Doctor Hit by Inquiry Works in Florida Now : Medicine: UCSD physician left the state after the death of a patient whose symptoms he misread. Some wonder if a physician who surrenders a license in one state should be allowed to practice in another.

For seven days before her death, Olga Kulp, 64, suffered classic symptoms of a heart attack--symptoms her doctor misinterpreted.

She saw her doctor twice and spoke to him after the two office visits, still complaining of pain that radiated up her arm to her left jaw.

Dr. Brunildo Herrero, then director of UC San Diego’s Internal Medicine Group, conducted two electrocardiograms on two consecutive days and each time told the retired schoolteacher that she had no reason to worry. It was probably arthritis, he said. When the Rancho Bernardo resident continued complaining about the searing pain, Herrero prescribed Tylenol with codeine.

On that day, Sept. 23, 1988, Kulp died of a heart attack--she collapsed one hour before her appointment to see another doctor for a second opinion.

Experts with the Medical Board of California established that Herrero missed a subtle red flag on the first EKG and one day later, “misread or misinterpreted” the second electrocardiogram, according to medical board disciplinary records.

Although the first test showed subtle damage to her heart, the second one showed she had already suffered a heart attack, said Dr. Richard Ikeda, the Medical Board of California’s chief medical consultant.

“Obviously, it was grossly negligent and incompetent--there was evidence that there was heart wall damage, and he still did nothing,” Ikeda said. “This is very basic--a woman comes in with chest pain, up the jaw and down the arm. That’s stuff a third-year medical student would know. Thank goodness he’s not practicing with a California license.”

Herrero, 58, who has tended patients for more than 30 years, surrendered his license to practice medicine in California in December, after being charged by the medical board with gross negligence and incompetence--a process that took more than three years. The attorney general’s office pursued the case on behalf of the medical board.

Today, Herrero practices at the Watson Clinic in Lakeland, Fla., where he had worked for 17 years before joining UCSD.

Some medical experts and Olga Kulp’s husband, Fred, believe Herrero’s inept EKG reading contributed to Olga’s death, which might have been prevented had she received appropriate treatment. Kulp’s anger over his wife’s death is fed by his rage that Herrero is still practicing medicine.

“If a doctor in California murders somebody--maybe that’s too strong a word--and goes to Florida where he gets away with a slap on the wrist, is that right?” asked Kulp, 77, in tears. “My hope is that the man will not be allowed to practice in Florida anymore.”

But Herrero, who acknowledges a mistake, said he, too, has suffered anguish over the incident, as well as spending $30,000 in legal fees.

“Fundamentally, it was a very unfortunate situation where a mistake was made on the EKG. Mrs. Kulp died later,” Herrero said.

“The question really is can you make an error without having to die for it? Are doctors perfect and are they always 100% correct? The answer is ‘no.’ It’s a very, very unfortunate situation and one that has given me three years of sleepless nights and pain.

“I have had enough suffering. I don’t want to think about it anymore, but obviously Fred (Kulp) hasn’t gotten enough, he wants more of my flesh.”

When Kulp’s attorney told UCSD that Kulp was considering a malpractice suit, UCSD paid $125,000 in an out-of-court settlement.

“There was no question on the part of Dr. Herrero or the (UCSD) committee that investigated the matter that there had been an error made in reading the electrocardiogram,” said Dr. Paul Jagger, medical director of UCSD Medical Center. “Unfortunately, I think that may well have contributed to Mrs. Kulp’s death.”

Herrero first told UCSD’s internal investigators and those from the state medical board that he had no contact with Olga Kulp after her second office visit--which was contradicted by the existence of the Tylenol with codeine prescription, said Jagger and sources familiar with the state board’s investigation.

Herrero’s statement that he had no contact with Olga Kulp on the day of her death “was simply an untruth,” according to a confidential memo by the state medical board investigator.

So far, the incident involving Olga Kulp has not derailed Herrero’s career--Herrero has since been named to the American Board of Internal Medicine, which reviews and awards credentials to doctors in the specialty.

Dr. Boyd Honeycutt, medical director of the Watson Clinic, said he readily employed Herrero when he requested his job back. “He is a caring physician who has an excellent record,” he said.

By all accounts, Herrero is a well pedigreed physician. Herrero, a graduate of the University of Florida College of Medicine, has held a research position at Johns Hopkins Hospital, and faculty appointments at Duke University and Yale University.

In San Diego, he said, his patients included a number of prominent San Diegans, such as UCSD’s chancellor Richard Atkinson and renowned oceanographer Roger Revelle, who died last year.

“We were very sorry when Dr. Herrero left,” said Ellen Revelle, whose husband was a patient of Herrero. “He was a wonderful man.”

Colleagues, too, give him glowing reviews.

“Herrero was a good, caring physician and was not somebody who was careless or sloppy. Physicians are not infallible and can certainly make mistakes,” said Dr. Gerard Burrow, dean of the UCSD medical school and vice chancellor for health sciences.

“I think doctors are human, and I really do believe he’s a good physician. If he missed it (the EKG), it’s one of these missed chances that happen on occasion,” said Burrow, who has known Herrero since about 1965 when they met at Yale.

The question at the center of the controversy is whether Herrero--touting a 32-year track record of tending patients--should continue practicing medicine after making a potentially deadly mistake. And should a doctor who surrendered his license in one state be allowed to practice in another?

In Herrero’s case, the California Medical Board did not want him to practice in the state after Olga Kulp’s death, said Janie Cordray, board spokeswoman. “In California, one mistake--especially if it kills a patient--is enough.”

In Florida, the medical board’s Department of Professional Regulation is reviewing Herrero’s case. Surrendering a doctor’s license in another state is grounds for possible disciplinary action in Florida, according to state law. Saying that investigations are confidential, Florida board spokeswoman Cara Cannon declined to discuss Herrero’s case.

Ethics experts say a medical board must draw the line to ensure public safety--even if it means ending a sterling career.

“I don’t mean to be indifferent to a career lost on the basis of a tragic error, but sometimes the error is egregious enough to pull somebody out. Sometimes, in order to assure the public that the profession is vigilant, you have to make a clear example of what is an intolerable error,” said Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota.

“You don’t only punish the individual, but you send a message to the rest of the profession that they must strive as hard as they can--so there is not only punishment but there’s deterrence,” said Caplan, who was a member of New York’s medical board for six years. “You are telling other doctors to think twice, get a second opinion if you are not sure.”

Every year, more than 100,000 Americans are injured or killed in hospitals as a result of negligence, estimates Dr. Sidney Wolfe of Public Citizen Health Research Group.

One problem, some critics say, is that a doctor in trouble can leave one state and practice in another because each medical board can take several years to review and adjudicate a case. To prevent this, consumer activist Charles Inlander advocates a national licensing system.

“The (state) medical board has acted in their eyes and protected the people of California from this guy. Now the question is, will Florida do anything?” said Inlander, president of the Pennsylvania-based People’s Medical Society, a consumer advocacy group. “This guy could be practicing for another three years. . . .In the real world, a cop gives you a parking or speeding ticket, and, in two months, you are in court.”

California has been criticized in recent years for being sluggish in adjudicating cases such as Herrero’s. Statistics from the medical board show that these kind of cases take an average of 2.8 years to resolve.

The medical board says it hopes that it will soon take less time as the attorney general’s office allocates more resources to pursuing errant doctors.

“It takes a long time because, if you have a defendant who takes advantage of due process, you can imagine all the hoops you have to go through,” Cordray of the medical board said. “No one is going to lay down and play dead if you are talking about taking away their livelihood.”

Indeed, three years after Olga Kulp’s death, Herrero says, the California Medical Board’s proceedings against him mean little now; and the board says accepting Herrero’s license surrender was the fastest way to stop him from practicing in the state.

Herrero said he surrendered his license, which was expiring, because he intended to return to Florida. Herrero was not asked to leave UCSD, though he did leave 10 months after Olga Kulp’s death, Burrow of UCSD said.

“The charges were being reduced, and the charges were being dropped, my license expired in California, and I left the state of California with no intention of ever returning,” Herrero said. After surrendering the license, “that was the end of the case. There was no discipline, no charges, no penalties. I thought the whole thing was over.”

Informed of Herrero’s version of his license surrender, Cordray of the medical board said: “I’m not surprised. How many people on Death Row say they didn’t do it? What someone calls a crime, someone else will call an error in judgment. The charges speak for themselves.”

Rather than go through an administrative hearing to pursue revocation of Herrero’s license--which could add another year to the case--the medical board and attorney general’s office decided to accept Herrero’s surrender of his license, said Margaret Lafko, deputy attorney general.

“We agreed to drop proceedings in exchange for him surrendering his license,” Cordray said. “Professionals understand what it means--he voluntarily surrendered his license in a case where a woman died.

“Basically, this woman went in to see him with chest pains and, over and over again, he didn’t hospitalize her, he didn’t read the EKG correctly--and, if he couldn’t read it, he should have sent it to someone who could.”

Olga Bobrowski arrived in the U.S. in 1937; a Russian Jew escaping Hitler. Fred Kulp arrived a year later from Frankfurt. The two met in a resort in the Catskills in upstate New York. Kulp, then 28, was dazzled by Bobrowski’s beauty.

But, shortly after that weekend, unbeknown to Kulp, Bobrowski changed her last name to Barrow--inadvertently thwarting his efforts to find her. It was five years before Kulp again met this woman. After a one-year courtship, the couple married June 22, 1947.

The couple lived for years on Long Island, where they raised their two daughters. Fred worked as a quality assurance engineer for a defense contractor, and Olga taught grade school.

In June, 1986, Fred Kulp, prompted by his wife, reluctantly agreed to retire after working 40 years. Olga Kulp was smitten with San Diego. They bought a house in Rancho Bernardo and another car because Olga Kulp was always so busy. She taught reading to adults, gardened and learned to play bridge.

Although Fred Kulp found it difficult to adjust to retirement living, Olga Kulp flourished. She held parties in their back yard. And she teased her husband that he took little maladies too seriously. “You always run to a doctor,” she used to chide him.

It was Fred Kulp who found Dr. Herrero, who had been recommended by another local physician. Fred and Olga Kulp liked Herrero and decided he would be their doctor.

On Sunday, Sept. 18, 1988, Olga Kulp complained of a pain radiating up her arm to her left jaw. The couple had spent the evening in Laguna and, when they returned, Olga Kulp called Herrero about the pain at 9:34 p.m., according to the Medical Board’s complaint against Herrero.

Herrero advised his patient to come to his office at 7:30 a.m. on Monday, the next morning. That morning he conducted an examination and performed an electrocardiogram. The EKG was normal, he told Olga Kulp, according to records. He diagnosed her condition as angina and prescribed medication.

As Fred Kulp drove his wife to the pharmacy, Olga said her pain was getting worse. Fred Kulp called Herrero and told him he wanted to take her to the hospital, according to medical board records. Herrero said the medication itself would be the appropriate treatment, according to the records.

But the pain continued. The next day, Olga Kulp saw Herrero again, after coming in for a previously scheduled mammography. Herrero conducted another EKG and told his patient the results were the same as on the previous day. Her pain was probably a result of arthritis, Herrero told her, according to records.

He recommended that she take Advil, an over-the-counter pain medication.

That Tuesday was Yom Kippur, the Jewish day of atonement. On Wednesday, the Rancho Bernardo couple went to temple. Olga Kulp believed Herrero when he said it was nothing serious, Fred Kulp said.

“Obviously, she believed him. And I did too. I had no reason not to believe him; I am not a doctor,” Fred Kulp said. “She hated going to doctors. She always liked believing what a doctor told her, and this doctor told her nothing was wrong.”

On Friday, Sept. 23, 1988, Olga Kulp’s pain continued. She called Herrero and asked for stronger medication, records show. Fred Kulp picked up Tylenol with codeine for his wife from the drug store. Olga Kulp canceled her bridge class.

But the pain continued. Olga Kulp called Sharp Memorial Hospital and made an appointment at 4 p.m. to see a cardiologist for a second opinion that day.

An hour before her appointment, Olga Kulp collapsed as she was putting on her blue skirt. She died at 9 p.m., having suffered a heart attack.

“I hope to forget this, but I can never forget,” Fred Kulp said.

Fred Kulp sees the world now in terms of what Olga Kulp is missing: the grandchildren she never knew, the Russian immigrants who moved to San Diego whom his wife would have enjoyed because she had no one to speak Russian with.

“This is awful,” said Kulp, choked in tears. “I’m 77. I was married 41 years. Now I’m alone. Memories are only good if you have someone to share them with.”

Serious Disciplinary Actions

Revocations, suspensions and probations by state medical licensing boards in 1989

Number of Number of Serious Actions Rank State Serious Actions Doctors per 1,000 MDs 1. Missouri 74 10,536 7.02 2. Georgia 78 11,467 6.80 3. Mississippi 24 3,621 6.63 4. Oklahoma 31 5,063 6.12 5. West Virginia 20 3,394 5.89 34. California 141 76,272 1.85

Source: Public Citizen Health Research Group