Media Library

The Crisis Response Dance

By David McGrath Schwartz Tue, Mar 18, 2008 (2 a.m.)

Gov. Jim Gibbons and his staff looked Sunday night to take “decisive action” on the health care crisis that was more than two weeks old.

So after a full day of phone calls, a late-night news release called for the resignation of three members of the Board of Medical Examiners, the board’s executive director and the head of state inspections. Separately, Gibbons also asked for his own medical adviser to step down.

Now some of those folks are pushing back, questioning the governor’s actions and whether the right heads are rolling.

Gibbons had assured himself a healthy round of questioning from the media after the Reno Gazette-Journal published an interview with him Sunday in which he defended the Endoscopy Center of Southern Nevada against charges of gross negligence. The governor contradicted findings by state inspectors, proclaiming the center was not reusing single-dose vials of medicine on more than one patient. And he blamed media “buffoonery” for the public hysteria.

On Sunday he apologized for the “buffoonery” swipe. In the same news release, he called for the five resignations.

Tony Clark, executive director of the state Board of Medical Examiners, argues that Gibbons’ request for his resignation is a case of political payback.

The three members of the board reportedly have ties to Dr. Dipak Desai, majority owner of the Endoscopy Center of Southern Nevada, where six people became infected with hepatitis C because of unsafe health practices.

Clark said he has no association with Desai and had nothing to do with the licensing of the clinic.

“This is just payback,” said Clark, former adjutant general of the Nevada National Guard.

He said he replaced Gibbons as vice commander of the Air National Guard after Wing Cmdr. Chuck Chinnock, noting that Gibbons had served 20 years in the Guard, said it was time to let other officers move up the ladder.

“I know how the game is played and what goes around comes around. This was his (Gibbons’) opportunity to get rid of me,” said Clark, who had announced last year he would retire in September after 23 years of service.

Gibbons insisted there was no reason for asking for Clark to resign other than his job performance.

“He did not do his job. Any suggestions that my call for his resignation is anything other than that is patently false and preposterous,” Gibbons said in a conference call Monday.

Gibbons said he was calling for the resignations to restore public confidence in the state’s health care system. He acknowledged he did not have the authority to remove board members, but said he would ask them directly to resign if they did not act.

He also raised the possibility of removing them for “cause.”

Gibbons did not say specifically what he believes Clark should have done when the issue arose.

Dr. Ikram Khan, who resigned as Gibbons’ special adviser on health care after being asked to do so Sunday, told the Sun on Monday that he saw no reason for the request because he played no role in the hepatitis scare or in determining Desai’s future.

Khan said he served only in an advisory capacity to Gibbons and the governor had not sought his opinion.

Khan said the resignation request came simply because he knows Desai socially and has worked for him in the past. Desai once hired the company that Khan and Dr. Javaid Anwar own jointly, Quality Care Consultants, which specializes in health care policy and strategy.

Gibbons’ call for his resignation, Khan said, sullied his reputation after 30 years of practice in Nevada, including eight years on the Board of Medical Examiners.

Khan said he is worried about how the controversy will affect the state’s ability to attract good doctors and, more immediately, doctors for patients who went to Desai’s now-closed practices, but who now are having difficulty arranging for care because investigators have seized their records.

Gibbons called on Anwar, the board’s president, and board members Dr. S. Daniel McBride and Dr. Sohail U. Anjum to resign also. Anwar said he had not made up his mind about whether to resign and did not want to comment further.

Lisa Jones, chief of the state’s Licensure and Certification Bureau, was not taking calls, according to staff members. But others in the state rose to her defense.

“This is a knee-jerk reaction that’s not going to fix the problem,” Assemblywoman Sheila Leslie, D-Reno, said. “This is a systemic problem that’s much deeper than Lisa Jones.”

Angie Silla, a patient advocate and registered nurse, also defended Jones.

“Lisa needs to stay in her position,” Silla said. “She works hard with inadequate amount of staff.”

Gibbons said he called for Jones to be removed because the department “failed to take action in a timely manner.”

The Endoscopy Center was allowed to continue operating until Las Vegas pulled its business license. Although the state has the authority to pull a license from an ambulatory surgical center, it cannot close a business. The center could have continued operating and performing procedures as a doctor’s office, which the state cannot regulate, Deputy Attorney General Linda Anderson said.

In Monday afternoon’s conference call with reporters, Gibbons said he was “focused like a laser on the health care system.”

He also retreated from his contention that single-dose vials of medication were not reused by nurses at the Endoscopy Center.

In the Gazette-Journal’s Sunday story, Gibbons was quoted as saying: “There was no single vial of medication reused. There were no reused needles. Gross negligence when you have far below the number of average hepatitis C cases listed? That’s trial-lawyer speak to me. I think if you’d had gross negligence, you’d have a higher number.”

When the Sun asked him about the single-dose vial comment Monday, he said:

“I was informed that by an individual, a health care professional. It may have been a little bit premature.”

He wouldn’t identify that person.

So just how much money did Desai, his clinic gain by reusing syringes and anesthesia vials?

By Brian Eckhouse Tue, Mar 18, 2008 (2 a.m.)

The answer appears to be less than $100 per patient.

Here’s the math: A vial of propofol anesthesia costs between $60 and $94.70 and a single-use syringe is worth between a nickel and a half dollar.

Health officials allege the clinic’s managers, nurses and technicians reused syringes and tapped into the same vial of anesthesia on multiple patients. Regional and federal investigators are examining whether that practice enabled the clinic to bill Medicare, Medicaid and insurance companies. If so, the clinic could have collected multiple payments for the same vial of propofol.

Confirming that allegation requires poring over potentially hundreds of documents, but the method would be straightforward: seeing whether label numbers for the same vials were used to charge health care providers for multiple patients.

It’s still too early to tell whether the clinic’s managers defrauded the health care providers, said Conrad Hafen, the chief of the state attorney general’s criminal division. The investigation could last months.

“Insurance companies wouldn’t make a big deal out of it, but Medicare would,” said Dr. Michael Karagiozis, a former medical director of Nevada prisons who has been offering free hepatitis and HIV testing to the clinic’s uninsured former patients.

Propofol is worth $94.70 per vial, according to Web site Medscape.com, and that’s also the amount the clinic would have charged the health plans, Karagiozis said.

McKesson, a prominent San Francisco-based distributor of the anesthesia, refused to confirm that figure, however, and a University Medical Center spokesman said for an outpatient colonoscopy, UMC generally bills health providers $60 for a 200-milligram single-dose vial of propofol.

On most workdays, about 60 patients walked through the doors of the Endoscopy Center of Southern Nevada. If, as has been rumored, a single vial was used at least two times — but billed to each customer — that outpatient center would have amassed at least $430,000 extra in a year if it charged the health providers at UMC’s rate. If it followed Medscape.com’s figure, the main clinic would have collected at least $676,000 for vials used twice.

The clinic had six satellite offices, most of which offered some endoscopic procedures, so the grand total could be much higher.

It’s also possible that one vial was used for more than two people.

Then there are the reused single-use syringes. “Who knows how many times they reused them?” said Dennis Dunn, executive director of the Nevada AIDS Project.

It’s highly unlikely such reuse yielded a boatload of dollars for the clinic, but perhaps the ramifications of that practice could have been somewhat profitable.

Karagiozis suspects the reuse of syringes eliminated two succeeding steps: quality assurance and infection control. That, he believes, would have reduced or eliminated the need for at least one full-time nurse per office at an hourly salary of about $27, representing an annual savings of nearly $54,000 per office.

When it came to quality assurance and infection control at the center, “no one did that,” Karagiozis said.

OK, Now I’ll ask the questions.

By Marshall Allen Wed, Mar 5, 2008 (2 a.m.)

Nevada health care had a terrible reputation even before last week. But public trust in doctors and nurses may now be at an all-time low.

Already, the state ranks among the worst in the nation for numbers of doctors and nurses per capita, the number of uninsured patients, and the number of non-vaccinated children.

Nevada now has the indignity of having the nation’s largest patient notification of a potential hepatitis C outbreak.

And it’s come to this: State health officials urged patients Wednesday to ask the most basic questions of their doctors before undergoing medical procedures, to make sure fundamental safety measures are taken by the physicians and nurses who treat them.

Among the questions specifically suggested by the Nevada State Health Division:

“Can you assure me that I am safe in your facility from the transmission of communicable diseases?” “How does the staff at this facility conduct sterilization of diagnostic equipment after each patient use?” And this one, which is analogous to asking a car mechanic if the air filter he put in your car is new or used: “Are syringes and needles disposed of after each use?” What does it say about the state’s own confidence in health care delivery in Nevada when it issues such an advisory?

It was prompted by an outbreak of cases of hepatitis and subsequent advisories by the Southern Nevada Health District that 40,000 patients of a downtown endoscopy clinic be tested for hepatitis B, hepatitis C and HIV because of unsafe injection practices.

On Tuesday, as many thousands waited for blood test results, the conflict between Dr. Dipak Desai, the clinic’s majority owner and one of the state’s most powerful physicians, and local officials escalated when Henderson and North Las Vegas officials shut down the doctor’s Gastroenterology Center of Nevada clinics in those cities.

Desai’s clinics’ Las Vegas and Clark County business licenses had already been suspended.

At doctors’ offices throughout the city, patients are questioning their doctors and nurses about basic injection practices for fear they’ll contract an infectious disease.

“I had a brand-new patient this morning who asked: ‘Doctor, you don’t reuse needles, do you?’ ” said Dr. Bill Pierce, a Henderson physician who is president of the Nevada Academy of Family Physicians. And that patient, apparently, hadn’t heard the state’s advisory to ask the question.

Pierce assured the patient that no, he does not reuse needles.

According to health officials, the hepatitis cases came from Desai’s Endoscopy Center of Southern Nevada, where patients were administered anesthetics for colonoscopies and other procedures. If the patient stirred during the procedure and needed a second dose, nurses used the same syringe — which might have contained the patient’s blood due to back-flow — to draw from a vial of medicine. That vial was then used to draw medicine for other patients, and if the first patient’s blood was infected, it would have contaminated the anesthetic that was then administered to other patients through the shared vial.

Pierce worries that even though the standard of care at the Endoscopy Center was far outside the bounds of basic medical practices, patients lump all doctors together.

“We’re just one big group to a lot of people,” Pierce said.

For example, Betty Bufis, who had procedures performed at the Endoscopy Center, said her confidence in Nevada medicine is at an all-time low. She told her husband that she might not have any more surgeries performed in the state.

“I’ll go to UCLA to do it,” she said.

Even as the crisis unfolds and anger grows, some experts suggest this is an opportunity to build trust in Nevada health care. Patients can become more informed, doctors and nurses can engage in self-examination to determine how this isolated breach of public trust took place. And agencies charged with enforcing standards and laws — the Nevada State Medical Examiners Board and the Nevada State Nursing Board, Metro Police and the district attorney’s office, which are all investigating what happened at Desai’s endoscopy center — can fulfill their responsibilities to hold violators accountable.

Sally Hardwick, interim director of the Nevada Center for Ethics & Health Policy at the University of Nevada, Reno, compared the public outcry over the hepatitis outbreak to how a neighborhood responds to crime in its midst. After the initial outrage, people take stock and look at the larger picture. In this case, not all doctors are violating basic tenets of patient care.

“There are some bad apples, and we need to make sure that we have clear ways of making sure that these physicians are no longer practicing,” Hardwick said.

If the enforcement is swift and public, people will realize the system works, she said.

“It has to be done in a timely manner,” she added.

Larry Matheis, executive director of the Nevada State Medical Association, which represents doctors, said “people’s trust has been put to the test,” and that doctors now face a unique challenge.

Doctors will have to spend additional time with patients and understand the nature of the hepatitis C problem and the treatment options.

“We restore trust by showing that there never was a breach of trust by most health professionals,” Matheis said.

In the long term, the profession needs to take a close look at the ethics that are at its core, Matheis said.

Health Clinic Exposes Patients to Hepatitis & HIV

InjuryBoard.com, FL - March 8, 2008

The Southern Nevada Health District is in the process of notifying approximately 40,000 patients of a local medical clinic about potential exposure to hepatitis C. This notification comes after an investigation of several cases of the illness.

Shoddy practice sickens thousands

By KATHLEEN HENNESSEY – Mar 5, 2008

LAS VEGAS (AP) — Nearly 40,000 people learned this week that a trip to the doctor may have made them sick. In a type of scandal more often associated with Third World countries, a Las Vegas clinic was found to be reusing syringes and vials of medication for nearly four years. The shoddy practices may have led to an outbreak of the potentially fatal hepatitis C virus and exposed patients to HIV, too.

Thousands Possibly sickened by Las Vegas Clinic

Mar 6, 2008 5:30 am US/Mountain

LAS VEGAS (AP) ― Nearly 40,000 people learned this week that a trip to the doctor may have made them sick. In a type of scandal more often associated with Third World countries, a Las Vegas clinic was found to be reusing syringes and vials of medication for nearly four years. The shoddy practices may have led to an outbreak of the potentially fatal hepatitis C virus and exposed patients to HIV, too.

NRI Doctor's Clinics Raided In US

March 11th, 2008 - 11:23 pm ICT by admin

New York, March 11 (IANS) Federal and state authorities have raided six medical offices of Indian American doctor Dipak Desai in Nevada and seized patient records as part of a joint criminal investigation into his clinics following a hepatitis C outbreak. The raid on Monday followed the criminal investigation by the Las Vegas police and the FBI, which stemmed from a health inspection.

How the culture of cost-cutting in Nevada's capital contributed to the Endoscopy Center scandal

By Jon Ralston Sun, Mar 9, 2008 (3:01 a.m.)

If the world as we know it were to come to an end, we always knew it would start here.

I have visions of a Crichtonesque warren of underground laboratories, with a team of scientists racing against the clock to find the right strain of hep C, while overhead Dustin Hoffman and Cuba Gooding Jr. are helicoptering for help before the Big One is dropped on Las Vegas, thus saving the world from infection.

Feds' blitz 30 days, 50 clinics

By Marshall Allen, David McGrath Schwartz

Sat, Mar 8, 2008 (2 a.m.) With patients in unprecedented numbers endangered by a Las Vegas endoscopy clinic, the state’s appetite and resources for regulating and enforcing laws governing medical practices are facing new scrutiny.

After Dr. Death & Dr Kidney, Dr. Greed

11 Mar 2008, 0840 hrs IST,CHIDANAND RAJGHATTA,TNN

WASHINGTON: After the notorious Dr Kidney of New Delhi and the infamous Dr Death of Australia, yet another physician of Indian origin has courted infamy -- this time as Dr Greed -- much to the dismay of a large, thriving and influential Indian-American doctors community in the United States.