Leslie Enzian, MD

November 12, 2021

Washington Medical Commission

Re: Scott Miller, PA-C Case Review

I have been asked to submit an opinion on the standard of care provided by Scott Miller, PA-C. A copy
of my CV has previously been filed. This letter is in follow up to a preliminary statement dated 10/7/21. This
subsequent report includes additional details and references to support prior contentions as well as responses
to Respondent’s answers to the Statement of Charges. Documents provided me for review, including those
received after my preliminary statement, are summarized in an attachment to this document. The Order Packet
and Respondent’s answers to the Statement of Charges have also been reviewed. My opinion regarding the
documents received are summarized below (numbers refer to Inv pages, references pertaining to Patients A-F
are noted in [brackets], TOC refers to Table of Contents document numbers, Exh refers to exhibits). Documents
related to the care of six patients, A-F, were reviewed. Patients B-F were all unvaccinated, developed critical
COVID infections and died from COVID-related complications. Patient A’s vaccination status is unknown. After
detailing general concerns regarding Respondent’s medical care and professional behavior below, the disease
courses for Patients A-F are summarized and additional patient-specific concerns are noted.

It remains my opinion that the Respondent’s practices jeopardize public safety related to proper
precautions for and management of COVID-19 in the context of an ongoing pandemic that has resulted in
devastating national and world-wide death tolls. Containment of transmission and optimal medical
management of the infection is of utmost priority. Health care providers, when presenting themselves in their
professional role, hold a critical and grave responsibility to dispense accurate information about COVID-19
precautions and management. To do otherwise is a clear breach of our oath to do no harm. Due to the
Respondent’s potential endangerment to patients and the public, the commission may wish to consider
continued restrictive action on his license to practice, pending full consideration of this case by the WMC.

RESPONDENT BROADLY AND PROACTIVLY DISSEMINATED INACCURATE INFORMATION REGARDING COVID-19

INFECTION PRECAUTIONS
Using public forums, media outlets and church pulpits, Respondent vociferously spread COVID-19 prevention
misinformation that placed the public at risk of harm.

• Respondent professed and demonstrated that the use of masks was not necessary for COVID-19
prevention, despite evidence showing the efficacy of masking, and with disregard for CDC and
Washington State mandates. This created the potential for increased COVID transmission.
o At a school board meeting, Respondent encouraged parents to disenroll their students from
school because of school mask mandates and other school procedures for preventing COVID-19
transmission (Exh P)
o Respondent informed an audience that he had written mask exemptions for his children and
would not allow them to wear masks to the airport or on an airplane, as science did not support
masking (Exh P). It is unlikely that his children had appropriate evaluation or legitimate medical
reasons to support these exemptions.

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 o Respondent shared personal examples and photos with his patients of himself flouting
recommended masking and distancing practices and encouraged his patients to follow suit (Exh
P).
o Respondent was not masked at the school board meeting (Exh P)
o Respondent presented at an indoor church meeting where the Respondent and every visible
attendee was unmasked and Respondent was in very close proximity to others (TOC 32).
o On a talk show interview, after suspension of his license, Respondent complained about mask
mandates, “Wear a mask there. Why? It just is and if you don’t do it, you are not doing your
part?” (TOC 34)
o In the many presentations Respondent delivers, he expounds on numerous effective
supplements for decreasing susceptibility to COVID-19 infection, but never once recommends
masking as a means of decreasing risk of contracting or transmitting COVID-19.

• Respondent discouraged the public and his patients from social distancing, contrary to CDC,
Washington State and public health recommendations. This created the potential for increased COVID
transmission.
o Respondent discouraged social distancing at a school board meeting (Exh P).
o Respondent shared personal examples and photos with his patients of himself flouting
recommended masking and distancing practices and encouraged his patients to follow suit (Exh
P).
o Respondent was not socially distancing (while unmasked) when attending a church gathering to
present to a fully unmasked audience (TOC 32).
o On a talk show interview, after the suspension of his license, Respondent complained about
social distancing guidelines, “Stand six feet apart, 3 feet apart. Why?” (TOC 34)
o In the many presentations Respondent delivers, he expounds on numerous effective
prophylactic supplements, but never once recommends social distancing as a means of
decreasing risk of contracting or transmitting COVID-19.

• Respondent did not recommend COVID vaccination. This increased risk of harm to his patients and
the public.
o Respondent strongly advocated, in all his speaking venues and articles, for the use of
prophylactic supplements and medications as the best way to decrease the risk of contracting
COVID-19 or the severity of disease, if infected. Respondent’s recommendations included
Vitamin D, Vitamin C, glutathione supplementation, colchicine treatment and ivermectin (TOC
32).
o In his many presentations, Respondent glaringly omits a recommendation for vaccination
when discussing ways to prevent the risk or severity of COVID-19 infection.
o When the topic of vaccination arose, Respondent stated that he could provide a vaccine
exemption to anybody who needed one, rather than discussing the safety and efficacy of COVID
vaccinations (TOC 32).
o Respondent does not believe in the efficacy of COVID vaccination. Respondent’s Supplemental
Response to the Statement of Charges (p. 2) refers to the experimental nature of the initial
COVID-19 global vaccination campaign. Additionally, Respondent contends, “Sadly, the data on
the efficacy of the vaccine at mitigating infectivity, transmission, or mortality has been grossly
misrepresented. Millions of people who have received the vaccine still become very sick, right
along with those that have chosen not to get the vaccine. Both camps are left vulnerable to the
devastating health impact the virus is causing including death.”
o The above opinions, espoused by a medical professional, are profoundly concerning and
strongly suggest that Respondent did not encourage his patients or the public to get vaccinated

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 and that he would be unlikely to do so if he resumes practice. Even if Respondent were to
resume practice strictly in a pediatric capacity, he would be highly unlikely to advocate for
vaccination, as is now recommended for children greater than or equal to 5-years-old.
 It is notable that Respondent seems uncritical of the Ivermectin efficacy data, which has
been found to be notably flawed, yet is unaccepting of the rigorously studied, highly
powered and validated efficacy data on COVID vaccinations. Despite waning immunity,
the need for booster doses and the infiltration of COVID variants, vaccination has still
proven to be of significant benefit.
o None of the hospitalized patients in the cases provided for review were vaccinated for COVID-
19, which is of concern. It is unclear to what extent the Respondent was involved in the care of
some of the patients, prior to their COVID-19 diagnoses, and whether he had an opportunity to
recommend vaccination (outpatient records have not been provided for review).
o Respondent’s presentations and response to the statement of charges are disparaging regarding
CDC recommendations. Respondent professes the CDC offers no COVID-19 treatment options
and merely proffers the option of isolating until one gets so sick that they need hospitalization
and oxygen support. Not only is this untrue, but the CDC strongly advocates for COVID
vaccination. Though vaccination outcomes vary somewhat depending on the vaccine type and
regimen, evidence demonstrates efficacy in decreasing rates of symptomatic COVID infections,
infection transmission (with widespread vaccination), likelihood of COVID-related emergency
department visits and hospitalizations and decreased severity of illness. If vaccinated individuals
contract COVID-19, the vaccinated state acts in the manner of a treatment, in that it limits the
severity of illness. In this fashion, effective prevention through vaccination limits the need for
curative treatment.

• Respondent recommends that patients with covid infections avoid going to the hospital because, he
contends, hospital protocols are completely ineffective and hospital-based providers blindly follow rigid
and ineffective guidelines, rather than considering compelling research on supplements and repurposed
medications. (TOC 32, Exh Q.)
o This placed patients at risk of harm due to presenting to the hospital late in the course of their
disease
o The inpatient guidelines used were evidence-based and consistent with standard of care. The
treatment options recommended by Respondent lacked demonstrated efficacy.

RESPONDENT DISSEMINATED INACCURATE AND MISLEADING INFORMATION TO THE PUBLIC AND HIS
PATIENTS REGARDING APPROPRIATE MANAGEMENT OF COVID-19 INFECTION

• Respondent informed the public that there was a cure for COVID-19 (Exh P)
• Respondent refers to Ivermectin as a “miracle” treatment on Facebook postings (576)
• Respondent referred to Melatonin as a “silver bullet” for COVID (TOC 32)
• Respondent reported that “50 percent of the COVID-19 mortality could have been mitigated if people
had adequate vitamin D levels.” (3728)
• In speaking about hydroxychloroquine, Respondent stated, “And anecdotally, I’ve had patients who
were sick. They got one dose and after the first dose, they were 100 percent better the next day.”
(3729)
• Respondent informed the public, his patients and patients’ family members that he had successfully
treated hundreds of COVID patients through his office practice (2735[E], 588[F], 595, TOC 21, 22, 34)
(reported treating as many as “1400” adult COVID patients, TOC 34)

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 o Many cases of COVID (> 80%) are marked by mild symptoms with a benign course and
spontaneously resolve without complication or need for an inpatient level of care. Providing
COVID positive patients with supplements or prescribing them Ivermectin and declaring
treatment successes if the patients don’t get hospitalized or die is a misrepresentation of the
facts and does not reflect a demonstration of efficacious therapeutics.
o Some public members believed that these alternative, purportedly efficacious treatments,
would allow them to avoid getting the COVID vaccination which they considered potentially
dangerous, thus increasing their risk of harm.
• Respondent touted his outpatient success in treating hundreds of COVID patients in the context of
recommending supplements, high-dose methylprednisolone and Ivermectin for critically ill patients.
This compelled patients’ family members to believe that Respondent’s treatment recommendations
would be efficacious for critically ill COVID patients (590[B], 585[D], 588[F], 595).
o Respondent indicated to inpatient providers and family members of COVID patients in the ICU
that he had “treated over 600 patients with COVID and that he had “gotten patients out of the
ICU with his treatment recommendations” (1081[E]).
o Respondent touts, “I have offered solutions, treatments, protocols that would virtually ensure
that all your ICU patients being able to go home to their loved ones.” (576)
• Respondent recommended medications for COVID treatment, including ivermectin, melatonin and high-
dose vitamins, despite a lack of proven effectiveness (593, 414[B], 631-2[F], TOC 21 & 22, Inv 576)
o Respondent acknowledged that many of his recommendations were based on anecdotal
outcomes (TOC 30, 3729).
o Respondent recommended, in a public presentation, Ivermectin dosed on a weekly basis for
COVID-19 prophylaxis (TOC 32).
o Respondent recommended use of colchicine for the treatment of COVID-19 infections and
advised an audience to keep this medication in stock (TOC 32).
 Some data indicates that colchicine may decrease hospitalization rates if used in early
mild to moderate COVID-19 infections, though there is no mortality benefit and adverse
side effects are common. Diarrhea is a very common side effect of colchicine and was
increased in study participants who received colchicine. Additionally, those treated with
colchicine had an increased rate of pulmonary embolus. Respondent did not inform the
audience of these associated risks.

o Subsequent to Respondent’s summary suspension, he was interviewed on a weekly news show
“Against the Wind: Doctors & Science Under Fire” (TOC 34). During this program, Respondent
reported he had treated 1400 adult COVID patients and reported having treated a 3-year-old girl
with asthma and COVID-19, who developed concerning symptoms, with Ivermectin. He
continued to tout the effectiveness of Ivermectin treatment.
• In talk show interviews, Respondent expounds on the ineffectiveness of guideline-driven inpatient
management of COVID-19, stated that CDC recommendations equated to “doing nothing”, questioned
masking and social distancing recommendations and indicated agreement with interviewer’s
contentions that conflicts of interest dictated current COVID management guidelines and practices (TOC
21, 32, 34).
• Misinformation about the appropriate management of COVID-eroded patient trust in consensus
evidence-based treatment protocols.
• Respondent made therapeutic recommendations for critically ill COVID patients despite his lack of
information regarding full details of the patients’ current clinical status in terms of vital signs, physical
examination, lab results, study findings or medications prescribed.

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• A non-intensivist pediatric practitioner, who is not providing direct care to a patient, is not in a
reasonable position to provide nuanced and complicated therapeutic recommendations for critically ill
inpatients.
• Respondent informed or indicated to his patients, their families and the public that hospital-based
doctors did not know how to treat COVID-19 and that patients would not receive appropriate
treatment in a hospital setting.
o 539-542, TOC 21
o In a presentation, Respondent professed, “I’ve worked every single angle with hospitalists. They
don’t care . . . You should be able to go to the hospital and get treatment, they don’t care—and
I’m not talking about some of them . . . [We’re] trying to make our own hospital. We can’t go
into the hospital. We are going to have our own x-ray machine too.” (TOC 32).
o Respondent’s presentations and response to the Statement of Charges references CDC’s
misguided narratives, mimicked by inpatient providers, that there are no treatments available
for COVID. This neglects to acknowledge the numerous treatments that are offered, including
monoclonal antibodies, oxygen, steroids, remdesivir, and others.
o Patient B: (585, 590, 2745, 2712, 3536, 2734-5, 2778, TOC 11, 21, 22)
o Patient C: TOC 21
o Patient D: (671)
 Tocilizumab, an IL-6 inhibitor, was recommended by inpatient providers, Dr. Li and Dr.
Shobhit. Patient D had no contraindications to this treatment and the potential benefits
were deemed to exceed the known risks. Patient D’s son declined tocilizumab
treatment after discussing it with Respondent (681, 687). Of note, this treatment is
suggested, but not necessarily recommended, in IDSA guidelines. However, the
inpatient critical care physicians directly managing Patient D, would be in a better
position to determine the advisability of this treatment and guide a risk and benefit
discussion with the patient and their family.
 During a call with Patient D’s son, Respondent and the pulmonary critical care physician,
Respondent insisted on the need for a different steroid treatment plan. When the
pulmonologist discussed the highest level of steroid evidence from the RECOVERY trial,
Respondent retorted, “you should use outcome evidence and that is why patient needs
to leave your hospital”. The pulmonologist intended to follow up with the son about
whether the son wished to initiate a transfer of his mother to a different hospital,
though the physician added that Patient D was not stable to leave without being
intubated prior to possible transfer (697). Patient D was placed at potential risk of harm
by the possibility of transferring when critically ill.
o Patient E: (1081)
o Patient F: (588, 2180)
o Respondent touted this perspective of hospital provider incompetence despite the fact that his
work is limited to an outpatient pediatric practice and he is not an experienced inpatient
hospitalist or intensivist (586[B], 668[D], 683[D]).
o Respondent was interviewed on a widely viewed talk show during which the host reported that
“ventilators are equivalent to guillotines”, 9 out of 10 patients placed on ventilators die,
ventilators are used for hospitals’ financial gains (rather than for clinical indications), and that
doctors were denying patients life-saving treatment with ivermectin. The respondent failed to
comment on or counter these opinions, thus tacitly agreeing with these pronouncements. His
presence, as an introduced medical provider, during the above proclamations, granted veracity
to the blatant misinformation being widely distributed. Additionally, Respondent stated that
hydroxychloroquine treatment was of benefit but, unfortunately, could not be utilized because
of medical commission interference (TOC 21) and did not contest the host’s follow up

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 contention that this was motivated by the “Big Pharma” control of medical boards. Respondent
professed this opinion despite proven lack of treatment efficacy and clear guideline
recommendations not to prescribe hydroxychloroquine for COVID-19.
o Respondent’s criticisms of guideline treatments and inpatient care seriously undermined
therapeutic doctor-patient and doctor-family relationships for critically ill patients being
managed in the ICU in a manner that compromised appropriate care and placed patients at
risk of harm (539-542, 588[F], 575, 595, TOC 21)
 Respondent guided 2 families to seek emergency injunctions to compel hospitals to
administer Ivermectin for COVID 19 (541-2[B], 540[E])
 Respondent’s claims regarding the incompetency of inpatient providers and lack of
efficacy of standard inpatient COVID treatment protocols may have contributed to
Patient B’s decision (supported and encouraged by his wife) to decline intubation and
leave the ICU against medical advice to acquire ivermectin (and other medications
recommended by the respondent), only to re-present to the hospital in critical condition
the following day (2681, 2712, 3528-9, 2681, 2688, 2722, 3534-5).
 After readmission and intubation, as Patient B’s status became increasingly critical and
Respondent was providing guidance, Patient B’s wife requested that her husband
transfer to a hospital that would allow him to receive ivermectin. The wife was
informed that all local hospitals had declined to accept patient and were not offering
ivermectin treatment for COVID-19 (2717-8). Moreover, she was informed there was a
possibility that her husband would not survive the transport (2718).
 Patient D: Respondent expressed dissatisfaction with (and recommended alteration of)
Patient D’s steroid treatment and advised Patient D’s son against tocilizumab treatment
recommended by his critical care hospital providers. One of the hospital providers
offered to “transfer patient to the hospital that PCP Dr. Miller has privileges to take care
of the patient” (687). Given that Respondent has a pediatrics practice, he likely does
not have inpatient critical care medicine privileges or sufficient expertise to provide
critical care patient management. This scenario likely significantly eroded the patient’s
son’s trust in the hospital care being provided.

o Respondent indicated that Ivermectin, and/or a higher-dose, alternative steroid formulation

(methylprednisolone instead of dexamethasone) and/or vitamin treatment could be life-
saving interventions for critically ill hospitalized COVID patients on ventilators whom he felt
were not receiving any effective interventions. Respondent repeatedly attempted to intervene
in in the treatment plan of critically ill COVID patients in the ICU to recommend alternative
treatment. (TOC 11--B: 585, 590, 2760, 2706, 2717, 2778, TOC 21, 22--Patient D: 658, 671, 683--
Patient E: 540, 1081-- Patient F: 588, 2180).
 Respondent posted Facebook statements professing, “I have offered solutions,
treatments, protocols that would virtually ensure that all your ICU patients being able to
go home to their loved ones . . . Let me please make something crystal clear with this
memo that a hospital system put out, they specifically and intentionally chose to
undermine all of science. Ivermectin is a miracle, and I don’t want to say this
unequivocally, because things have changed since April and May with the rollout of
mass inoculation, but prior to that, this singular medication used to treat head lice and
scabies, but also used to treat Zika, and dengue fever, and Asian flu, and Hanta. All very
deadly viruses, this very cheap antiparasitic medication unequivocally saves lives. You
could ask me, but that would be silly, because our local hospital systems think I am the
devil. So don’t ask me, ask the 800+ people that called us in desperation. It’s okay, you
can actually call them up and ask them, because they are alive.” (575-77)

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  Properly dosed Ivermectin and vitamin treatment may be unlikely to cause patient harm
and could, conceivably, offer a yet-unproven therapeutic benefit for COVID-19
infections. However, the Respondent’s assertion that these treatments, rather than the
purportedly ineffective standard of care treatment, was likely to be lifesaving for
critically ill patients on ventilators was inaccurate, interfered with the receipt of optimal
care and endangered patients.
 High-dose steroids have numerous potentially dangerous side effects. Evidence is
insufficient to indicate that the benefits of high-dose steroids outweigh the risks in the
management of severe or critical COVID-19 infections.
• The RECOVERY trial demonstrated that treatment with 6 mg of dexamethasone
per day was associated with a statistically significant decrease in the 28-day
mortality risk for critical COVID-19 patients. Though this steroid dose appeared
to yield favorable results, it does not necessarily follow that more steroids
would be more beneficial. Evidence is insufficient to indicate that higher doses
of steroids or a different steroid formulation would yield better outcomes. Early
treatment with or excessive doses of steroids have been associated with
delayed viral clearance, multi-organ injury and increased mortality (Liu, 2020).
• Steroids offer a beneficial dampening of the uncontrolled inflammatory
response that occurs in later stages of critical COVID-19 infections. However,
steroids also have numerous serious negative side effects including
immunosuppression (with risk of opportunistic infections and delayed clearance
of infection), adrenal suppression, fluid retention and hyperglycemia.
o In the context of a critically ill patient with ARDS (marked by diffuse lung
injury and pulmonary edema) and volume overload from renal failure,
high-dose steroids may have worsened Patient B’s pulmonary function.
o While anti-inflammatory treatments are used to treat the inflammatory
phases of COVID-19, steroids at high-doses could tip the balance
towards a risk of opportunistic infections due to immunosuppression
compared to the benefit of the anti-inflammatory effect.
• Anti-inflammatory treatments during the pro-inflammatory stages of critical
illnesses have yielded mixed results. Immune suppression often occurs
concurrently with the pro-inflammatory cytokine storm phases of illness.
Immunostimulants, such as interferon, have also demonstrated success in
treating COVID-19. These facts raise additional concerns about advocating for
high-dose steroids that lack sufficiently demonstrated efficacy for COVID-19
infections.

RESPONDENT CONDUCTED HIMSELF IN AN UNPROFESSIONAL MANNER

• Respondent repeatedly called hospital staff, in an intrusive fashion, to inform them that they were not
appropriately treating critically ill COVID 19 patients and that he could educate them on the therapeutic
benefits of treatment methods that lack proven efficacy
o Respondent details how he called hospital providers “every thirty minutes, night after night,
week after week, month after month trying to get an on-call doctor to make a few simple
changes . . .” (575)
o General: 539-542, 593, 595, TOC 11, 21
o Patient B: 2745, 3607-3711, TOC 21, 22
o Patient D: 671, 683
o Patient E: 1081
o Patient F: 588, 2180

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 o PeaceHealth Southwest Washington Medical Center sought a restraining order to block
Respondent’s phone calls to their institution (536)
• Respondent misrepresented himself as family members of patients (TOC 11, 593, 2180)
• Respondent misrepresented himself as a medical doctor to hospital staff (593, 595, 538, 683) and did
not correct references to being a doctor on widely viewed talk-show interviews (TOC 21) or by patients’
family members (683, 697)
• Respondent attempted to direct care for patients whom he had never evaluated or treated (593[B],
538[B] 540[E])
• Respondent exhibited unprofessional conduct when communicating with hospital staff (589)
• Respondent publicly disparaged hospital systems on widely viewed talk shows (TOC 21)
• Respondent publicly called out physicians by name, on Facebook, as dangerously mismanaging COVID
19 patients, referred to them as executioners and accused them of killing patients in exchange for
money in a manner that might incite threatening public reactions towards the named providers (575-
577). Reading Respondent’s Facebook postings titled, “to Legacy Salmon Creek hospital system
providers that haven’t suckled from the teeth of evil” would offer important context to the notable
and concerning degree with which Respondent exhibited unprofessional behavior.
• Respondent tacitly agreed with accusations about hospitals intubating and killing COVID-19 patients for
financial gain (Exh R) and that ineffective COVID-19 management guidelines were dictated by conflicts of
interest (TOC 34).
• He inaccurately wrote the indications for ivermectin prescriptions as treatment for lice infestations
when, in truth, he was prescribing the medication for COVID infections (3675, 3678). Respondent’s
attempts to conceal his prescribing intentions reflects his understanding that the prescribing of
ivermectin for COVID-19 was not consistent with standard of care practice and guidelines.
o Respondent’s contention that the lice diagnosis was included because the pharmacy required a
diagnosis code to dispense the medication does not make sense. Respondent could have used a
diagnosis code of COVID 19 infection or viral syndrome.
o The “Stay Health Stay Free” video (TOC 32) includes multiple clips of Respondent making jokes
about pretending to prescribe ivermectin for lice, scabies and parasites in the guise of treatment
or prophylaxis for COVID-19.
• Respondent misrepresented facts in his response to the Washington Medical Commission’s Letter of
Cooperation.
o Respondent did not admit advising others against wearing masks and denied discouraging social
distancing, though video evidence of his presentations indicates otherwise.
o Respondent denied ever prescribing Ivermectin for COVID-19 (395). Records document that
Respondent prescribed Ivermectin for COVID-19, though the prescriptions provided for review
documented the indication for the medication was for head lice (3675, 3678).
• Respondent provided inaccurate information in his response to the Letter of Cooperation regarding the
prescribed steroid dose and indications for administration for Patient A.
o Respondent indicated that the dexamethasone prescription was for 6 mg daily for 5 days “if
patient was starting to have respiratory issues”.
o Respondent wrote the prescription for 12 mg daily for 5 days.
o Moreover, neither chart documentation nor the prescription indicates that administration of the
steroid treatment was to be contingent upon the patient’s respiratory status.
• Respondent charged money for visits related to the prescribing of unproven treatments for COVID-19
• Respondent indicated, in his response to the Letter of Cooperation, that the costs of medications he
prescribed were offset by potential negative health impacts and costs accrued if the patient were
hospitalized.
o This is based on a premise that the treatment Respondent prescribed effectively prevents the
onset or worsening of a COVID infection and substantially decreases the likelihood of
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 hospitalization. However, evidence does not support the effectiveness of the medications
prescribed by Respondent.
o Respondent seemed to have been profiting off a high-volume treatment of COVID-19 patients
with unproven and potentially harmful treatments.

RESPONDENT FAILED TO MEET THE STANDARD OF CARE IN TREATING COVID PATIENTS

He treated and advocated for treatment of COVID patients with Ivermectin (414[A], 2669[B], 3675 [Relative of
B], 3678[B], 538[C], TOC 22[C], 692[C]), despite a lack of proven efficacy and explicit standard of care
recommendations against this treatment. Respondent relied upon evidence supporting Ivermectin efficacy (and
efficacy of additional treatments) that is not of sufficient quality or not adequately substantiated to support
therapeutic effectiveness. Many of the studies were small and insufficiently powered, not placebo controlled or
involved the intervention of Ivermectin along with other possibly therapeutic agents. A reasonably prudent
Physician’s Assistant would not rely upon the evidence put forth by the respondent to justify his COVID
treatment practices.
• A randomized controlled trial published in JAMA (Lopez-Medina, et al, JAMA March 2021) did not
demonstrate effectiveness of ivermectin, compared to placebo, in time to resolution of symptoms for
mild COVID-19 infection
• An Infectious Disease Society of America (IDSA) summary of evidence reviewing 15 studies (deemed of
sufficient quality to warrant evaluation) determined that the evidence was insufficient to demonstrate a
beneficial effect of ivermectin treatment on mortality, on avoidance of progression to severe disease or
on viral clearance. The IDSA Guideline Panel recommends against ivermectin treatment for COVID-19
outside the context of a clinical trial.
• CDC and FDA advisories indicate that ivermectin is not authorized or approved for the prevention or
treatment of COVID-19. The NIH, WHO and Merck (Ivermectin’s manufacturer) agree there is
insufficient evidence to support the use of ivermectin to treat COVID-19. The AMA, and 2 national
pharmacist associations have issued statements opposing the ordering, prescribing, or dispensing of
ivermectin to prevent or treat COVID-19 outside of a clinical trial.
• As aptly summarized in The lesson of ivermectin: meta-analyses based on summary data alone are
inherently unreliable, “. . . many hundreds of thousands of patients have been dosed with ivermectin,
relying on an evidence base that has substantially evaporated under close scrutiny. Relying on low-
quality or questionable studies in the current global climate presents severe and immediate harms.”
• The Chest article cited by Respondent, though published in a peer-reviewed journal, does not provide
sufficient evidence-based justification for ivermectin treatment. The following points detail some of the
weaknesses of this study:
o It was a retrospective observational cohort study reporting post-treatment outcomes. A low
level of confidence is held for the validity of outcomes from observational studies. The evidence
from these study designs is considered weak.
o Clinical criteria indicating ivermectin treatment in this study are not specified (treatment with
ivermectin was at the individual physicians’ discretion)
o Ivermectin treatment appeared to be the standard of care during the study period such that
there were likely unmeasured confounders that impacted the results stemming from those
patients who did not receive ivermectin
o Chronologic bias was of concern in that more of the non-ivermectin treated cohort were
enrolled earlier in the study and overall COVID mortality rates improved later in the study, when
more ivermectin-treated patients were enrolled
o Ivermectin doses administered were thought to be too low to reach therapeutic tissue
concentrations, based on prior in vitro studies
o The study authors concede, in response to study rebuttals, that “properly powered randomized
control trials are needed to confirm the findings of our study”.

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• The Journal of American Therapeutics ivermectin therapy article relied upon by the Respondent is
fraught with Invalidating issues and cannot reasonably be relied upon. One of the randomized
controlled trials that significantly weighted the measured effect was found to have data irregularities
and was withdrawn from the server. Authors of another of the randomized controlled trials did not
respond to a request for data when concerns about randomization failure were raised.
• The BMC Infectious Diseases Journal ivermectin article was included in the studies reviewed in the IDSA
summary of evidence which did not find sufficient evidence of benefit. I have never heard of this journal
before and was unable to readily find published information about number of manuscript submissions
to the journal per year, or the percent of manuscripts accepted and rejected to inform the quality of the
journal. Online ratings by authors (based on 3 reviews) indicated the quality of review reports was 1.7
(range 0-5, poor-very good) and the overall rating of manuscript handling was 1.3. The journal website
lists one editor who has a Master of Science in biology and 2 assistant editors with unlisted credentials.
None of the editors are physicians or doctorate level researchers. BMC charges $2380 plus taxes for
each article accepted for publication.
• The “Real Scandal About Ivermectin”, published in The Atlantic, summarizes the flawed methodologies
reflected in key COVID Ivermectin studies. This article details study authors who declined to clarify
queries about their data, studies that were withdrawn when questions about data arose, studies that
recruited participants from hospitals that had no record of having participated in the research, severe
data irregularities and copied and pasted patient records (Heathers, 2021).
• The pandemic produced fertile ground for rapidly performed and poorly designed studies that did not
yield convincing results. Additionally, voluminous research articles were broadly distributed through the
media and previously obscure journals that bypassed the standard quality peer-reviewed process.
Despite the pressures felt to respond to a rapidly spreading, deadly infectious agent, the integrity of a
formal scientific process is a necessity.
o “Although crises present major logistical and practical challenges, the moral mission of research
remains the same: to reduce uncertainty and enable caregivers, health systems, and policy-
makers to better address individual and public health. Rather than generating permission to
carry out low-quality investigations, the urgency and scarcity of pandemics heighten the
responsibility of key actors in the research enterprise to coordinate their activities to uphold the
standards necessary to advance this mission . . . Individual clinicians should avoid off-label use of
unvalidated interventions that might interfere with trial recruitment and resist the urge to carry
out uncontrolled, open-label studies. They should instead seek out opportunities to join larger,
carefully orchestrated protocols to increase the prospect that high-quality studies will be
completed quickly and generate the information needed to advance individual and public health
. . . In a report on the ethics and science of research conducted during the 2014-2015 Ebola
outbreak (during which ethical and practical concerns about using standard research
methodologies, like randomization and placebo comparators, yielded a body of inconclusive
findings), a U.S. National Academy of Medicine committee argued that clinical research is an
integral part of outbreak response and that “despite [the] sense of urgency, research during an
epidemic is still subject to the same core scientific and ethical requirements that govern all
research on human subjects” (London, 2020)
 A multi-site randomized placebo-controlled clinical trial evaluating the efficacy of
Ivermectin and other generic medications on the outpatient management of COVID-19
infections is underway and currently 50 percent enrolled. Respondent could have
focused energies on joining or supporting these research efforts to determine whether
Ivermectin treatment for COVID-19 could be supported.
• Clinical practice guidelines are evidence-based and offer various levels of recommendations depending
on the strength of the supporting research. For example, a 1A grade of recommendation indicates a
strong recommendation based upon high-quality evidence. The benefits for this recommendation

10
 would clearly outweigh risk and burdens. Practitioners can feel confident in applying the
recommendation to most patients in most circumstances without reservation. Grade 1B is a Strong
Recommendation based upon moderate quality evidence, benefits clearly outweigh the risks and the
recommendation likely applies to most patients. Grade 2C is a Weak Recommendation based upon low
quality evidence with suboptimal study designs such that the estimate of effect is uncertain and with an
uncertain risk to benefit ratio. A 2C recommendation is considered “very weak”. The range of
categories offers practitioners flexibility to adapt recommendations to individual case scenarios and
patient preferences.
o Dexamethasone treatment for hospitalized critically ill COVID-19 patients, for example, has a 1B
recommendation in the Infectious Disease Society of America COVID-19 Guidelines (Strong
recommendation, Moderate certainty of evidence)
o Steroid treatment for mild to moderate disease without oxygen requirements is considered
“very low” such that guidelines suggest against the use of steroids in this context. (Respondent
inappropriately prescribed steroids to this category of patients.)
o The evidence for Ivermectin treatment for outpatient COVID-19 management, in mild-moderate
disease without oxygen requirements, severe but not critical disease and critical disease is all in
the “very low” category. Recommendations suggest against use except in a clinical trial.
o Respondent’s random selection of low-quality, questionable studies to support Ivermectin
treatment does not fall within this standard formal and reasonably prudent model of practice
guidelines such that his treatment practices fall outside the standard of care.

RESPONDENT’S CARE OF PATIENTS FAILED TO MEET THE STANDARD OF CARE

Care of the general public:

• Respondent discusses treating multiple members of a family with various prescriptions, including
ivermectin, seemingly without appropriate evaluation (3727).
o The morbidly obese, Type 2 diabetic patient with asthma and vascular issues referred to was at
high risk for a severe COVID infection and would have been a candidate for monoclonal antibody
treatment. (Respondent comments during a public presentation suggested this treatment was
available in the community (TOC 32).)
o The article suggests prescriptions were written, in short order, without necessarily completing
an adequate evaluation to determine the patient’s severity of illness, without risk stratification
of his expected course and planning in accordance with this.
o The multiple relatives for who he “immediately” sent prescriptions for, did not likely provide the
history that would be necessary to appropriately manage a COVID illness.

RESPONDENT’S CARE OF PATIENT A FAILED TO MEET THE STANDARD OF CARE

Patient A: 40-year-old male who contracted COVID-19 infection, 5/19/21 telephone visit with Respondent (414)
• Past Medical History: Obesity--260 pounds, “intermittent GI issues”.
• COVID history: symptom onset 5 days prior with congestion, cough, fatigue, and headache. He had a
fever the first 3 days which had resolved. He had no associated shortness of breath.
• Respondent’s management: Assessed Patient A via the phone and prescribed and/or recommended the
following medications and supplements:
o Ivermectin
o Azithromycin
o Dexamethasone
o high-dose Vitamin D (20,000 IU per day)
o N-acetyl cysteine, glutathione
o high-dose vitamin C (1000 mg every hour or until bowel tolerance)

11
 o zinc
o melatonin
o quercetin
o aspirin 325 mg daily
o selenium.

• Concerns Regarding Respondent’s Care of Patient A:

o Patient A had a mild case of COVID with symptoms that were already improving. The
prescriptions prescribed by Respondent were not indicated and lack evidence basis for
prescribing.
o Though Patient A’s BMI is unknown (height is lacking), he likely had a BMI in the range that
would place him at risk for more severe COVID infection.
 Respondent did not assess Patient A’s BMI to assess patient’s risk for a more serious
infection (based on BMI +/- diabetes) or inform the decision about referral for
monoclonal antibody treatment. A BMI > 25-30, criteria he likely met, would have made
Patient A eligible for monoclonal antibody treatment.
 Respondent did not counsel him on this risk factor, the potential pattern of delayed
onset respiratory deterioration or inform him of warning symptoms that would indicate
the need for an urgent evaluation.
o Patient A may well have had undiagnosed diabetes (with obesity as a risk factor), hypertension
or other medical issues that might have impacted patient management. These issues were not
considered or explored.
o Patient A reported “intermittent GI issues”. Aspirin would be contraindicated in a patient with a
history of peptic ulcer disease, history of GI bleeding or notable renal dysfunction. Respondent
did not specifically query Patient A on whether he had a history of peptic ulcer disease, GI
bleeding or renal dysfunction, as would have been indicated.
o COVID-19 infection has prothrombotic effects in later, severe stages. Prescribing aspirin for a
mild, already resolving outpatient case of COVID-19 is not recommended, not indicated and
placed Patient A at risk of aspirin-induced side effects, such as GI bleeding.
o Steroid treatment was not indicated or recommended and subjected Patient A to potential
steroid-associated side effects though there was no apparent benefit of treatment.
o Respondent treated Patient A with dexamethasone (414) for a mild COVID-19 infection
managed on an outpatient basis, which is explicitly not recommended per standard of care
guidelines that include notations that this treatment may cause harm. Of note, dexamethasone
is not recommended for outpatient COVID infections or for hospitalized patients with non-
severe COVID-19 infections without hypoxemia requiring supplemental oxygen. Respondent
prescribed a dose of dexamethasone, for Patient A, that is twice the dose recommended for
hospitalized patients with severe and critical COVID-19 infection (414).
o Respondent’s reference regarding glutathione depletion (response to SOC 1.16) is merely a
theoretical review of a possible common biochemical pathway. This reference, in no way,
demonstrates efficacy of glutathione supplementation. Similarly, the NAC reference article
discusses physiologic effect characteristics of NAC that suggest it might prove beneficial in the
prevention and treatment of COVID-19. The reference does not evaluate or demonstrate
treatment efficacy.
o Respondent treated COVID patients with broad-spectrum antibiotics (414), in the absence of
evidence of a bacterial superinfection, which is not consistent with standard of care treatment
guidelines and not consistent with responsible antibiotic stewardship practices
o Though Respondent offers literature explaining observed effects of macrolide antibiotics on
COVID 19 viral loads and immune mediators in supernatant liquids and within cells, the

12
 information presented proposes a theoretical mechanism of efficacy without clinical trials
demonstrating outcomes.
o Documentation does not reflect counseling on the potential side effects of prescribed
medications.
o Respondent did not assess whether Patient A’s home setting would allow him to adhere to
recommended isolation precautions and did not assess whether Patient A lived with high-risk
individuals that might require additional counseling.

RESPONDENT’S CARE OF PATIENT B FAILED TO MEET THE STANDARD OF CARE

Patient B: 48-year-old male who contracted COVID-19 infection
Past Medical History (pertinent): Increased BMI of 52.7, Sleep Apnea Syndrome, presumed prediabetes,
Unvaccinated for COVID-19
Course of Illness
• 9/1/21 presentation Southwest Medical Center emergency department, via ambulance, with an 8-day
history of COVID symptoms. Patient’s oxygen saturation was unreadable (< 50%) and medics reported
they found him unresponsive (2681).
• Required supplemental oxygen at 4 liters per minute via nasal cannula when admitted. His oxygenation
progressively deteriorated requiring escalation of oxygen to moderate and then high-flow
supplementation.
• On 9/2/21, required BIPAP 100% FiO2 for still worsening oxygenation
• On 9/3/21 at 0035 Patient B remained hypoxic on BIPAP and was transferred to the intensive care unit.
Intubation was recommended to avoid death.
• 9/3/21 Patient B’s wife requested ivermectin treatment.
• 9/3/21 Patient B (and his wife) declined intubation and planned to leave the hospital AMA. They were
informed that the patient had a high likelihood of death if he were not intubated and chose to leave the
hospital (3529, 3535). Patient B’s wife stated an intention to go directly from the hospital to a doctor’s
office, in order to get ivermectin treatment (2712) and indicated that she and the patient believed the
patient was going to live (3534). Respondent was the outpatient provider involved in Patient B’s care at
this time. Patient B’s wife indicated that, if hospital arrangements for a high-capacity home oxygen
concentrator took too long, she would leave the hospital without it (3534-3535). When Patient B left
the hospital AMA, his oxygen saturation was 58% on 10 liters per minute of oxygen.
• Respondent prescribes Ivermectin for an indication of head lice (3678), a 15-d methylprednisolone taper
starting at 96 mg a day (3687), cyproheptadine, azithromycin, doxycycline, and additional medications
for Patient B on 9/4/21 (3677, 3678, 3685).
• 911 was called to Patient B’s home on 9/4/21 and Patient was readmitted to Southwest Medical Center.
The emergency department triage RN note (2688) indicates Patient B arrived appearing purple with
generalized mottling, an oxygen saturation of 47%, a respiratory rate of 65, unable to speak in more
than 1-word responses, using accessory muscles to breath, slumped to one side in bed. Patient B
declined intubation. Staff were concerned about an impending cardiac arrest and the chaplain was
called. Patient B changed his mind and agreed to an emergent intubation (2686).
• 9/10/21, Hospital received an emergency injunction requesting treatment of Patient B with Ivermectin.
There had been prior conversations with Patient C regarding taking legal actions to compel the hospital
to treatment Patient B with Ivermectin (541-542).
• Patient B was treated for severe COVID-19, per guidelines recommendations, with dexamethasone and
tocilizumab (an Interleukin-6 inhibitor which acts to decrease systemic inflammation). He was
maintained in a prone position as needed, treated with anticoagulants, antibiotics (initiated for
increasing white blood cell count and worsened pulmonary infiltrates concerning for possible bacterial
pneumonia) and insulin. Patient B was provided nutrition via tube feeds and was maintained on

13
 mechanical ventilation. Remdesivir was not a treatment option for Patient B as he presented for care
too late in the course of his COVID infection.
• Patient B developed severe COVID pneumonia, Acute Respiratory Distress Syndrome (ARDS), a
hypercoagulable state, and acute renal failure followed by multi-organ system failure. Patient B died
from these COVID-19 complications on 9/12/21.

Concerns regarding Respondent’s care of Patient B

• Respondent prescribed medications to a critically ill patient, who had left the hospital against medical
advice after declining transfer to the ICU for intubation, without ever having met or examined the
patient (578)
• Respondent prescribed ivermectin for Patient B, despite lack of demonstrated efficacy and despite
guideline recommendations against this treatment
• Respondent prescribed medications for a patient with severe COVID infection without evaluating the
patient and without producing chart documentation. This patient was critically ill, having left the ICU
against medical advice after declining recommended intubation and ventilator treatment (538).
o Respondent treated this critically ill patient with ivermectin, despite a lack of sufficient efficacy
data
o Respondent treated this critically ill patient with methylprednisolone at over 3 times the steroid
dose recommended for severe and critically ill COVID patients (3687), though there is
insufficient data to support this, and potential harm related to this treatment
• Respondent’s prescribing of a 15-day taper of oral methylprednisolone reflects an expectation and plan
for Patient B to successfully complete COVID-19 treatment on an outpatient basis, after leaving the ICU
against medical advice when critically ill. This assessment is gravely misguided and not consistent with
standard of care.
• The steroid dose Respondent prescribed is three times higher than that recommended in guidelines.
This placed Patient B at risk of harm.
• Respondent made medical recommendations to Patient B’s inpatient providers though he had never
met, taken a history from, examined or, presumably, reviewed medical records of the patient (578).
• After patient B was readmitted to the hospital, Respondent advocated for treatment with high-dose
steroids that is not supported by evidence
• Respondent indicated to Patient B’s wife that ivermectin and other unproven treatments would likely be
lifesaving. Respondent informed Patient B’s wife that he had successfully treated over 900 COVID
patients with his medication protocol giving them an unfounded and unrealistic belief in the efficacy of
unproven treatments. These beliefs, in part, compelled them to question the inpatient treatment
protocols and repeated request treatment with Respondent’s unfounded therapeutic
recommendations.
• Between Patient B’s readmission on 9/4/21 and his death, Patient B’s wife and Respondent repeatedly
attempted to intervene in the patient’s care with insistent requests for changes in the treatment plan.
They requested treatment with ivermectin, replacement of dexamethasone with methylprednisolone at
a higher equivalent dose, and Vitamins D and C.
• Respondent harassed ICU staff and indicated to them (and to Patient B’s wife) that the inpatient team
was not offering effective COVID treatment and was denying Patient B the life-saving treatments noted
above. Patient B’s wife desired to transfer Patient B from the ICU, while his status was critical and
unstable, to another medical center that would prescribe ivermectin, though all surrounding hospitals in
the area had declined to offer this treatment. Respondent interfered with therapeutic provider-
patient/family relationships and placed Patient B at risk of harm that might have transpired from
hospital transfer while critically ill.

RESPONDENT’S CARE OF PATIENT C FAILED TO MEET THE STANDARD OF CARE

14
Patient C: Unknown age (appears to be a middle-aged female), wife of Patient B
Past medical history: unknown
Course of Illness:
o Patient C reports having contracted COVID-19 infection.
o Patient C (and her brother and mother) were treated with Ivermectin for COVID-19.
Respondent, presumably, prescribed the Ivermectin for Patient C as she refers to him as her
family physician (538, TOC 22) and respondent prescribed Ivermectin for Patient B and another
family member (3675, 3678).

Concerns regarding Respondent’s care of patient C:

o Respondent prescribes ivermectin despite lack of demonstrated efficacy for COVID-19 and
despite explicit recommendations against this treatment
o Respondent does not assess Patient C’s eligibility for monoclonal antibody treatment (based on
information provided for review)
o Patient records and video recordings indicate that Patient C had significant influence over
Patient B’s decisions about whether to get intubated and played a central role in Patient B
leaving the hospital against medical advice. For example, INV3556 documents that Patient B
declined recommended intubation saying that his wife “never wants me to have a breathing
tube”.
o Respondent impresses upon Patient C, the wife of Patient B, that hospital providers do not know
how to appropriately treat COVID-19 and that patients may die because of the inpatient
providers’ failure to use available treatments, though these treatments do not have
demonstrated efficacy.
o Respondent impresses upon Patient C, the wife of Patient B, that Ivermectin is potentially life-
saving treatment for Patient B who is critically ill with COVID 19.
o Respondent tacitly agrees, during the talk show interviews, that mechanical ventilation is the
cause of death for 9 out of 10 critically ill COVID 19 patients. The host refers to “putting the
execution device down his throat”. The host also refers to a conspiracy theory about authority
figure orders to bring COVID (+) patients to infect and kill others and professes that hospitals
follow “murderous protocols”.
o The talk show host purports, in reference to placing patients on ventilators, that the hospital is
“pulling hits” and that the “cash pours in” to the medical centers for each patient they intubate.
Respondent tacitly agrees that intubation and mechanical ventilation of COVID-19 patients is
motivated by financial gain for hospitals and is, therefore, carried out despite the devastating
associated clinical outcomes.

RESPONDENT’S CARE OF PATIENT D FAILED TO MEET THE STANDARD OF CARE

Patient D: 77-year-old female who contracted COVID-19 infection
Past medical history: Diabetes, Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), Hypertension,
COPD, Reactive Airway Disease (asthma), Unvaccinated for COVID-19, history of breast cancer, history of
histoplasmosis, vitiligo

Course of Illness: (692)

• Diagnosed with COVID-19 infection on 7/11/21
• Respondent treated Patient D with ivermectin, methylprednisolone 32 mg daily for 5 days followed by
16 mg daily for 5 days, Fluvoxamine, Tylenol, Vitamin C, Vitamin D, Zinc, melatonin and cyproheptadine
• Patient D’s symptoms did not progressively improve. On 7/18/21 she had a fever of nearly 102 degrees
F (634).

15
 • Patient D developed hypoxia with an O2 saturation < 88% prompting Respondent to order home oxygen
therapy. When the oxygen supply ran out, Patient D’s O2 saturation was 84% (634).
• Presented to Southwest Medical Center on 7/19/21 when running out of home oxygen and having
difficulty breathing
• 7/24/21 Transferred to the ICU for progressive hypoxia, imaging was consistent with ARDS, Patient D
was reluctant to be intubated
• 7/26/21 Patient D decided against intubation, desired comfort care, and transferred out of the ICU
• 7/27/21 Patient D expired from severe COVD-19 pneumonia and ARDS

Concerns regarding Respondent’s care of Patient D:

• Patient D was at very high risk for severe COVID-19 infection (based on her age, diabetes, CHF,
hypertension, and COPD) such that COVID-19 vaccination should have been prioritized. She had not
been vaccinated due to her vitiligo (634).
o Vitiligo is not a contraindication to vaccination.
o Vaccination might have prevented COVID-19 infection or prevented the development of severe
infection and death for Patient D.
• Patient D had a multitude of risks for progression to severe infection including age, diabetes,
hypertension, and COPD that warranted assertive management of COVID-19 infection.
• Patient D met eligibility for treatment with monoclonal antibodies (prior to initiation of oxygen therapy),
which can decrease the risk of progression to severe disease and hospitalization. Respondent treated
Patient D with a multitude of unproven therapeutics but did not consider treatment with monoclonal
antibodies.
• Respondent treated Patient D with ivermectin, methylprednisolone and home oxygen on an outpatient
basis for COVID-19 infection. This is not consistent with standard of care or guidelines
recommendations and placed Patient D at risk of harm.
• Steroid treatment is recommended for hospitalized patients with severe or critical COVID-19 infections
marked by hypoxia. Steroid treatment is not recommended for outpatients or hospitalized patients with
non-severe COVID-19 infections (O2 saturation > 94% not requiring supplemental oxygen). Outpatient
records for Patient D were not provided for review. It is unclear whether the steroid treatment
preceded her onset of hypoxia. Steroid treatment might have been indicated in the setting of a COPD
exacerbation. Outpatient records would need to be reviewed to assess whether Respondent was
treating a COPD exacerbation. Records reveal, however that Patient D’s inpatient care for was not
marked by focused management of a COPD exacerbation.
o Respondent treated Patient D with methylprednisolone 32 mg per day on an outpatient basis.
This is the steroid dose that is recommended for hospitalized patients with severe or critical
COVID-19 infections requiring supplemental oxygen. Either Respondent was inappropriately
treating a mild COVID infection with steroids or he was inappropriately treating Patient D’s
severe COVID infection in an outpatient setting (692).
• Patient D manifested evidence of severe COVID infection with hypoxia but Respondent treated her with
home oxygen, rather than referring her for emergency department evaluation and inpatient care. It
appears that Respondent’s belief in the lack of efficacy of standard COVID treatments contributed to a
delay in the receipt of timely care for patients with serious COVID infections, placing them at risk of
harm and death.
o Patient D was diagnosed with COVID-19 on 7/11/21 and had been taking ivermectin to treat her
symptoms. She had low oxygen saturation readings of 88% and home oxygen treatment was
arranged. When the oxygen tank was empty, her oxygen saturation dropped to 84%. She had a
fever of 102 on the day prior to admission and numerous other active COVID symptoms upon
presentation to the hospital on 7/19/21, 8 days after her COVID diagnosis. Patient D developed
progressive hypoxia requiring transfer to the ICU and imaging was consistent with ARDS (acute
16
 respiratory distress syndrome, marked by diffuse lung injury with fluid accumulation in the air
sacs that causes worsening hypoxia and, in turn, prevents oxygenation of vital organs).
o Given her very high risk of severe COVID infection, Patient D should have been referred to the
hospital for care when she was determined to be hypoxic. Upon presentation, she had an
elevated respiratory rate of 31, her oxygen saturation was 86% on room air and she had
widespread bilateral ground-glass densities Involving all aspects of both lungs. Her oxygen
requirements rapidly increased on the day of admission (655)
o Patient D presented to the hospital in a delayed manner that potentially negatively impacted
her outcome. She presented too late to be treated with remdesivir (677, 696).
• Respondent interfered with the provision of Patient D’s inpatient care, requesting providers alter
treatment to non-evidence-based regimens. Respondent, in the role of Patient D’s PCP, spoke with an
ICU provider to insist on changes in the prescribed steroid treatment regimen (671, 683). Respondent
(with Patient D’s son present) indicated treatment with methylprednisolone would be more beneficial
than dexamethasone. The ICU provider informed Respondent that current available medical literature
indicated that the prescribed dexamethasone provides the best mortality benefit (683).
• Respondent insisted on non-evidence-based treatments with another ICU provider. Respondent was
introduced to Patient D’s inpatient pulmonologist/critical care physician as “Dr. Miller”. Respondent
insisted on a change to high dose solumedrol steroid treatment (683). The pulmonologist informed
Respondent that the highest level of evidence supported the current treatment with dexamethasone.
Respondent acknowledged that the steroid studies he relied upon were only observational and
retrospective studies. Respondent informed the pulmonologist that “you should use outcome evidence
and that is why patient needs to leave your hospital”. The pulmonologist planned to follow up with the
family about whether they desired to transfer the patient to a different medical facility (697). Patient
D’s son was present during the conversation when Respondent indicated Patient D needed to leave the
hospital due to the inadequacy of treatment being provided.
o This behavior disrupted a therapeutic relationship with the family and created mistrust of
guideline-recommended, evidence-based treatments.
o Respondent placed Patient D at risk of harm by interfering with medication management and
potentially prompting a hospital transfer while she was severely ill.
o Patient D’s son continued to request the change in steroid treatment (696) and an inpatient
provider considered transferring Patient D to the hospital that “PCP Dr Miller has privilege to
take care of pt” (687). Respondent was questioned by the inpatient provider about whether
Respondent was an intensivist. Respondent replied that he was a pediatrician (683).
 As an outpatient pediatric provider, Respondent likely does not have inpatient admitting
privileges to provide acute care for adult (or, perhaps, pediatric) patients.
 Respondent intrusively strove to guide inpatient care decisions despite his lack of
inpatient scope of practice and despite a lack of sufficient information on Patient D’s
clinical status.
 Respondent reported, in an online news article, “I treat kids. I am not used to talking to
people when they are dying” (3725).
o Respondent informed an inpatient provider, in the presence of Patient D’s son, that he has
taken care of many ill COVID patients in the past year and has personally adjusted their steroid
regimens. He also advocated for IV thiamine and vitamin C and zinc treatment (683).
 Despite his purported significant experience with treating outpatient COVID positive
patients, Respondent recommended unproven treatments and criticized efficacious
treatments.

RESPONDENT’S CARE OF PATIENT E FAILED TO MEET THE STANDARD OF CARE

Patient E: 64-year-old male, contracted COVID-19 infection

17
Pertinent Past Medical History includes: Nonobstructive Coronary Artery Disease with an abnormal cardiac
stress test 4/2021, Echocardiogram in 3/2021 revealed a normal left ventricular size and function and was
without other notable abnormalities, Diabetes, Hypertension, Reactive Airways Disease (asthma), Overweight,
Hypothyroidism, Spinal Stenosis with chronic back pain, Unvaccinated for COVID-19
Course of Illness:
• Presented to Southwest Medical Center on 7/17/21. He reported a 4-day history of shortness of breath
that had worsened, fevers up to 104 degrees F, severe headaches, muscle aches, fatigue, decreased
appetite, lightheadedness, and oxygen saturation readings of 88-93%. He indicated that his entire
family had tested positive for COVID-19 on 7/13/21.
• In the ED, Patient E was noted to have a fever of 103 degrees F, he was hypotensive with a blood
pressure of 80/45, oxygen saturation was 93% on room air. Chest X-ray revealed a streaky opacity in the
right lower lobe concerning for a developing infiltrate. A serum creatinine elevation reflected acute
kidney injury. ECG revealed no acute ischemic changes.
• Treatment with IV Dexamethasone 6 mg, IV Remdesivir, IV Ceftriaxone and IV fluids were administered
in the ED.
• Shortness of breath and oxygenation requirements progressively increased over time
• 7/20/21 High-flow oxygen requirements, chest x-ray reveals patchy bilateral opacities
• 7/22/21 Transferred to the ICU. Patient E indicated he would be agreeable to a time-limited trial of
intubation but that he would not desire a tracheotomy if he were unable to be liberated from a
ventilator.
• 7/25/21 High Flow oxygen requirements
• 7/27/21 Febrile, Patient E and family informed that patient’s likelihood of survival is low, even with
aggressive treatment, given patient’s age, comorbidities and lung fibrosis that develops in the later stage
of COVID infections. Code status is changed to DNR, but intubation allowed, Intubated for ventilator
treatment
• 7/28/21 Patient E develops hypotension, reflecting circulatory shock due to viral pneumonia,
vasopressor treatment initiated to support blood pressure and perfusion
• 7/28/21 the ICU RN is informed that Patient E’s brother-in-law has hired an attorney to force the
hospital to treat the patient with Ivermectin. Patient E’s wife mentions treatment with Ivermectin and
hydroxychloroquine to the ICU RN.
• 7/29/21 Hospital receives an emergency injunction request for treatment with Ivermectin from a law
firm (540)
• 7/29/21 ICU Provider informs Patient E’s wife that Ivermectin does not have demonstrated effectiveness
in treating COVID-19 pneumonia and discusses numerous potential associated side effects including
rash, liver dysfunction, TENS and Stevens Johnson Syndrome. Patient E’s wife indicated an
understanding of this information and stated she no longer desired Ivermectin treatment for her
husband.
• 7/29/21 Patient E develops Atrial Fibrillation with a rapid ventricular rate
• 7/30/21 Circulatory shock progresses, requiring additional vasopressor treatment and IV albumin
• 7/30/21 Patient E’s wife calls the ICU RN with concerns that her husband is not being treated with the
right medications.
• 7/30/21 Respondent calls the ICU RN around 0243 am, introducing himself as a PA who is a family
friend. He expressed displeasure with not being able to speak with the treating physician and concern
that Patient E was not receiving a particular high-dose medication. Respondent indicated he would be
joining a next morning call between the wife and the treating physician.
• 7/30/21 Patient E’s son calls the ICU RN around 3 am then Respondent gets on the line. Respondent
indicated that Patient E was not being treated with the right medication, that he had treated over 600
COVID patients and that his treatment recommendations had “gotten patients out of the ICU”.

18
 • 7/30/21 Care Conference is held with Patient E’s wife, daughter, Medical Director of Care Management
and Director of Risk Management. Patient E’s wife stated she was withdrawing her legal representation
regarding the appeal to use ivermectin treatment.
• 8/1/21 Patient E’s wife apologizes to the ICU RN about the family dynamics and legal issues that arose
and expressed appreciation for the care provided for her husband.
• 8/2/21 Patient E remained critically ill; family decided to transition to comfort care. Patient E was
extubated, and medications were discontinued, except for IV fentanyl. Patient E passed away with his
family at his bedside.

Concerns about Respondent’s care of Patient E:

• Respondent repeatedly contacts hospital staff to attempt to direct treatment though he is not aware of
the Patient E’s current clinical status and, seemingly, has not been previously involved in the patient’s
care, and despite his lack of expertise in directly managing critically ill COVID-19 (or other critically ill)
patients.
• Respondent recommends treatment with Ivermectin, despite lack of demonstrated efficacy.
• Respondent, presumably, calls to recommend high-dose steroids (based on his contention that Patient E
was not receiving a particular high-dose medication), though this is not evidence-based and might have
significant deleterious effects such as a potential increase in pulmonary fluid accumulation in the setting
of ARDS (with consequent worsening of hypoxia) and increased susceptibility to secondary infections.
• Respondent leads Patient E’s family to believe that ivermectin is a life-saving treatment for late-stage
critically ill COVID-19 patient with ARDS who is on a ventilator and in circulatory shock. Respondent
indicates to the family that this life-saving treatment option is being withheld by the inpatient care team
and this prompts the family to take legal action to compel treatment with Ivermectin.
• Patient E’s wife indicates that Respondent guided her children on seeking the emergency injunction for
Ivermectin treatment and that her children had pressed her to accede to this plan (540).
• Respondent interferes with the family-care team relationships in a manner that is disruptive to patient
care and that erodes trust in the inpatient care team

RESPONDENT’S CARE OF PATIENT F FAILED TO MEET THE STANDARD OF CARE

Patient F: 63-year-old male who contracted COVID-19 infection
Pertinent Past Medical History: status post renal and pancreatic transplant (2015), mild transplant rejection, BK
Polyomavirus viremia (opportunistic infection in an immunosuppressed host),Type 1 Diabetes (resolved since
pancreas transplantation), Stage IV Chronic Kidney Disease requiring dialysis (resolved after renal transplant),
Transient Ischemic Attack, Cerebellar Stroke, Hypertension, Atrial Flutter (cardiac arrhythmia) requiring
anticoagulation treatment, complete heart block, Osteoporosis, Lumbar spinal stenosis, spinal osteomyelitis,
bacterial endocarditis, Retinopathy, Depression, Unvaccinated for COVID-19 (had received numerous other past
vaccinations, 2036)
Notable Medication History: Transplant status required long-term immunosuppressive treatment with
basiliximab (interleukin-2 inhibitor), tacrolimus and prednisone 5 mg daily, Lasix 20 mg daily, lisinopril 5 mg
daily, warfarin (2.5 mg 2 days/week, 5 mg other days)

Course of Illness:

• Presented to Southwest Medical Center emergency department on 7/25/21 reporting a 1-week history
of COVID-like symptoms, including shortness of breath. Patient F had abnormal breath sounds on lung
exam, bilateral perihilar infiltrates on chest x-ray and tested positive for COVID-19 infection (2046,
2048). Additionally, Patient F presented with acute renal failure (BUN of 60, Creatinine 3.35 compared
to baseline of Cr of 1.18), a markedly elevated cardiac troponin level without ST elevations on ECG
(concerning for non-ST-elevation acute myocardial infarction [heart attack] or COVID cardiomyopathy),
19
 an INR > 10.2 (consistent with a hypercoagulable state often seen in severe COVID infections), and a BNP
level of 1,439 (consistent with congestive heart failure) (2048).
• Patient F was notably hypoxic en route to the ED via ambulance. Oxygen saturation upon arrival in the
ED was 61% on room air and 93% on high-flow oxygen at 10 liters per minute via non-rebreather mask
(2060)
• Patient F’s oxygen requirements rapidly escalated while being admitted to the acute care unit but no
ICU beds were available on-site or at OHSU for patient transfer, as was desired. BIPAP was initiated on
the acute care unit.
• Patient was treated with dexamethasone. Remdesivir treatment was contraindicated in the setting of
acute renal failure.
• 7/26/21 Treatment with Tocilizumab was recommended but declined by Patient F
• 7/27/21 Cardiology consultant determined Patient F likely had demand ischemia (type 2 myocardial
infarction) due to acute hypoxia from COVID-19 pneumonia (2092)
• 7/31/21 positive blood culture results are noted, IV vancomycin treatment is added to previously started
IV ceftriaxone, Patient F is reported to be lethargic, frequently moaning, and difficult to understand.
Patient F states he wants to go home, does not want to fight anymore (2167).
• 8/2/21 The ICU provider informed Patient F’s daughters that, given the lung fibrosis that would have
developed after more than 7 days with ARDS and progressively worsening respiratory failure, Patient F
was unlikely to improve and was in the process of dying (2194). The Palliative Care consultant
determined Patient F had limited decisional capacity due to somnolence and delirium. After numerous
discussions between Patient F’s two daughters with the Palliative Care and ICU provider, the code status
was determined to be DNR/DNI and care was transitioned to comfort measures (2190).
• Date of death 8/3/21 at 0800

Concerns about Respondent’s care of Patient F:

• Patient F was unimmunized (2046) despite his phenomenally high risks for severe COVID-19 infection.
(It is unclear whether Respondent had ever met or cared for Patient outpatient records have not been
provided for review).
• Patient F’s very complex medical issues were well beyond Respondent’s scope of experience.
• On 8/1/21, Respondent misidentified himself as Patient F’s brother (he later admitted to being S. Miller,
PA-C) during a phone call with the ICU provider and recommended changing antibiotic treatment to
doxycycline (which would not have been appropriate based on microbiology results) and adding
cyproheptadine (588, 2180). Respondent stated he had successfully treated over 600 COVID patients.
This behavior is overtly unprofessional and disruptive of a therapeutic alliance between providers and
Patient F’s family and the family’s trust in evidence-based treatment protocols. Moreover,
Respondent’s therapeutic recommendations for the ICU provider are outside Respondent’s practice
expertise, were given without direct knowledge of the patient’s current clinical status, were not
evidence-based, and were provided for a patient he may never have previously met or cared for.

20
References:

Lawrence, J.M., Meyerowitz-Katz, G., Heathers, J.A.J. et al. The lesson of ivermectin: meta-analyses based on summary data alone are inherently
unreliable. Nat Med (2021). https://doi.org/10.1038/s41591-021-01535-y

Bhimrah, A. et al. IDSA Guidelines on the Treatment and Management of Patients with COVID-19 Published by IDSA on 4/11/2020. Last
updated, 10/1/2021

Washington Department of Health News Release

For immediate release: August 26, 2021
Ivermectin should not be used to prevent or treat COVID-19
https://www.doh.wa.gov/Newsroom/Articles/ID/2908/Ivermectin-should-not-be-used-to-prevent-or-treat-COVID-19

This is an official CDC HEALTH ADVISORY Distributed via the CDC Health Alert Network August 26, 2021, 11:40 AM ET
Rapid Increase in Ivermectin Prescriptions and Reports of Severe Illness Associated with Use of Products Containing Ivermectin to Prevent or Treat COVID-
19
https://emergency.cdc.gov/han/2021/pdf/CDC_HAN_449.pdf

Rajter, J. et al. Use of Ivermectin Is Associated with Lower Mortality in Hospitalized Patients with Coronavirus Disease 2019
The Ivermectin in COVID Nineteen Study CHEST 2021; 159(1):85-92

Eduardo Lopez-Medina, et al. Effect of Ivermectin on Time to Resolution of Symptoms Among Adults
With Mild COVID-19: A Randomized Clinical Trial JAMA. 2021;325(14):1426-1435. doi: 10.1001/jama.2021.3071
Published online March 4, 2021.

Bryant, A. et al. Ivermectin for Prevention and Treatment of COVID-19 Infection: A Systematic Review, Meta-analysis, and Trial
Sequential Analysis to Inform Clinical Guidelines American Journal of Therapeutics (2021) 28(4)

Heather, J. The Real Scandal About Ivermectin. Atlantic, Oct 23, 2021

London, A. et al. Against Pandemic Research Exceptionalism. Science, 368 (6490)

Jeronimo, A. et al. Methylprednisolone as Adjunctive Therapy for Patients Hospitalized With Coronavirus Disease 2019 (COVID-19; Metcovid): A
Randomized, Double-blind, Phase IIb, Placebo-controlled Trial. Metcovid Team SO Clin Infect Dis. 2021;72(9):e373.

The RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19, N Engl J Med 2021; 384:693-704. Feb 25, 2021

ACTT-1 Study Group Members. Remdesivir for the Treatment of Covid-19 - Final Report. SO N Engl J Med. 2020;383(19):1813. Epub 2020 Oct 8

NIH COVID Treatment Guidelines https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/

Okums, N, et al. Evaluation of the effectiveness and safety of adding ivermectin to treatment in severe COVID-19 patients. BMC infectious Diseases, May
2021 https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-021-06, 104-9

PRESS RELEASES SEP 1, 2021

AMA, APhA, ASHP statement on ending use of ivermectin to treat COVID-19
HTTPS://WWW.AMA-ASSN.ORG/PRESS-CENTER/PRESS-RELEASES/AMA-APHA-ASHP-STATEMENT-ENDING-USE-IVERMECTIN-TREAT-COVID-19

Scirev, https://scirev.org/journal/bmc-infectious-diseases/

Reardon S. Flawed ivermectin preprint highlights challenges of COVID drug studies. Nature 2021; 596:173

Liu, J. et al. Corticosteroid treatment in severe COVID-19 patients with acute respiratory distress syndrome
J Clin Invest. 2020;130(12):6417-6428

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 TABLE OF CONTENTS/
Documents Reviewed:

1. Complaint to the Washington Medical Commission dated May 21, 2021 (Inv.332- 335)
2. Camas-Washougal Post Record newspaper article by Kelly Moyer dated May 13,
2021 (Inv.336-339)
3. LOC to Respondent dated June 30, 2021 (Inv.417-418)

4. Amended LOC to Respondent dated June 30, 2021 (Inv.419-420)

5. Respondent’s answer to LOC dated August 23, 2021 (Inv.394-407)
6. Complaint to the Washington Medical Commission dated May 28, 2021 (Inv.390- 392)
7. LOC to Respondent dated August 31, 2021 (Inv.421-422)
8. Respondent’s answer to LOC dated August 31, 2021 (Inv.409-413)
9. Respondent’s treatment records for Patient JB (Inv.414-416)
10. Respondent’s voicemail message to the Washington Medical Commission (WMC) Chief
Investigator Adam Calica regarding the LOCs (2021-5907 Attachment 1)
11. Voicemail message from Complainant to the Washington Medical Commission – (2021-9342
Attachment 1)
12. Complaint to Washington Medical Commission dated August 9, 2021 (Inv.536-537)

13. Bryant, A., Lawrie, T., Dowswell, T., Fordham, E., Mitchell, S., Hill, S., & Tham, T. Ivermectin for
Prevention and Treatment of COVID-19 Infection: A Systematic Review, Meta-analysis, and
Trial Sequential Analysis to Inform Clinical Guidelines, 28, e434-e460 (2021) American Journal of
Therapeutics
14. Email from Stephen Kormanyos, MD, Medical Director Care Management, PeaceHealth to LJ
Raleigh, RN, BSN, MS, Director Clinical Risk Management for Peace Health Hospital dated
September 11, 2021 (Inv.593-594)
15. Email from Charanya Sivaramakrishnan to Stephen Kormanyos, MD, Medical Director Care
Management, PeaceHealth and LJ Raleigh, RN, BSN, MS, Director Clinical Risk Management
for Peace Health Hospital dated September 11, 2021(Inv.595)
16. Email from LJ Raleigh, RN, BSN, MS, Director Clinical Risk Management for PeaceHealth
to WMC Chief Investigator Adam Calica dated September 13, 2021 (Inv.538)

17. Email along with attached timeline from LJ Raleigh, RN, BSN, MS Director Clinical Risk
Management for Peace Health Hospital to WMC Chief Investigator Adam Calica dated
September 13, 2021 (Inv.539-543, 578-579)
18. Statement from Shobhit Gupta, DO dated September 27, 2021 (Inv.585-587)

19. Statement from Michael Shen, MD dated September 15, 2021(Inv.588-589)

20. Statement from Alicia Parks, RN, BSN, CCRN dated September 15, 2021 (Inv.590- 593)

23
21. Video FreeWorldNews.TVInfoWars.com - HospitalHolds Patient Hostage (2021- 9342 Attachment
2)

22. Video FreeWorldNews.TVInfoWars.comHospitals Treating Covid Patients Like Prisoners

(2021-9342 Attachment 3)
23. Records for Patient RC obtained from PeaceHealth Southwest Medical Center (Inv.616-
1000)
24. Records for Patient FD obtained from PeaceHealth Southwest Medical Center (Inv.1001-
2009)
25. Records for Patient MK obtained from PeaceHealth Southwest Medical Center (Inv.2010-
2662)
26. Records for Patient RG obtained from PeaceHealth Southwest Medical Center (Inv.2663-
3673)

Additional records sent for review October 7, 2021

27. Investigator’s Memo dated October 4, 2021 (Inv.3676-3677)
28. Prescription Records (Inv.3678-3692) (sent to you on October 5, 2021 incorrectly numbered
as Inv.3674-3690)
29. Verbatim Transcript of Audio Proceedings – Excerpt of Phone Call September 9, 2021
October 23, 2021 Summary Suspension Pleadings including theDeclaration of Health Care
Investigator In Support of Motion for Summary Actionand attached Exhibits A-R
Exhibit A: Respondent’s Application for a Washington Physician Assistant
Credential received October 28, 2013
Exhibit B: Citation Order for Case Number 1E-2012-2244536 issued by the State
of California Physician Assistant Board dated March 14, 2014

Exhibit C: Washington Practitioner Attestation Questions signed by Respondent September 6, 2015

Exhibit D: Respondent’s Statement dated October 12, 2020
Exhibit E: Respondent’s treatment records for Patient A
Exhibit F: Memorandum and Timeline of Events authored by LJ-Raleigh, Director Clinical Risk
Management Peace Health
Exhibit G: Select records from Patient B’s hospitalization
Exhibit H. Verbatim Transcript of Audio; Excerpt of Phone Call September 9, 2021
Exhibit I. Select records from Patient D’s hospitalization
Exhibit J. Select records from Patient E’s hospitalization
Exhibit K. Select records from Patient F’s hospitalization
Exhibit L. Comments from Respondent’s Facebook page

Exhibit M. Respondent’s answer to LOC dated November 22, 2020

24
Exhibit N. Patient B Prescriptions
Exhibit O. Respondent’s Response to LOC dated August 23, 2021
Exhibit P. Video Camas School Board Meeting May 10, 2021(Respondent
appears at the 40-minute mark)

Exhibit Q. Video Covid Patients Treated Like Prisoners

Exhibit R. Video People in Hospitals Being Held Hostage

Additional records sent for review on October 28, 2021

30. Area health provider Scott Miller discusses COVID19 October 27, 2020, Clark
CountyToday.com(Inv.3726-3729)
31. How to stay health by boosting your immune system during pandemic October 11, 2021,
Clark CountyToday.com(Inv.3719-3725)
32. Video Stay Healthy Stay Free with Scott Miller and Others recorded October 9, 2021 Respondent
is introduced in this video at the 1 hour 12 minute mark
33. Video Clark CountyToday.com Washougal Pediatrician Scott Miller discusses Covid-19
October 27, 2020

Additional record sent for review on November 5, 2021

34. Video Against the Wind with Dr. Paul – October 27, 2021, Episode 22, featuring Scott Miller,
PA-C,
Additional record sent for review
35. The lesson of ivermectin: meta-anlyses based on summary data alone are inherently
unreliable Nature Medicine/www.nature.com/naturemedicine, published online September 22,
2021
36. The Real Scandal About Ivermectin – Ivermectin Shows That Not All Science is Worth
Following – The Atlantic, published 10/26/21 - James Heathers

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