'30

 

155. Dr. Greene testi?ed that the signal intensity at 04-05 was below where he
placed the spinal cord stimulator at 02.73

156. Dr. Saiz noted that was doing well until physical therapy and that the MRI
demonstrated that RJ's was a progression of his underlying oonc?tion. not
due to Dr. Greene's placement oftha spinal cord s?nmlator.? RJ had severe spinal
stenosis that progressed, with reversal of cervical lordosis, bulging. and impingement of the
eord from the front and hook.i5 Dr. Sat: explained that the cystic changes on the MRI were
below Dr. Greene?s surgery and that the architectural changes in RJ's spine (front and
back) most likely caused the signal shanges5'E

157. Dr. investigative report to the Board noted that ?[tjhere is a very
high adverse event rate in spinal oord stimulator prooedures reported in various studies
beaveen 30% and 

. - so. [Case NOJMB-QTMEAI

158: DC was a TQeyear-old female .on Mrom Dr. Greene had performed surgery
on February 15, 2007. His operative report documents his revision iaminectomy at L3-S1
with foraminotomies on the left at Dr. Greene testi?ed that he discharged DC on
Febmary 1s. 2.007 with instructions to see him for follow up in another two weeks."

159. DC stated that she returned to the CORE institute on February 26. 200? for
staple removal. Although there is no dictated summary of her visit, check-out

 

 

 

7?3 T. 855?856.

it T. 671. on.

?5 T. omen. sen-s1-
?5 T. omen-

Board Ex. CG.

T. 559.

31

 

sheet shows that DO was seen. her staples were removed, and was told to return in four
weeks?9

160. Dr. Greene testi?ed that his typical follow up regimen is to see laminectomy
patients at two weeks, six weeks, three months and six It is the patients?
responsibility to schedule successive appcintments before they leave alter an appointment.
but sometimes they do not.?

161. DC called CORE on March 4, 2007, stating that she was doing well and was
ready for physical therapy and requesting an authorizalion from CIGNA for her therapy.arz
Dr. Greene provided the referral.as

162. DC and CORE coordinated for a physical therapy appointment on April 4.
sore.M

163. On June 4, 200?, DC complained to her primary care provider at SIGMA that
she had not bene?tted from Dr. Greene's surgerr and that she was dissatis?ed with the
care she had received at CORE because Dr. Greene ?took approximately seven weeks to
send her to her and . . . when she calls she doesn't get any answer.was

164. The ?rst follow up report from CORE was from a physician?s assistant and
was dated July 3, 2007. The physician?s assistant mported that DO stated that ?although
she was doing well at her two-week checkup following the surgery and sutures were

removed, she was not able to start physical therapy until several weeks later, and she is

 

7? Greene Ex. 95%.
soc-e1, ass.
T. 5E3.

5* Greene Ex. see; T. 564.
33 Greene Ex. 950; T. 565-
3? Greene Ex. 96; T. 556.
Greene Ex. 97.

32

 

here today indicating that her pain has returned to almost baseline in intensity in the same
distribution that she had beforef?a I

165. Dr. Greene and Dr. Sat: testi?ed that Dr. Greene had met the standard of
care for the follow up of DC. Dr. Greene saw DC two weeks post-surgery and instructed
her to retum to the office in four weeks, but she had not made an appointment. Instead,
DC called on March 4, 2007, requesting assistance in scheduling physiwl
therapy.

CD [Case No. 

166. CD was a 36?year?old male upon whom Dr. Greene performed L5-81 .
laminectomy, and instrumented fusion on May 25, 2007.37 On June 4, 2007, on retumed
to Dr. Greene. complaining of left groin and hip pain.? Because x-rays did not reveal any
problems, Dr..Greene ordered a CT seen.

167. A CT scan was performed on CD on June 8, 2007- John Simon. MD.
reported in relevant part-astollowsz-

The right 31 screw is oorntairred totally within the osseous
structures; however, the left 81 screw does extend out of the
anterior cortex approximately 1.1 cm. the tip tying 2 to 3 mm
from the common iliac vein. There is approximately 5.5 mm 'of
anteroiisthesis of L5 on 81. Bony fusion masses are seen
posteriorly as well. There is soft tissue stranding
postoperatively- Extensive streak artifact from postenor freion
hardware limits evaluation of the immediately "adjacent soft
tissues for ?uid oollection and abscess. No de?nite coilec?ons
are seen; however. no contrast was administered. . . .39

 

3? Greene EX. 98.
a? Greene Ex. T2.

5? Greene Ex. 'r'tiA.
a? Greene Ex 

33

 

1168. On June 9. 2907, Dr. Greene's progress note re?ects that he informed DC
that he ?had looked at his previous CAT scan. His serene look ?ne, no issues here's?

169. On August 31. 2007. DC was seen by another physician, Jonathan C.
Landsman. MD. Dr. Landsman reported the extension of the St screw beyond the
anterior cortex, but reported that he was not able to download the CT scan itsetf. Dr.
Landsman ordered a hard copy of the June 8, 2007 CT scan and ordered an MRI of DC's
lumbar spinal)?1

170. Because DC felt that Dr. Greene had misrepresented the results of the June
8, 2607 CT scan, he made a cornptaint to the Board.

171. Dr. Greene testi?ed that. atthough the placement ofthe $1 screw in BC was
suboptimal, the screw was de?nitely in the safe zone.?

172. Dr. Sat: testi?ed that theplaoement of the 81 screw was acceptable and
within the standard of care. -. There is no standard ofcare on whether to discuss screw
placement, unless the screw poses atrial: of neurovascular injury!"3 Dr. Greene's faiure to
discuss placement of the St screw with DC was within the standard; DC was not harmed
thereby.

1?3. Dr. Green testi?ed that. although the placement of the S1 screw was
acceptable and will not harm DC, in retrospect he should have explained it to 

SN {Case No. 

174. SN was a 65-year4lld female patient with diagnoses of spinal stenosis and

degenerative scoliosis. SN had no neurological ddicits.

 

Greene Ex. Toe.
92 Greene Ex. 
T. sis-580; Ex. 129.
T. 
T. 531, 975.

34

 

175. On April 10I 2007 Dr. Greene Operated on SN. acoomplishing a Iaminectomv
at transforaminal interbody fusions at and a posterior instrumented fusion at
+40 to L5-with a dural repair at Lane??

176. Dr. Greene testi?ed that, to ensue acceptable screw placement, he used
palpation, visualization, neurophysiological monitoring. intraopera?ve x-rays (?uomscopy).
and poet-operatirfe Hays.? Dr. Greene tati?ed that these methods all shmved
acceptable screw placement??

177. Dr. Greene?s progress note for April 1 2007'documented that SN had right
lower extremity pain secondary to nerve root irritation and an elevated white blood cell
scan, which he noted was secondary to steroids ?iat he had prescribed to her for nerve
root irritation. An April 11, 2007 x?ray report noted that SN was post-instrumental fusion of
the morass-lumbar spine-

178; Greene'reported on April 12, 2007 that SN continued to have'right lower
extremity pains He. reported on April 13, 2007 that ?ts right lower extremity pain was
resolving and that she was ready for transfer.

179. SN was discharged from the hospital on April 13. 2007. Dr. Greene?s
discharge note indicated 1lhat 8N had nerve root irritation post surgery and had been given
steroids. He attributed SN's continued elevated white blood cell count to having been
given steroids.

180. [in April 23, 2007. Dr. Greene examined SN at ru's cities at CORE. He
reported that answers ?havin a little bit of right hip pain, is getting-a little bitbetter.?
Dr. Greene also noted that Wound does not appear to be infected" but ?just Iookled]

 

'5 Greene Ex. 36.
T. Ber-see.
?7 sea.

35

 

like it [was] not completely healing appropriately?? Dr. Greene did not think that antibiotics
were necessary.

181. On April 30, 2007, Dr. Greene noted that wound had ?started to
breakdown a little bit" and noted ?signi?cant redness around the incision." Dr. Greene
noted that wound had ?not frankly broken down and dehisced.?99 Dr. Greene noted
that he had placed SN on antibiotics three days earlier.

182. On May 4, 2007, Dr. Greene reported that SN did not have signi?cant
drainage and that the drainage she was having was ?serous or serosanguineous, nothing
purulent." neurological examination was intact, although she was having ?signi?cant
right?sided radicular-type Dr. Greene ordered a CT scan, a Bad Rate, CRP,
and CBC.

183. An MRI scan of SN taken May 5, 2007 was reported as demonstrating dorsal
enhancement of the suggestive of an early epidural abscess and soft tissue swelling
posterior at compressing the dorsal ponion of the dural sac. The abdominal CT
scan was reported as showing no intra-abdominal abnormality.

184. On May 10, 2007, Dr. Greene performed surgery on SN to treat the wound
infection and to evaluate the hardware.101 Dr. Greene reported that, "even though two CAT
scans showed the pedicle screws were in excellent position, it looked to me as if at L5,

there was potentially nerve root hitting up against some of the threads of one of the

L5 screws. In addition, at the L4 screw, the pedicle, when I put the screw in, appeared to

be loose at some of the medial bone and maybe this was impinging on the exiting nerve

root-? Dr. Greene removed the two screws.

 

5'3 Greene Ex. 90.
99 id.

100 i
101 Greene Ex. 92.

36

 

185. SN continued to complain of pain through physical therapy, eventually
requiring a walker, although in September and October 2007 Dr. Greene noted that she
was ?slowly improving.""J2

186. On September 5, 2007, SN was evaluated by Dr. Greene?s partner, David
Jacofsky, MD, who reported that she had had left lower extremity discomfort since Dr.
Greene?s second procedure. Dr. ordered an EMG, which was taken on
September 6, 2007. On September 13, 2007, Dr. reviewed the EMG and noted
that EMG demonstrated a chronic right L5 radiculcpathy and bilateral L4
radiculopathies.

187. On October 1, 2007, Dr. Jacofsky reported that there was no evidence of
infection and that SN was improving.

188. Dr. Greene testi?ed that he had met the standard of care intraoperatively and
post-operativer because all monitoring techniques showed acceptable screw placement
and SN did not complain of post-operative nerve root pain in a dermatomal distribution to
implicate a screw. Further, he had followed SN closely, obtained a CT scan on May 4,
2007, which was reported as normal, and had returned SN to surgery on May 10, 2007.103

189. Dr. Saiz agreed that Dr. Greene had met the standard of care and that SN
did not have of a screw abutting against a nerve root, which typically results in
intractable, obvious pain.?J4 Dr. Greene had ordered a CT scan earlier than he would have

to identify SN's pathologym?

 

"3'2 Greene Ex. 93A and 933.
I: T. 337-90.
105 T. 688-91, 694-95.

T. sea-9T.

37

 

190. Dr. Greene and Dr. Saiz both testi?ed that Dr. Greene had not harmed SN
and that the screw placement did not cause 

191. Dr. testi?ed that, when he reviewed the May 4, 200? CT scan of
SN, he had seen the mat?positioned screw that Dr. Greene later documented in his
surgery. Dr. Greene had not personally reviewed the CT scan and had relied on the doctor
who had reported it. If Dr. Greene had ordered a CT scan immediately after the ?rst
surgery, or when SN began reporting he might have recommended surgery
earlier.1?7

DR. Gneeue?s THE PAGE PROGRAM

192. Dr. Greene voluntarily participated in the PACE program after the Board
summarily su3pended his license. Dr. Norcross testi?ed that, although it is not unheard of,
it is unusual for a physician to voluntarily participate in the PACE evaluation program.

193. Dr. Norcross testi?ed that the physician in charge of the orthopaedic program
is Wayne Akeson, MD.

194. Phase 1 of the PACE program involves administration of a 2-day
examination to evaluate the physician?s clinical competence and communication skills.
Phase 2 is 5?day clinical evaluation, during which the physician accompanies other
physicians and is evaluated in patient care. After Phase 2, ?ve to seven physicians,
including three from different specialties, conduct a multi-disciplinary meeting to evaluate
the physician.

195. Dr. Norcross testi?ed that he understood that Dr. Greene planned to pursue a

general orthopaedic surgery practice. Dr. Norcross testi?ed that Dr. Greene scored 97%

 

T. 390, 597. 742.
T. 355-56.

38

 

Phase Phase 1 cf the PACE program. On crossexamination,
Dr. Norcross admitted that Dr. Greene had scored in the 10th or lowest percentile on ethics
and communication.

196. Dr. Norcross testi?ed that Dr. Akescn had been provided with the Board?s
August 7, 2007 order of censure on the ?rst ?ve surgical complications in case no. MID-06-
0143A. The PACE program had not been provided any information regarding the 13
patient complaints at issue in this case. The additional complaints might have affected Dr.
Norcross' opinion of Dr. Greene's safety to practice.

19?. Dr. Norcross testi?ed that Dr. Greene displayed a solid fund of knowledge
and clinical judgment.

198. Dr. Norcross testi?ed that the PACE program evaluates its attendees
critically because it knows that licensing boards are relying on its judgment. Dr. Norcross
testi?ed that Dr. Greene had shown an excellent attitude and demeanor toward his
participation in the PACE program. Dr. Norcross testi?ed that a physician?s PACE
evaluations were a good predictor of future behavior.

199. In Dr. Norcross? opinion, Dr. Greene is safe to practice with a proctoring
requirement. Dr. Norcross explained that any hospitaI would require'sorne proctcring of a
physician who had recently been granted or been restored priviieges.

ADDITIONAL TESTIMONY

200. Dr. Greene testi?ed that. during the August 9, 2008 formal interview, he
misunderstood that the Board was requesting all surgical complications not only surgical
mistakes (complications from surgical techniques) of the type being discussed during his
interview in case no- He therefore did not discuss all complications related
to surgery if such complications were recognized or known risks of surgery. He admitted at

the hearing that he should have disclosed to the Board complications involving patients DE

39

 

(DIC and death), DK (infection and case migration), RJ (neurologic change), and SN
(infection and foot de?cit).

201. Dr. Greene testi?ed that, while he was in medical school, he was interested
in both spinal orthopaedic surgery and a general orthopaedic surgery that focused on
sports medicine. He felt that he had chosen the wrong fork in the road when he had
decided to become a spinal surgeon. He does not wish to continue performing spinal
surgery, in part because some of the cases at issue here have made him unwilling to
expose patients to the unavoidable risks of spinal surgery. He wishes to continue his
medical career as a. general orthopaedic surgeon.

202. Dr. Greene testified about and had admitted into evidence articles from
medical joumals about the high rate of complications, including complications of the sort
that occurred in his care of the thirteen patients at issue, during complex, multi?level andi'or
revision spinal surgery. He testi?ed as to the large number of spinal surgeries that he had
performed. Even considering the complications that occurred in the cases at issue, his rate
of complication was lower than the overall reported rate for comparable cases. For some
of his patients, he had ?hit a home run? and obtained extraordinary relief of 

203. Dr. Greene had admitted into evidence letters from his former partners,
spinal surgeons Dr. Appei, Dr. Jacofsky, and Dr. Saiz, who all have personal experience
with Dr. Greene on many cases, attesting to his judgment and skills. Dr- Jacofsky?s letter
stated that Dr. Greene?s rates while at CORE were comparable to other spinal surgeons
and that the complication rates ?are higher in this type of high risk patient population

despite the fact that these are some of the most talented surgeons in the 

 

Greene Ex. 3.

40

 

204. Dr. conceded that there is no question that Dr. Greene has
undergone extensive training by quality programs. Dr. questioned whether Dr.
Greene is safely able to practice, given his obvious lapses in judgment and errors
attributable to limited technical pro?ciency. These de?ciencies cannot be remedied by
additional training or oversight.

205. In response to the suggestions from PAGE and Dr. testimony, Dr.
Mocz?ynski offered the opinion that Dr. Greene should, at a minimum, be precluded from
any clinical practice involving direct patient care, and should be restricted to an
administrative practice. The Board's attorney requested that the Administrative Law Judge
recummend that Dr. Greene?s license be revoked and that he be assessed the costs of this
proceeding.

CONCLUSIONS OF LAW

1. The Board has jurisdiction over this matter?9 The Board properly referred Dr.
Greene?s request for hearing to the Of?ce of Administrative Hearings.??

2. The Board bears the burden of proof and must establish that Dr. Greene
committed unprofessional conduct as de?ned by applicable statute by a preponderance of
the evidence.111 Dr. Greene bears the burden to establish af?nnative defenses by the
same evidentiary standard.112

3. preponderance of the evidence is such proof as convinces the trier of fact that

the contention is more probably true than not."1 ?3 A preponderance of the evidence is

?[t]he greater weight of the evidence, not necessarily established by the greater number of

 

See 32-1401 et seq.
See A.R.s. 414.392.0243).
?1 See A.R.S. AAC. and see also vazanna v. Superior 
Ariz. 369, 372, 249 P.2d 33? (1952).
:2 See A.A.C. 
3 Morris K. Udall, ARIZONA LAW OF EVIDENCE 5 (1960}.

41

 

 

1'witnesses testifying to a fact but by evidence that has the most convincing force; superior
evidentiary weight that, though not suf?cient to free the mind wholly from all reasonable
doubt, is still suf?cient to incline a fair and impartial mind to one side of the issue rather
than the other."1 ?4
Case No. MD-07-0728A


4. The standard of care requires a physician to perform a surgical procedure in a
manner to avoid injury to vascular structures and, if excessive bleeding is encountered, to
terminate the procedure and determine the source of the bleeding.

5. The Board established that Dr. Greene more like than not departed from this
standard during his May 15, 2007 surgery on DE, when he encountered excessive
bleeding and continued the procedure rather than terminating it. As a result, DE died.

6. A physician is required to maintain adequate medical records, which means a
legible record containing, at a minimum, suf?cient information to identify the patient,
support the diagnosis, justify the treatment, accurately document results, indicate advice
and cautionary warnings that the physician has provided to the patient, and suf?cient
information to allow another practitioner to assume continuity of the patient?s care at any
point in the course of treatment.115

7. Dr. Greene deviated from this standard because he did not document pathology
for DE that necessitated the surgical intervention or any discussion of alternative

treatments.

 

?4 LAW at page 1220 (8th ed. 1999).

42

 

Dr. Greene admitted at the hearing that he should have disclosed the surgical
complications in case in response to the Board?s questions at the August 9, 2007
formal interview in Case No. MD-06-1043A-



9. The standard of care requires that a patient having posterior fusion for scotiosis,
the screws be placed within the pedicle and vertebral body so as not to create a risk of
damage to organs or vessels.

1D. The Board has established that Dr. Greene deviated from this standard by
placing at least one screw in spine that was malpositioned and by failing to recognize
that the screw was malpositioned.

11. MB suffered harm in that she required a second surgery for removal of the
malpositioned screws. In addition, MB was at risk for signi?cant complications as a result
of the malpositioned screws, including a pneumothorax and erosion of the aorta, which
could have resulted in massive bleeding and death.



12. The standard of care requires that, during an elective, two?stage surgical fusion
procedure, if the patient becomes unstable in anesthesia, the surgeon should delay the
posterior portion to another time.

13. The Board has established that Dr. Greene deviated from this standard of care

by continuing with the posterior portion of the surgery although he had been noti?ed that

 

?5 A.R.S. 32-1401 (2).

43

 

was developing acidosis. After Dr. Greene decided to proceed with the elective
surgery, MC died.
14. The Board has not established that Dr. Greene caused a vascular injury to MC

or that he should have been aware of excessive bleeding during surgery and investigated

its cause.

15. The standard of care requires that, when a patient requires surgery, the
surgeon should perform the surgery in an ef?cient and appropriate manner and avoid injury

to adjacent vascular structures.

16. The Board has not established that Dr. Greene deviated from this standard.
Even though Dr. Greene iacerated vena cava during the surgery, the evidence
shows that such laceration was within the known surgical risks and appropriater
addressed by Dr. Greene.



17. The standard of care requires that a patient with failed prior back surgeries
should be carefully evaiuated and that, ifthere is increased cardiac risk, the
recommendation should take that into consideration. cardiologist cleared him for
surgery, after discussing its cardiac risks. The Board therefore has not established that Dr.
Greene deviated from this standard in his care of TB.

18. The standard of care requires that surgery be performed carefully and
appropriater to avoid increased nerve injury. Although TB had a foot drop post-surgery,
which neurological de?cit he did not exhibit pre-operatively, there is no evidence that any
surgical error by Dr. Greene caused the de?cit. The Board therefore has not established

that Dr. Greenedeviated from this standard in his care of TB.

44

 

19. The standard of care requires that, ifa dural tear occurs during surgery, the
surgeon should repair it. Dr. Greene presented evidence that dural tears are notoriously
dif?cult to spot and are frequently not noted during surgery. He appropriately repaired the
tear after TB exhibited The Board therefore has not established that Dr.
Greene deviated from this standard in his care of TB.

DC (Case No. 

20. The standard of care for a patient with a neurologic injury due to extrusion of
cement into the spinal canal post-Kyphopiasty requires that the physician present the
patient with options, bene?ts, risks, and complications of treatment. Surgical intervention
should be accomplished in a manner to prevent further nerve injury if possible. The
patient's pre?operative and post-Operative neurological evaiuation should be accurately
recorded.

21. The Board has established that Dr. Greene deviated from this standard in his
care of DC. She suffered a foot-drop that was not present pre?operatively. Dr. Greene?s
disclaimer in operative report that he did not sever the rootlets is not credible, especially in
light of post?operative neuroiogical de?cit. Unlike the case of TB, there is evidence
that Dr. Greene negligently injured DC.

22. In addition, the Board has established that Dr. Greene deviated from the
standard by not discussing less invasive treatment options with DC, especially in light of
her normal EMG.

RW (Case No. 

23. The standard of care for an anterioriposterior lumbar approach is that the
physician should monitor for abdominal distention and the presence of bowel sounds. This
responsibility cannot be delegated to nurses. The Board has established that RW had an
ileus when Dr. Greene discharged him that that Dr. Greene deviated from this standard by

45

 

not checking RW for bowel sounds before discharging him. RW suffered actual harm in his
readmission.

24. The standard of care also requires a physician to advise patients about the
effects and dangers of the medication he prescribes, especially in combination with other
medication. The Board has established that Dr. Greene deviated from this standard by
prescribing MS Contin to RW, without speci?cally advising him of its delayed effect or effect
in combination with other sedatives, especially after RW said that he was ?immune? to
narcotics. RW suffered actual harm when he died of a drug overdose from a combination
of pain and sedative medications.

AZ (Case No. MT-OTBWM

25. The standard of care requires that, if a post-surgery complication occurs, the
surgeon should diagnose the complication through a careful history, physical examination,
and appropriate diagnostic studies. If the complication is beyond the scope of the
surgeon?s training and expertise, he should obtain appropriate consultation.

26. Clear serous draining post-spine surgery should raise concern for a CSF leak.
A CSF leak should be timely addressed to prevent the possibility of infection. If the
surgeon must perform additional surgery to resolve a CSF leak, he should resolve the
problem. The Board has established that Dr. Greene deviated from this standard of care.

27. Dr. Greene?s December 20, 2005 progress note for AZ re?ects a mechanism
for the dural tear that is inconsistent with the histories obtained by other physicians. This
inaccurate history may have contributed to his failure to appropriately manage the dural
tear.

28. The Board has established that Dr. Greene, as a result of his September 23,
2005 surgery on A2, created a dural tear posteriorly, which was unrelated to the area of the

IDET procedure, and that he failed to diagnose a CSF leak for almost eight weeks, despite

46

 

having surgically revisited the area and failing to correlate the non-purulent ?uid with a
possible CSF teak. Dr- Greene, on his third surgery on AZ,.failed to identify the posterior
dural tear and ascribed the CSF leak to a more ancient surgical procedure.

29. AZ, as a result of the dural tear and delayed diagnosis of that tear, had
apparently sustained bacterial meningitis. Additionally, AZ had to undergo three additional
surgical procedures after Dr. Greene?s initial fusion on September 23, 2005. AZ has
chronic pain and requires Fentanyl patches and has evidence of arachnoiditis on an MRI
scan at the surgical area. Dr. Greene placed AZ at increased of harm for a more
signi?cant episode of meningitis and was at risk of additional neurological changes or
death. I

RJ {Case No. 

30. The standard of care for a patient who is a candidate for an implanted spinal
cord stimulator is to have the procedure performed in a manner to avoid injury to the spinal
cord. After surgery of the cervical spine, the patient should have a documented
neurological evaluation. If the patient has changing neurologic condition, appropriate
diagnostic studies should be performed.

31. Dr. Greene's argument that the evidence does not show that his September
23, 2006 surgery caused a neurologic injury to RJ is based in large part on the absence of
any record of a neurological change until the December 12, 2006 MRI. This absence in
turn is based on Dr. Greene?s failure to perform a documented neurological examination of
RJ in his immediately post-surgery of?ce notes of September 1, 2006 and September 13,
2006. However, Dr. Greene?s of?ce note of October 23, 2006 stated that RJ was
neurologically intact.

32. Dr. Greene performed a laminectomy on August 16, 2006 at the level to

place the spinal cord simulator initially. This is one of the levels at which the signal



 

alteration was noted on the December 12, 2006 MRI. Both Dr. Greene and Dr. Saiz
testi?ed that Dr. Greene placed the paddle, after 30 attempts, at the CZ level during the
September 1, 2006 revision, which could not have injured 03-04 or C4-C5. This location
is not reflected in the Operative report.

33. The Board has established that Dr. Greene deviated from the standard of care
by making 30 attempts to place the spinal cord stimulator during the September 1, 2006
revision and by failing to document RJ's neurological status for the next six weeks.

34- But the Board has not established that Dr. Greene caused actual harm to RJ.

QC (Case No. Mp-cr?uaasm

35. The standard of care requires a physician to monitor a patient post-operativeiy
to evaluate recovery.

36. The Board has not established that Dr. Greene deviated from this standard in
his care of DC. Although Dr. Greene advised DC to schedule a follow up appointment
when he removed her staples, she failed to schedule an appointment.

CD [Case No. 

37. The standard of care requires that test results be accurately recorded and
communicated to patients. The Board has established that Dr. Greene failed to accurately
record or to communicate the results of the June 8, 2007 CT scan to CD.

38. The Board has not established that Dr. Greene?s failures potentially or actually
harmed CD.

SN (Case No. 

39. The standard of care requires a physician to perform a procedure in an

appropriate manner. An orthopaedic spinai surgeon should place pedicle screws to avoid

causing nerve or vascular injury. A patient should be monitored post?surgery for progress

48

 

1and complications. A patient with persistent of radicular after surgery
should be evaluated for possible nerve root impingement-

40. The Board has established that Dr. Greene deviated from this standard of care
by placing the L5 screw in his April 10, 2007 surgery on SN such that it abutted against the
nerve root. 

41. The Board has established that Dr. Greene also deviated from the standard of
care by failing to obtain a CT scan when SN developed radicular post?
operatively. Dr. Greene failed to diagnose surgical complications in a timely manner.

42. The Board has established that SN suffered harm in that she developed
chronic right rad iculopathy due to Dr. Greene?s placement of the screw.

FACTORS IN MITIGATION AND AGGRAVAHON

43. The patients in the cases at issue illustrate that candidates for spinal surgery
generally have multiple concomitant morbidities. Dr. Greene established that the risks
nherent in complex spinal surgeries are much greater than and are not comparable to the
kinds of surgery in which Dr. has had most of his experience.

44. But Dr. Greene has not disquali?ed Dr. as an expert. Dr.
is an orthopedic surgeon, has been involved in spinal surgeries. and is

competent to testify. Dr. Greene?s criticism goes to the weight to be given his testimony in

each case.
45. The inherent risk of a surgical procedure cannot exonerate a surgeon?s error.
A surgical error cannot be inferred from a poor result but must be based on evidence of

the surgeon?s speci?c errors.
46. Most of the cases, viewed alone, would be the kind of result that might occur
once in a surgeon?s career. The sheer volume of cases created grounds for special

concern. In general, ?evidence of other crimes, wrongs, or acts is not admissible to prove

49

 

 

the character of a person in order to show action in conformity therewith.??3 In a licensing
case, however, the protection of the public requires, at some point, that the sheer volume
of established error be considered.

47. Dr. Greene is entitled to defend against these complaints. But his continued
nsistence that he made no mistakes in his care of patients, only in his disclosure to the
Board and to patients, is considered a factor in aggravation. For example, Dr. Greene
continued to insist that there was no problem in his screw placement in MB's case, even
with the CT scan in front of him and after Dr. Saiz testi?ed that the screw placement was
problematic. It does not appear that Dr. Greene is capable of recognizing evidence of that
he may have made a mistake in the care of any patient.

48. The Board noted several issues that repeated throughout the review of Dr.
Greene. In the ten cases in which the Administrative Law Judge recommends that the
Board ?nd that Dr. Green deviated from the standard of care and violated applicable
statute, three patients died (MC, DE, .and two patients experienced excessive
bleeding (MC and three patients showed evidence of malpositioned screws (MB, CD,
and two patients suffered nerve injury (RJ and ?ve patients raised issues of
surgical judgment concerning whether to initiate or terminate a procedure (MC, DC
(kyphoplasty removal), AZ, RJ, and and ?ve patients? medical records were deficient
DC, RW, MB, and SN).

49. The Board has established that Dr. Greene?s care of these ten patients
constituted unprofessional conduct pursuant to ARS. (?[?ailing or
refusing to maintain adequate records on a patient?); ARS. 

conduct or practice that is or might be harmful or dangerous to the health of the patient or

 

Ariz. R. Evid. 404(b).

50

 

 

the public"); A.R.S. making a false or misleading statement
to the board . . and that the Board determines is
gross negligence, repeated negligence, or negligence resulting in harm to or the death of
a patient?).
ORDER

Based on the foregoing, the Board orders that License No. 32747 for the practice
of al'lopathic medicine previously issued to David L. Greene, MD. be revoked. Pursuant
to A.R.S. 32-1451 (M) and 41 -1 DOT, Respondent shall reimburse administrative costs.

RIGHT TO PETITION FOR REHEARING 0R REVIEW

Respondent is hereby noti?ed that he has the right to petition for a rehearing or review.
The petition for rehearing or review must be ?led with the Board's Executive Director within thirty
(30) days after service of this Order. A.R.S. The petition for rehearing or review
must set forth legally suf?cient reasons for granting a rehearing or review. A.A.C. 
Service of this order is effective ?ve (5) days after date of mailing. A.R.S. 41 -1 If a
petition for rehearing or review is not ?led, the Board's Order becomes effective thirty-?ve (35)
days after it is maiied to Respondent.

Respondent is further noti?ed that the ?ling of a motion for rehearing or review is required

to preserve any rights of appeal to the Superior Court.

51

 

 

RIGINAL of the foregoing ?led this
day of August, 2008 wi?x:

Arizona Medical Board
9545 East Doubietree Ranch Road
Scottsdale. Arizona 85258

Executed copy of the foregoing
I .i ed by U.S. Mail this
day of August, 2008, to:

David L. Greene, MD.
Address of Record 

Paul J. Gianmla-

Sne? 1M!an LLP.
One Arizona Center

. Phoenix AZ 35004-2202

 

 

#246199

day of August. 2008.

THE ARIZONA MEDICAL BOARD

 



LISA WYNN
Executive Director

52

 

BEFORE THE ARIZONA MEDICAL BOARD

in the Matter of
Board Case No. 

DAVID L. GREENE, M.D.,
ORDER ON REHEARING

Holder of License No. 32747
For the Practice of Allopathic Medicine
In the State of Arizona.

 

 

 

 

On February 4, 2009, this matter came before the Arizona Medical Board (?Board?)
for oral argument and consideration of the Administrative Law Judge (ALJ) Diane
Mihalsky?s proposed Findings of Fact, Conclusions of Law and Recommended Order
after rehearing of the issue of the penalty in this case. David Greene, M.D.,
(?Respondent?) was not present but was represented by legal counsel Paul Giancoia.
Assistant Attorney General Anne Froedge represented the State. Chris Munns, Assistant

Attorney General with the Solicitor General?s Section of the Attorney General?s Of?ce was

present and available to provide independent legal advice to the Board.

The Board, having considered the Decision on rehearing and the entire

record in this matter, hereby issues the following Order.
IT IS HEREBY ORDERED THAT:

1. The ALJ's Decision on rehearing is rejected in its entirety because the
Board concludes that the serious nature of Respondent?s misconduct

demonstrates that he is un?t for licensure to practice medicine.

2. The Findings of Fact, Conclusions of Law and Order of revocation dated
August 8, 2008, attached hereto and incorporated herein by this reference

are re-adopted; and

 

Pursuant to A.R.S. and 41-100?, Respondent shall

reimburse the costs of the rehearing.

RIGHT TO APPEAL TO SUPERIOR COURT

Respondent is hereby noti?ed that this Order is the ?nal administrative decision of
the Board and that the Respondent has exhausted his administrative remedies.
Respondent is advised that an appeal to superior court in Mariodpa County may be taken
from this decision pursuant to Title 12, Chapter  article 6, within thirty-?ve (35) days

from the date this decision is served.

day of February, 2009.

 

THE ARIZONA MEDICAL BOARD
By  
ISA WYNN

Executive Director

 



INAL of the foregoing tiled this
ay of February, 2009 with:

Arizona Medical Board
9545 East Doubletree Ranch Road
Scottsdale, Arizona 85258

COPY THE FOREGOING FILED
this day of February, 2009 with:

Cliff J. Vanell, Director

Of?ce of Administrative Hearings
1400 W. Washington, Ste 101
Phoenix, AZ 3500?

Executed copy of the foregoing
mail by U.S. Mail this
day of February, 2009 to:

David L. Greene, MD.
Address of Record

 

Paul J. Gianoola Esq.
Snell and Wilmer LLP
400 E. Van Buren
Phoenix, AZ 35004
Attorneys for Respondent

Anne Froedge

Assistant Attorney General
Of?ce of the Attorney General
CIVILES

12?5 W. Washington
Phoenix, AZ 85007

f?

 

 

BEFORE THE ARIZONA MEDICAL BOARD

For the practice of Allopathic Medicine
In the State of Arizona


In the Matter of et. 



ORDER GRANTING

David L. Greene, M.D., MOTION FOR.

REHEARING OR
Holder of License No32747 REVIEW







 

On October 8, 2008, the Arizona. Medical Board met to consider Dr. David L.
Greene?s (?Respondent?) motion for rehearing or review of the Board?s Order of August
3, 2008. Paul Giancola appeared as attorney on behalf of Respondent. The Board was
represented by Assistant Attorneyr General Dean Brekke. Christopher Munns of the
Solicitor General?s Of?ce was present to provide independent legal advice. A?er full
consideration of the record in this matter and the arguments of the parties, the Board
voted to GRANT ReSpondent?s request for rehearing to consider newly discovered
material evidence under A.A.C. namer recently completed Physician
Assessment and Clinical Education evaluation results regarding Dr. Greene.

ORDER
Respondent?s Motion for Rehearing or Review is GRANTED. The Board will
refer the case to the Of?ceof Administrative Hearings to conduct further hearing related
to the August 2008 PACE evaluation results and for the administrative law judge to

submit an updated recommended decision accounting for the new evidence.

Datedthis of ?ameenoos

??uctuation,?

  

a 33% Arizona Medical Board
.3 i 0 {Ta 
a 
2" 

 

Lisa Wynn, Executive Director

1'
"Hamill

Executed copy of the foregoing
US. Mail thi?day
W008, to:
Paul J. Giancola, Esq.
Snell 8: Wilmer, L.L.P.
One Arizona Center
400 E. Van Buren

Phoenix, Arizona 85004?2202
Attomey for Respondent

Dean Brekke, Esq.
Assistant Attorney General
1275 West Washington
Phoenix, Arizona 85007