This story broke last week, but I’m just starting to catch up on it now: in Las Vegas, more than 100 people have tested positive for Hepatitis C and HIV after being treated at the Endoscopy Center of Southern Nevada. Apparently, investigators have found that anesthesia needles were re-used on different patients without adequate cleaning, and in some cases, portions of the same dose of anesthesia was injected into multiple patients.
The person who founded the Center, who has also been its majority owner, is a doctor named Dipak Desai. Three class action lawsuits have been filed against the center, with more than 100 plaintiffs total. Doctor friends tell me it might be the biggest medical malpractice case in recent history (I have not been able to directly confirm this… any docs in the house?).
I haven’t come across anyone saying that Desai himself gave the order to use the syringes this way, though I gather that the anesthetists employed at the Endoscopy center were nurses rather than doctors (might be a little corner cutting there). Since the investigations started, the nurses employed at Desai’s clinics have given up their nursing licenses. As of now Desai has not given up his own medical license, though he has voluntarily agreed to not practice medicine until the investigations are complete. My own inclination is to “wait and see” before piling on against Desai: he ran several clinics, and employed many other doctors, nurses, and technicians. This particular policy, which has caused so much harm to so many people, may not have come from him.
Before this mess started, Desai was a very well-respected doctor in the state of Nevada; he had a $1 million contract with the University Medical Center, where he directed the gastroenterology department; and the governor had appointed him to the State Board of Medical Examiners. All of that is not to excuse him; rather, it helps give us some sense of the scope of this case. Incidentally, when two doctors working at his clinics had earlier complained about unsafe hygiene with syringes, the claims weren’t investigated.
I’m curious to know what people think about this case. Obviously, it doesn’t reflect the practices of Indian doctors more broadly (and I come from a medical family, so I’m quite proud of the contributions Indian-Americans have made in medicine in the U.S.). But it does seem like a terrible tragedy, and for the employees of this particular Endoscopy Center, a huge mess.
dude, he should watch his back. seriously. if people close to me had gotten infected with HIV due to medical malpractice….
Razib, you of all people should know that all HIV is is a virus, and AIDS is a disease not everyone infected will get, nor is it a ‘death sentence’ any more, if it ever was, nor is it entirely well-characterized in itself. People who are said to die of ‘AIDS’ actually die of a combination of organic causes and opportunistic infections that people even otherwise would die of. Like cancer or heart disease would spare you if you ‘hadn’t got AIDS’.
A number of Establishment and anti-Establishment agencies, both liberal and conservative, scientific and religious – like to scare people with it, as in ‘it’s a death sentence’, like you would otherwise live for ever or something.
This doesn’t excuse deliberate malpractice, but there is no need to treat HIV infection as if it were the worst thing, like, since, ever.
chachaji, all i can do is LOL. i disagree with you on so many levels no need to respond…. (and yes, i know the facts whereof you speak, but some other facts you leave out)
If AIDS doesn’t kill, then why did the US government infect blacks with it?
Malpractice suits, like this one against the prudent cost cutting that Prof. Desai’s center engaged in, are the biggest reason for the high cost of healthcare in the US, and should be summarily banned lest we are all forced into the trap of socialized medicine.
It is a very scary (and potentially tragic) situation for the patients, families and staff and probably even for Dr. Desai. Wish them all luck.
I hope no one gets the impression that Desis/Indians are stingy cheapskates from this. A health care setting is really not the place to reuse used syringes on different people etc. Although I noticed that Desis – my own friends and even relatives “regift” alot. One time one of my Desi friends gave my little one a book that I gave her young son the previous year. I knew it was the exact same one because it had my handwriting stating to so and so with love from g.m. and a message with my wording etc inside the front cover. Another Desi gave me a wedding present that was a salad shooter from the 90’s with some rotten shredded lettuce still in it!!! It was hilarious but kind of gross at the same time. (I realize it’s not the gift and it’s the thought that counts, I’m not materialistic etc.) Maybe the people who gave the rotten lettuce wanted me to get more interested in microbiology or something and thought they were doing me a favor.
My family lives in Las Vegas and both of my parents have been affected by this. They were both patients at the Endoscopy Center, and Dr. Desai himself performed a procedure on my mother. Both have been tested and are currently waiting for the results. From my understanding, Dr. Desai has already tried to get his business license back. But, thank goodness, that request was denied. And I have already sat in on discussions about the backlash towards doctors of South Asian descent. It will be interesting to see how that plays out here locally, especially since Dr. Desai’s wife is also a physician in Las Vegas. This has been getting a lot of coverage in the local Las Vegas area, and I am glad to see it on here. This has prompted more investigations at other clinics in the state of Nevada. But I’m interested to see how the rest of the country reacts to this.
HIV and Hep C aren’t “death sentences” but they are serious illness that require expensive, time consuming treatment to keep at bay. You can get both through blood contact–the point is, that this should not have happened.
What was the rationale behind this? Laziness? Cost-cutting? What a bizarre set-up (I don’t think the nurses vs. doctors distinction is that profound when it comes to standard sanitation procedures for injections).
HIV and Hep-C are awful diseases, they’re very expensive to treat/manage (which means that not everyone is able to afford adequate treatment), and they do advance death. “It’s not a death sentence”? As opposed to what, the chance that you might be hit by a car?
I totally sympathize with the nurses here. Nurses are independantly licensed, and can lose their practicing privileges if take the wrong “order” from an unscrupulous MD. Nurses are held accountable for their actions, but in reality there is a lot of pressure to go along with the MD. And it seems Desai is just the kind of doctor who would try to coerce his staff to ignore best practices for the sake of the bottom line.
BTW Amardeep, using RN anethetists instead of MDs is the least of the worries in a situation where the MD in charge has no concept of what it takes to sterlize needles!
Its bizarre. Probably a conspiracy by the nurses to trouble Desai
My brother called me up recently and mentioned this. “Hey crazy person” (directed at me), “turns out you had a point after all.”
When I have my blood drawn, I ask to choose my own needle out of the box that the phebotomist uses and make sure the seal is unbroken before it’s used. Of course, I don’t do this with everything (like, at the dentist, how do you know those things are cleaned. Like I said, crazy person). When I was a fellow, years ago, alas, an attending told me how he had to be screened because a univerity hospital because a phlebotomist was re-using a needle to draw blood.
One this I have to say as a physician – the practice environment is such that speed has become prized above much else and the degree of supervision that’s needed just isn’t there. Several years of practice in teaching hospitals has taught me that just because you instruct someone on how to do something, doesn’t mean they’ll do it the way they should be instructed. You have to constantly supervise.
Don’t know any particulars about this case, but it is a disgrace. Those poor patients.
Okay, it was a Palo Alto lab, I shouldn’t have said a particular lab or hospital without confirming it. I apolozied. Could the intern clean up the last comment and take out the hospital I initially referred to? Again, apologies.
And finally, chachaji, there’s a lot wrong with your statement. The virus weakens the immune system so that you are more prone to opportunistic infections – yes, treatment has much improved but’s it’s still not a cure.
Here’s the Palo Alto lab involved in 1999. Sorry for all the mispellings above, a little tired today.
I feel bad for everyone involved but as physicians we really need to stand our ground on this – the press to see more patients, more quickly, do more tests, more, more, more, as quickly, as rapidly, as we can, is not good. Not saying this is what happened in this particular instance. People need to be supervised. If a mistake can happen, it will. Human endeavor is always fallible. So the system needs to take that into account.
http://www.nurseweek.com/news/99-5/5d.html
MD – Done.
MD – my problem is that the medical profession consistently resists oversight and scrutiny. At the same time, they also resisted institutionalized practices like surgical checklists to make sure that they made fewer errors of execution. Doctors want to be trusted at a far higher level than we trust other people making important decisions, like airline pilots. When we ask pilots and mechanics to use a checklist, it’s because we realize that intelligent people make mistakes. However, when doctors are asked to standardize their procedures, they take personal offense.
And quite frankly, doctors do not do a good job of self policing. Many states with very low levels of professional sanctioning have high malpractice rates, yet doctors want to just focus on the insurance part of the problem.
My friend’s brother was a pediatric surgeon at a hospital where the senior doctor regularly operated drunk. He blew the whistle, lost his job, and was blackballed from other hospital jobs. Now, years later, the case has come to trial and it is ugly. The point isn’t that there are bad apples in every barrel, we know that. The question is how do institutions deal with improper and dangerous behavior. Do they build in checks and balances to monitor for it? What do they do when they find out it is going on? In all of these ways, the medical profession still wants to function very much like a guild. I don’t find, trust us we have your best interests at heart to be a sufficient answer. The question isn’t about individual doctors and the sacrifices they make. The question is about the systems that are built around those doctors.
I’ll probably write a proper post about this at some point, this comment is getting too long.
There’s not a thing I disagree with Ennis.
I would only add one of the (emotional) reasons doctors resist self-policing is that some of the policing is onerous and of little value, so, unfortunately, they think all policing is like that (accutane paperwork, anyone?). But, yes, I agree in general with your comments. And, if there is more policing, cases will take more time. Our practice has increasing volumes of work and decreasing reembursments for each piece of work. You cannot simultaneously ask for more rigorous policing and not provide the funds to do so. So, increasaing Medicare prescription drug benefits cuts into my payment per test which impacts how much I can put back into the system (hey, I’m in a big place, I don’t control all of it, and raises in one place lead to cuts in another).
But, yes, I agree with you wholeheartedly. Also, it’s not only docs. It’s the CEOs and other poohbahs who want to use hospital monies to pay for shiny new building and clinics, etc, who are a part of this. They talk safety, but they don’t pony up for it monetarily.
My point is different. I ask the phlebotomist myself to see if the needle’s seal is unbroken. We also need to move toward a system where health care professionals and patients are comfortable in that sort of give and take environment.
14 · MD said
I’m glad you chimed in, MD. Of course the virus weakens the immune system. Of course it mutates. That’s what viruses do! And of course opportunistic infections strike you when your immune system is weak. That’s what opportunistic infections are!
The initially baffling nature of HIV and the peculiar epdemiology that HIV infections have acquired in Africa, however, should not lead to exaggerated misconceptions of its true potency that ultimately, and especially for atheists, is about the same thing as believing in ‘God’.
Sparky, agree with you. But let’s also realize that how much it actually costs to ‘control’ the disease is a function of many things, including the intellectual property regime. The intrinsic nature of the virus plays a relatively minor role in it.
Another thing: I forget if SM covered it, but estimates of HIV infection rates worldwide, and especially in India, have been revised downward, quite substantially, and more than once. The media regularly conflates HIV infection rates with AIDS cases, and public health authorities release figures with liberal estimates ‘out of an abundance of caution’. Sure. Many people in public health I’ve talked to will admit, privately, that the idea is to scare people, at least a little, or a lot, depending.
That’s all from me on this. Thanks all, and Amardeep, thanks for blogging this.
chachaji
This is so wrong on so many levels I don’t know where to start.
HIV and Hep C aren’t “death sentences” but they are serious illness that require expensive, time consuming treatment to keep at bay.
and until this country gets its ass in gear and begins providing some decent kind of health care at low cost (as say the french, canadian, or brits do) the insurance companies should be rubbing themselves in peanut butter by now.
If this isn’t a reason for Indian parents to stop forcing their kids into medicine I dont know what is.
Viruses don’t necessarily weaken the immune system the way HIV does. The specific destruction of T-cells and the rate of mutation which is much higher than most other viruses are what make such a deadly combination. People don’t normally die from the kind of opportunistic infections that snatch the lives of AIDS patients.
I don’t understand how increasing Medicare benefits affects your payment per test.
sparky – that’s what the administors tell me – to expect decreased re-embursements for some areas because of higher costs in others (the gov want to pay less for certain tests so have more to pay for other things). Money don’t grow on trees. I don’t know if it’s true, but why is that hard to understand as a concept? To pay for X, you cut Y.
I spoke to a doc recently who has practiced in Sweden, England, and the US (all teaching hospitals). Anecdotally – the tumors are more advanced when she sees ’em in the UK and there is little money for small research projects for the typical physician in a teaching hospital. She saw more, non gov funding, in the US when she was here. Just FYI.
Okay, this has to stop. It’s like my own Sepia IM. Addictive!
HIV may not be the death sentence it once was, but, chachaji, I wouldnt wish it on my worst enemy-having seen the side effects of the meds, the infections and finally the END-it aint pretty.
If this does not deserve a lawsuit then I dont know what does. Desai should hang (not literally) if he really authorized re-using the needles. This is NOT from the govt cutting physician reimbursement. increasing paperwork etc. This is a result of GREED plain and simple. The amount of money saved per patient pales in comparison to the cost associated with transmission/detection/management of hepC or HIV. I work in a high pressure setting (busy ER) every day-we are always sweating the details when it comes to pt safety-‘time outs’ double checking doses of drugs, going through pts history/lists of meds etc. It pisses me off that jackasses like Desai (assuming he did give the orders) negates all that work with his GREED! Ulloo da pattha!
Like Meena said, the intrinsic nature of the HIV virus is that it has a high mutation rate. Correct me if I’m wrong, but that’s why we have not been able to develop a vaccine. The medications are expensive for a number of reasons, but are you implying if the meds were cheap, HIV wouldn’t be considered a serious disease? Telling someone to take multiple drugs for the rest of their life sounds much easier than it actually is. Yes, with cancer and heart disease, you also take multiple drugs, and I don’t think there is much utility in arguing what is worse.
The point is that HIV transmission from anesthesia needles should not happen..
Opportunistic infections are also extremely difficult to treat.
MD–I guess my feeling is, that the funding for Medicare/Medicaid overall should be increased. Not be like, “ok, if we give more money here, we give less money there”. They don’t use that kind of rationale for funding the Iraq war…if they want something, they get it. That’s also one of the big problems with health systems in other countries–insufficient funding.
@baingandabairtha – you really don’t read very carefully, do you? Unless you know more than some of us here, and maybe you do, we don’t know what caused this to happen, okay? It may have been greed, it may have been malicious, it may have been poor safety instruction (for which the doc is responsible). And the discussion of reembursements was a tangent conversation, not to be used as an excuse, but can you honestly tell me staffing doesn’t effect patient safety? I’m sure even with your checking and double checking, mistakes happen in your ED. AND NO, I am not trying to say someone doesn’t deserve to be sued here. This is bad and if the doc is responsible, let him hang is my response. Sure it’s the doc’s responsibility, but we have a problem in medicine, okay? We are trying to rush too much and that is my original point which led to a tangent conversation. Sheesh.
In the Palo Alto example above, there was a rogue tech. Was there a directive in this case, or poor training, or something else? I want to know.
It goes both ways. There are certainly bad doctors out there who deserved to get sued and lose their license for committing malpractice. However there are also times in which things are done correctly but the outcome is bad and the patient or the patient’s family are upset, so the doctor gets sued. From all appearances this guy appears to be in the wrong.
While I hate taking the JHACO mandated “time out” or writing an L on the left chest when performing a bronchoscopy on the left lung, these practices probably do help to prevent patient errors.
I would suggest two methods to help improve things. First a state medical board committee comprised of doctors, lawyers, and laypersons review each lawsuit to determine if the standard of care for a particular condition was followed and if the lawsuit has merit. Second I would favor a loser pays system. Plaintiff’s attorneys always ask for the defendant to pay court costs as part of their lawsuit. While some would argue that this would prevent poor people from going forth with lawsuits this would cut down on the need to carry large amounts of insurance or hide assets in order buffer against the threat of a lawsuit.
It costs relatively nothing to bring forth a lawsuit but a lot of money to defend it. A lot of the cost of American health care is built around practicing defensive medicine. It’s probably just a headache but you have to order a CT scan to rule out a mass or a head bleed.
As a physician my heart goes out to those people affected by this.
MD – I think it depends on the type of regulation. Some cops object to getting warrants, because it is paperwork. Others point out that the need to make a defensible arrest keeps them focussed on the areas where they can do the most good, and reduces corruption. Irresponsible doctors are a net drag on the system and curtailing their behavior would probably benefit all.
There are also areas which are win-wins. Standardizing surgical procedures may reduce the mystique of medicine, but it also probably makes things easier for everybody. Moving to computerized prescriptions which can be automatically cross-checked for drug interactions and correct dosage has probably made doctors’ lives easier, not harder.
It all depends on how costly the errors are, how frequent they are and how onerous the regulation is. But there are probably some clear areas of improvement that have a high ROI. As with all things, we should start with those first.
One of the solutions to the problems discussed above could be: U.S. should train/graduate more physicians.
I keep wondering how the medical staff could have been so dumb. Firstly, everyone knows not to reuse needles. Is’nt that the first thing they teach you in med school. even non-medicos know this is a big no no Secondly, how much money can you save skimping on needles. as a percentage of revenues, i am sure its miniscule. talk about being a cheap ass. Thirdly, it its not the money, are you really so lazy that you can’t open the wrapper on a new one.
even if dr. desai did’nt approve it, ultimately, he is the manager/owner and deserves some form of punishment. at least it will serve as a deterrent to others for enforcing stricter policies.
i am sure their malpractice insurance company is having a shit fit. i hope they don’t go bankrupt.
I definitely think that doctors should be trained differently. Right now they’re selected on their ability to memorize rather than their ability to problem solve, more like lawyers than engineers. A friend had a serious medical problem and was surprised at how much the top doctors in the field jumped to diagnoses based on their gut rather than systematically exploring the possibilities from most likely to least likely. It led to a lot of wasted effort as different doctors tried different tests in a somewhat random trial and error attempt to figure out what was going on.
Asha’s Dad:
Why do you hate doing these things? This is exactly what I’m talking about … and it’s a freudian slip to call them patient errors rather than doctor’s errors, which is what they are.
Okay, I want to apologize for my #28 directed at B#B. I was a little intemperate there.
Actually, some people are ‘dumb’ enough to reuse things. I can’t think of the number of times I’ve specifically told someone how to do something, only to find that what I thought was a fool-proof explanation wasn’t interpreted that way. Human beings are complicated.
As for resident/med student training; it’s not the way we pick -em, it’s the way we instruct/watch -em. When you are on my service, if you do something wrong, I will make you do it again and again until you get get it right (it’s pathology, a little different, so we can do this). You don’t work up a case correctly? Well, then, look at it again, read up on it and get back to me. You won’t go home until you do. There are no “I don’t know’s” on my service. It’s painful. Oh, and I need the same watching, too, which is Ennis’ point. No one is perfect.
Students and residents have to be watched closely; they think they understand something, you think they understand something, but you are both wrong and the wrong way of doing something is learned.
Well, that’s one idea. I’m sure there are many others.
MD, you really must be tired, to say that the cluster of cases in LV was a result of random mistakes as opposed to deliberate practices aimed at cost cutting.
The reason we patients have lawyers and regulators is because rogue docs are let off the hook by their fellow MDs out of a misguided sense of fraternity.
I totally see what you are saying. Even I often wonder if medical diagnoses can be automated so that they can be executed with the assistance of minimal medical training. Memorizing a lot of things (a large part of med school) seems like a waste of time anyway since in the modern day one can very easily use computers, etc. to search interactively and narrow down things from there. I think the value of a doctor lies probably more in the actual physical act they perform (ie. the surgeries, etc.) much more than the ability to diagnose.
Have you ever watched House M.D.? One thing I often wonder is why do they need to struggle so much to identify a condition that can explain a given list of symptoms from their unreliable memories?? Couldn’t someone standardize these things into HUGE medical computer database that just outputs an answer based on (a long and detailed)list of standardized symptoms?
Obviously, as I guessed, I’m not the first person to have thought like that. They is even a journal dedicated to this research:
What? No, you can’t. Not only is each person unique, but the deductive reasoning involved in solving a case and the need to set apart cause and effect, together with the fact that an anamnesis does not consist merely of physical symptoms but also of the patients personality and their mental make-up, make sure that it is pretty much impossible to solve a medical case just by googling a few symptoms. It is also not desirable, since it hampers patient communications and therefore is generally much less effective than face to face conversations with the patient. Even I know that and I’m not even a doctor.
Obviously I’m not talking about a google search, but something more sophisticated and tailored for the purpose, performed with some kind of a reduced human supervision, of course. And who says you can’t consider “mental make-up and personality” as symptoms?
As long as you are working within a finite bounded domain, and drawing your conclusions based on finite set of rules you’ve learnt in medical school, I don’t see anything fundamentally impossible about automating the process. As I pointed above, this not something that I am the first to propose. There is work going on in the direction, apparently.
At the heart of the problem is the self-perception of the medical community as the next best thing to sliced bread. As Ennis previously mentioned, the medical profession functions similarly to a medieval guild, in fact doctors are really the last remnant of an Artisan class that has all but disappeared in the post industrial world. To make medical care affordable and better, medical care needs to be totally transformed into a market commodity. I’m thinking a mix of McDonalds, Wal-Mart, and Six Sigma. Now obviously many readers will read the aforementioned and think I must be smoking some good shit but hear me out. The industrialization and standardization of medicine will both reduce costs, increase quality standards, allow for wider availability, and better troubleshooting of problems. The teaching of medicine needs to be revolutionized in that it should be more widely available to people beyond those willing to put in $100k in tuition and a decade of schooling and also the approach should be more mechanistic, similar to that of engineers. The ultimate goal would be that going to the doctor would be no more of a hassle than shopping for a cell phone.
Mr MD. Apology accepted. As I mentioned in my post (assuming he is responsible)-enough said. Jing-one day it might be the same way for medicine as for engineers-because there have never been engineering mistakes and disasters-medicine will then be perfect.
It’s usually not that straight forward. Sometimes parts of the history or physical exam can mislead you. Just b/c they are there, doesn’t make them necessarily relevant to the eventual diagnosis. That’s why primary care is important, someone out there having a relationship with the person, so someone can figure out what is significant or not.
oh and a lot of times, things that lead to the diagnosis of more obscure things are symptoms that the patient won’t volunteer b/c they haven’t really noted them themselves. You need someone knowledgeable about the pathology and pathophys of such diseases to ferret these details out.
It is evident that you did not read what I wrote. There will of course never be anything that is 100% certain, however that is not the goal. The goal is to reduce the mean time between failures i.e. medical malpractice through better science and management. 3.4 defects per million instances is exponentially better what we have.
35 · MD said
MD (or anyone who knows): Do internal and external quality audits get conducted? And if they do, how frequent are they? To me, issues like these scream poor quality management. In regular manufacturing, the person making the part should never be inspecting the part. And even after the inspector is done inspecting, another verification is conducted if warranted. Are there independent/dedicated medical ‘inspectors’ of such sort in the community? If a process/procedure has been established, a frequent review by an internal auditor, and if any kind of certification is needed via a third party registrar, an external auditor, would help flush problems out. Now, auditing can become BS in and BS out depending on who is reviewing. But still, it’s a tool used in many companies (for example: manufacturing companies certified to ISO 9001 2000). Quality system management especially when so many processes have human “touch points” effectively needs more active oversight and multiple modes of independent verification.
It’s Ms MD, not Mr. MD, but oh well 🙂
monimoni Sorry, didn’t make myself clear: I was talking about medicine in general, not this guy.
Gujudude: there is research on just that subject, and a lot of it, but I can’t direct you to just one paper. When I was a resident the big thing was TQI (total quality management) and now it’s LEAN (translation, committees designed to looking at processes within our department and the problems. Takes time, though, and that’s the kicker. Time is money and hpsital adminstrations hate spending money. So, the time comes out of doctors/nurses/technicians hide. There are external quality monitors, but often, they get thought up after the mistake has happened. It’s a very reactive, as opposed to proactive, profession. And I think the above criticisms are spot on. We can do much, much better. Ennis is right.
inspecting or auditing medical care is done but unfortunately it is not the same as inspecting a ‘part’ off an assembly line. People and patients are complex. ‘Standards’ of care cannot be upheld due to a myriad of causes more than a few of which can be entirely out of the control of the doctor or patient. People dont go to the doctor to simply have a diagnosis handed to them on a plate. Many of them are looking for someone to tell them them they are okay.
Jing I read it bud.
Medical experts have been around for a long time. The The first one called MYCIN was developed as early as the 1970s. It was based on simple inference from a base set of around 600 rules, and was focused on diagnosing between a narrow set of diseases based on symptoms, but its performance was comparable to (I think it exceeded, but can’t be sure) doctors. So an expert system of this sort is certainly not impossible, but practical implementation is hobbled by dozens of legal issues (who do you sue if the system screws up), and also the difficulty involved in getting expert doctors to translate their knowledge to a set of rules (it is apparently a lot more time-consuming than expected).
That should be: medical expert systems have been around a long time.