Disciplinary Action against
Viktor Bouquette, M.D.
Stephen Barrett, M.D.
The Georgia Composite Medical Board has concluded that Viktor Bouquette, M.D. improperly diagnosed and treated a 56-year-old woman who died in 2002 while undergoing intravenous chelation therapy. The consent order (shown below), requires Bouquette to (a) pay a $5,000 fine plus $800 for Board costs, (b) complete 20 hours of board-approved continuing medical education in environmental medicine and 10 hours in record-keeping, and (c) refrain from providing intravenous chelation therapy to patients without fully documenting the need for such treatment on the patient's chart. The order indicates that Board's peer-reviewer concluded that Bouquette had (a) failed to document a possible source of lead exposure, (b) failed to conduct a through physical examination, (c) relied on a provoked urine test rather than a standard blood test to measure the patient's lead level, and (d) administered intravenous EDTA chelation, which should not be done unless a patient has severe lead poisoning. Bouquette disputed these conclusions, but the Board agreed with them and Bouquette consented to be disciplined as noted. Bouquette is medical director of the Atlanta-based Progressive Medical Center, which claims to be "the most comprehensive integrative medical facility in the Southeast."
BEFORE THE GEORGIA COMPOSITE MEDICAL BOARD
STATE OF GEORGIA
IN THE MATTER OF:
VIKTOR RODRICK BOUQUETTE, M.D
DOCKET NO. 20110052
PUBLIC CONSENT ORDER
By agreement of the Georgia Composite Medical Board ("Board") and Viktor Rodrick Bouquette, M.D. ("Respondent"), the following disposition of this matter is entered pursuant to O.C.G.A. § 50-13-13(a)(4), as amended.
FINDINGS OF FACT
Respondent is licensed to practice medicine in the State of Georgia and was licensed at all times relevant to the matters stated herein.
Medical records indicate that Respondent treated S.A., a 56 year old female, for chronic fatigue, lack of concentration, and other constitutional symptoms. Respondent diagnosed S.A. with heavy metal poisoning based upon results from oral chelation and began intravenous chelation therapy on S.A. on or about May 28, 2002. During an intravenous chelation therapy session at Respondent's office on June 17, 2002, S.A. went into cardiac arrest and subsequently died.
The medical examiner's report lists as S.A.'s cause of death "Cardiac Dysrhythmia Due to Combination of Small Intramyocardial Coronary Artery Disease Superimposed Upon Prolapse Mitral Valve."
A Board-appointed peer reviewer evaluated the treatment of S.A. and concluded that Respondent's treatment of S.A. departed from and failed to conform to the minimal standards of acceptable and prevailing medical practice in the following ways:
(a) Without having documented a possible source of exposure to lead, Respondent gave S.A. an oral chelator to measure heavy metals excreted in her urine. The standard of care for lead poisoning evaluation, however, is obtaining a thorough history to find possible sources of exposure and conducting a thorough physical, followed by a venous blood level test. While oral chelation with succimer is a safe treatment for someone who does not require hospital admission for severe lead intoxication (i.e., someone demonstrating seizures, encephalopathy, renal failure, etc. from lead toxicity), it is not reliable for diagnosis of lead toxicity. Further, the records do not reflect that Respondent obtained a thorough history of S.A. to determine a possible source of lead poisoning.
(b) Rather than using a safe, proven oral chelator to remove lead from S.A.'s body, Respondent administered intravenously to S.A. Edetate Disodium, a parenteral chelator, which is known to have serious side effects such as hypotension, renal failure, life-threatening hypocalcemia, hypomagnesemia, and hypokalemia. Parenteral intravenous chelation is reserved for severe cases of lead intoxication, in which a rapid reduction in the body burden of lead needs to be accomplished in a matter of hours or up to 1-2 days, and should only be administered in a hospital setting where cardiac monitoring as well as electrolyte and renal function lab testing can be administered. S.A.’s records do not reflect that she had a severe case of lead intoxication that would warrant such treatment.
(c) Respondent's records indicate that S.A. was treated with "standard chelation," but there is no explanation in S.A.'s records of what "standard chelation" is. Respondent explained that "IV EDTA" was administered to S.A., and that his clinic had in-house published protocols which describe what standard chelation is and how it is administered by medical personnel. He added that the meaning of "standard chelation" and "IV EDTA" are spelled out in said protocols which are always available for review and which were familiar to all who prepared and administered the infusions for S.A.
Respondent asserts that the long term and underlying cause of death was the patient's chronic heart disease. Respondent maintains that a multi-year civil action against him, including testimony from expert witnesses in the field of toxicology, failed to establish causality or deviations from standard medical practice. Respondent alleges that the civil action against him was not only dismissed with prejudice, but also that the plaintiffs' allegations were retracted and withdrawn in return for his promise not to sue for abusive litigation.
Respondent asserts that S.A. had heavy metal poisoning from long-term exposure to lead paint over her twenty years as a house painter, but he acknowledges that he did not document S.A.'s work history and possible long-term lead paint exposure in her medical records. Respondent contends that he took a thorough history of S.A. to determine a source of lead poisoning but did not completely record that history.
Respondent's response to the Board's peer reviewer's evaluation is as follows:
(a) The peer reviewer alleges improper diagnosis for failure to administer a blood test, contending that oral chelation is not reliable for diagnosis of lead toxicity. Respondent contends that under these circumstances oral chelation was the only reliable diagnostic test. Respondent asserts that S.A. had heavy metal poisoning from long-term exposure to lead paint over her twenty years as a house painter. Respondent asserts that medical research clearly shows that blood tests are ineffective for diagnosing long-term exposure to lead because the lead is no longer in the patient's blood stream. The lead has settled into and is sequestered in the patient's tissues, and the extent of the toxic burden can only be revealed by an oral chelator which forces the lead from the tissues and into the patient's blood stream, where it can be measured through urinalysis. Respondent's position is that S.A. was therefore the worst possible candidate for blood lead level testing to determine her lead levels, and she was the best possible candidate for challenge testing.
(b) Respondent contends that only if the patient's exposure to lead is recent or ongoing is a blood test appropriate. It simply cannot be the case that a patently ineffective diagnostic test constitutes a satisfactory standard of care. Blood levels of lead may not be elevated, even in the presence of a toxic total body burden. The quantification of lead excretion via urine following a provocation challenge is a much more reliable indicator of serious lead toxicity. In this case a positive lead urine provocation challenge proves without question a patient's chronic exposure to lead, toxic body burden and need for treatment. If this same provocation test were to be done on an individual who has not been chronically exposed to lead, the results would be negative.
(c) Further, the reviewer alleged that oral chelation, while an improper test, was the required treatment because "intravenous parenteral chelation is reserved for severe cases of lead intoxication." Respondent's position is that the peer reviewer apparently regards only cases of acute and recent exposure as "severe." However, both clinical and basic research clearly establishes that long-term exposure can result in a near total toxic burden. Respondent contends that such cases are clearly "severe."
(d) Moreover, Respondent asserts that the only effective treatment for such cases is parenteral chelation. Neither clinical nor basic research supports the position that oral chelation is superior to IV chelation with EDT A for the treatment of heavy metals poisoning. Both laboratory and clinical experience support exactly the opposite conclusion. Respondent opines that it would have taken years of oral chelation to remove S.A.’s systemic toxic burden. So, while there is always an increased risk with more invasive treatment, in this area of medical practice such risk is far outweighed by the increase in effectiveness of parenteral chelation and the ineffectiveness of oral chelation.
(e) Respondent asserts that his diagnosis and treatment, while not endorsed perhaps by most practitioners, was sound scientifically and is the endorsed practice of a substantial minority of practitioners. Respondent does not deny that many practitioners do not test, diagnose or treat patients for heavy metal toxicity in the same manner as the respondent. It may even be the case that most physicians practice differently in this area. However, Respondent contends that even if he and his colleagues constitute a minority in this regard, that minority is a very substantial minority. If there are alternative methods of treating of lead toxicity, and a substantial minority of physicians agree with these methods, then an alternative standard of care has been created. Respondent's position is that alternative treatment is not a per se violation of the standard of care. If so, alternative medicine would vanish tomorrow.
(t) The reviewer further opines that parenteral EDTA chelation is dangerous and should only be administered in a hospital setting. However, Respondent contends that the administration of IV EDT A chelation therapy in integrative medical clinics has become a settled and widespread practice in the state of Georgia and that extensive information and standardized protocols regarding said practice are regularly presented during CME approved courses which teach the administration of EDTA chelation therapy in clinical settings.
(g) Respondent contends that he interviewed and examined the patient appropriately, performed the appropriate tests, formed a reasonable diagnosis after review of the positive lab results and treated the patient appropriately and competently.
CONCLUSIONS OF LAW
Respondent's conduct constitutes sufficient grounds for the imposition of discipline upon his license to practice as a physician in the State of Georgia under O.C.G.A. Title 43, Chapters 1 and 34, as amended. Respondent hereby waives any further conclusions of law with respect to the above-styled matter.
The Georgia Composite Medical Board having considered all the facts and circumstances of this case hereby orders, and Respondent hereby agrees, that the following sanctions shall be imposed upon Respondent's license to practice as a physician in the State of Georgia.
Respondent shall obtain twenty (20) hours of continuing medical education (CME) in the area of environmental medicine and ten (10) hours of CME in the area of record-keeping, in addition to the CME required of all Georgia physicians. Respondent shall complete the additional thirty hours within one year from the docketing of this order. Respondent shall submit the title of the course(s) he plans to attend and information concerning the course(s) to the Board to obtain approval from the Board prior to attending any such course(s). Within one year from the docketing of this consent order, Respondent shall submit proof of completion of the additional thirty hours to the Board. Failure to abide by this paragraph shall be considered a violation of a lawful order of the Board and shall be grounds for additional disciplinary action, including revocation, upon substantiation thereof.
Respondent shall submit to the Board a fine in the amount of $7,500.00 to be paid in full by cashier's check or money order payable to the Board within 180 days of the effective date of this Consent Order. Failure to pay the entire amount of the fine by the 180th day shall be considered a violation of this Order and shall result in further sanctioning of Respondent's license, including revocation, upon substantiation thereof. Partial payments may be made, but the entire fine amount must be paid in full by the 180th day.
In addition to the fine required in paragraph 2 of this Consent Order, Respondent shall pay administrative costs in the amount of $800.00 as reimbursement to the Board for expenses incurred in the investigation of this matter, which expenses do not include time spent by the investigative division of the Board. The fees shall be payable by certified check or money order to the Georgia Composite Medical Board within thirty (30) days of the effective date of this Order. Failure to pay the entire amount by the 30th day shall be considered a violation of this Order and shall result in further sanctioning of Respondent's license, including revocation, upon substantiation thereof.
Respondent shall not provide intravenous chelation therapy to patients until after he has provided proof to the Board in writing that he has completed 20 hours of CME in environmental medicine, and only after he has fully documented the need for such treatment on the patient's chart.
Respondent also understands that pursuant to O.C.G.A. Title 43, Chapter 34A, the contents of this order shall be placed on Respondent's Physician Profile. Furthermore, by executing this Consent Order, Respondent hereby agrees to permit the Board to update the Physician's Profile reflecting this Consent Order.
Respondent is represented by counsel in this matter and acknowledges that he has read this Consent Order and understands its contents. Respondent understands that he has the right to a hearing in this matter and freely, knowingly, and voluntarily waives such right by entering into this Consent Order. Respondent understands that this Consent Order will not become effective until approved and docketed by the Georgia Composite Medical Board. Respondent further understands and agrees that a representative of the Department of Law may be present during the presentation of this Consent Order and that the Board shall have the authority to review the investigative file and all relevant evidence in considering this Consent Order. Respondent further understands that this Consent Order, once approved, shall constitute a public record, which may be disseminated as a disciplinary action of the Board. However, if this Consent Order is not approved, it shall not constitute an admission against interest in this proceeding, or prejudice the right of the Board to adjudicate this matter. Respondent consents to the terms of discipline contained herein.
Approved this 5th day of May, 2011.
CONSENTED TO BY:
GEORGIA COMPOSITE MEDICAL BOARD
This page was posted on June 1, 2011.