Sunday, March 2, 2008 | 2 a.m.
There was no cause for alarm when, on Dec. 4, health investigators learned of a case of acute hepatitis C.
And there was no telling it would lay the groundwork for the largest health scare of its kind in the country — and possibly a criminal investigation into conduct that put 40,000 lives at risk.
Acute hepatitis C is contracted a couple of times a year in Southern Nevada, but the Southern Nevada Health District annually investigates more than 1,300 cases of other common ailments. So the initial acute hepatitis C report didn’t cause extraordinary concern when it crossed the desk of one of the six disease investigators. There were routine questions to ask the victim.
Interviews can be touchy because they’re so personal, and frustrating because they are often inconclusive. The investigator asked about new tattoos, blood transfusions, sexual contact — and then got what would later become a crucial clue.
Have you had any medical work done?
Yes, the patient said. A procedure on Sept. 21 at the Endoscopy Center of Southern Nevada.
The clue would remain dormant for weeks.
On Dec. 18, a second case of acute hepatitis C was handed to investigator Devin Barrett. It struck her as odd. Barrett, 26, who had been working at the Health District for three years, remembered the earlier case.
Hmmm ... what’s going on here?
“Anytime we get two unusual cases at the same time we’re definitely more curious to find out these risk factors,” Barrett said.
Barrett called the patient’s doctor to find out how to get hold of victim No. 2, then left a couple of messages for the patient. The patient returned the call Dec. 28, and Barrett conducted her interview.
Barrett was walking out to lunch when she overheard a colleague ask her boss for advice on the first hepatitis case. Where in the paperwork, she wondered, should she note that the patient had undergone a colonoscopy?
Barrett stopped in her tracks.
She told their boss, Epidemiology Supervisor Linda Verchick, that her patient had also had a colonoscopy — long known as a risk factor for hepatitis C transmission — on July 25. They realized both patients’ procedures were performed at the Endoscopy Center of Southern Nevada.
And there was a rush of relief, Barrett said, “because that means we can do something about it. We can stop it.”
Still, the two cases could be a coincidence, the investigators knew.
On Jan. 2, Senior Epidemiologist Brian Labus, 33, who holds a master’s degree in infectious diseases, learned of the “cluster” of cases.
Epidemiology is a science that focuses on the public incidence and outbreak of diseases. As a scientist, Labus is trained to conduct investigations using observation, interviews and records.
“If you get emotional about this, your judgment gets clouded and you can’t find the source to stop it from happening in the future,” Labus said.
That same day, Jan. 2, in between consultation calls to the Centers for Disease Control and Prevention, an e-mail arrived in Labus’ in-box.
“We got a third case,” it said.
This interview went quicker. The patient had undergone a procedure at the Endoscopy Center of Southern Nevada on Sept. 21, the same date as the first patient.
Labus called the state Licensure and Certification Bureau, which investigates ambulatory surgical centers such as the Endoscopy Center of Southern Nevada. They agreed to send investigators. The CDC would send two epidemic intelligence officers, both medical doctors, to assist.
The cause of the outbreak was still unknown. Maybe this was still a coincidence.
“You can’t just go on suspicion,” Labus said.
On the afternoon of Jan. 9 the 25-member Outbreak Investigations Team — compiled from the county, the state and the federal government — assembled at the Health District to map out a plan: Five of them would notify the endoscopy clinic’s administrators that it was the suspected source of an outbreak.
To deliver the news, they didn’t have far to go. The Endoscopy Center was across the street, on Shadow Lane — a street thick with medical services clustered around two of the valley’s largest hospitals.
The administrators and doctors were surprised by the news, Labus said. On paper, this was a top-notch endoscopy clinic — and maybe the busiest in Nevada. Its majority owner is Dr. Dipak Desai, a politically connected gastroenterologist, former member of the state medical board and a member of Gov. Jim Gibbons’ transition team in 2006.
The investigators’ mission: identify how the infection was spreading. It would be counterproductive, Labus would say later, to immediately close the clinic or order the staff to change its procedures in a wholesale manner because “we’d never find out what went wrong.”
The investigative team entered the clinic in full force the next day. Barrett was in the group that commandeered a conference room to cross-reference a log of clinic patients with a computer database of more than 20,000 known hepatitis C carriers in the county, to determine whether any recently identified carriers might have contracted it at the clinic.
The clinic performs 50 to 60 endoscopic procedures a day, so they started with the two days when the three patients were known to have been infected — July 25 and Sept. 21. Then they expanded to other dates. It took several days to compare all the patients, and more interviews had to be conducted to be certain they weren’t confusing chronic cases with new cases.
In the end, the team identified three more Endoscopy Center patients who had been infected with hepatitis C at the facility.
All three had visited the clinic Sept. 21.
The CDC doctors took the lead in observing the four certified nurse anesthesists in action in the two procedure rooms. Labus and Barrett assisted. What they saw, when announced later, seemed to enrage everyone who heard the news.
A nurse would administer an injection of Propofol, an anesthetic, to put the patient to sleep before a colonoscopy. If the patient started to wake up before the procedure was finished, the nurse would use a syringe to draw more of the drug from the vial, using a fresh needle — but reusing the syringe, allowing the vial to be contaminated with the patient’s blood.
And here’s how other patients would be infected: The vials were labeled as single-dose. One per patient. But nurses used that same contaminated vial to draw anesthesia for the next patient. And as vials were drawn to near empty, nurses would combine them to fill new vials — passing along any possible infection to still more patients.
Wide-eyed investigators could not intervene to stop the process because they needed to document every step without disturbing the nurses’ routine, for sake of the larger mission.
“If we shut it down, another place opens and they do the same procedure,” Labus said. “We had to look at the big picture. We had to think of the community in the long term.”
Nurses later told the investigators they were following the instructions of Desai and other managers. According to a City Hall letter that quoted investigators, Desai had ordered his nurses to engage in a life-threatening routine “in order to save money.”
The investigators spent about a week at the clinic, identifying the problem that led to the infections and ensuring that the flawed procedures — a violation of basic medical practices — were corrected. This is how the Licensure and Certification Bureau justified allowing the clinic to stay open.
Unresolved, though, was the task of calculating how many people might have been exposed to contaminated anesthetics. It became a math problem.
In March 2004, the clinic increased its volume by adding a second procedure room, Labus said. Logs showed that administrators bought medicine in bulk — in 20 cc or 50 cc single-dose vials. Going back to March 2004 it was clear that there were many more patients than vials of anesthetic. The conclusion: vials had been being reused for years.
Investigators concluded that 40,000 patients had anesthetic-required procedures since the facility’s expansion. And it seemed the practice that allowed patients to be infected with the blood of others had been in place the entire time. Unless they’re tested, most would never know they’ve been infected because symptoms, such as jaundice and nausea, appear in only one out of five cases.
So they issued the largest ever notification in the United States: 40,000 patients needed to be tested to determine if they had been infected by hepatitis B or C, or HIV, the virus that causes AIDS.
In two days, more than 5,000 frantic patients called the Health District’s hotline.
And on Friday, in the face of growing outrage over what had occurred at the Endoscopy Clinic of Southern Nevada, Las Vegas officials ordered the clinic shut and its business license suspended. The reason: The clinic owners were profiting by willfully endangering their patients.