OK, now I’ll ask the questions

By Marshall Allen

Wednesday, March 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 unvaccinated 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.