Are colonoscopies safe in Las Vegas? Some think so

Leave town? Find a new line of work? Change your name?

For most of the 14 doctors who practiced at Las Vegas endoscopy clinics associated with the outbreak of hepatitis C, the answer was none of the above. Virtually all of them quietly melted back into Southern Nevada’s medical community after February 2008, when federal officials announced that thousands of Las Vegans were potentially exposed at two clinics where it is alleged that doctors and nurse anesthetists reused anesthesia vials and syringes on colonoscopy patients.

While relatively small, the group of doctors involved account for nearly a quarter of the city’s gastroenterology specialists, so it’s possible anyone going for colon cancer screening today will encounter one of them.

Should you be worried?

Depends on whom you ask.

Some medical experts say Las Vegas may be the safest place to get a colonoscopy because medical personnel and patients are now keenly aware of the risks and safety practices associated with the procedure.

Officials with the state board that licenses and disciplines Nevada doctors say there’s no need for concern about those who didn’t work directly with the practice’s primary owner, Dipak Desai.

"There’s no reason to believe that the physicians employed by (Desai) at other offices have done anything wrong or that they perform substandard care," said Doug Cooper, executive director of the Nevada State Medical Board of Examiners.

But local doctors say Desai’s actions have caused more patients to delay or skip colonoscopies out of fear of hepatitis C exposure. They say that fear compounds the personal toll on patients who were infected, and may be the worst fallout from the hepatitis C crisis.

And industry watchdogs express concern that some of the endoscopy clinics’ former doctors might have known patients were at risk but continue to practice without limits or conditions. One watchdog goes even further, saying discipline of all doctors in Nevada lags far behind most other states.

FEARS OF HEPATITIS C STILL LINGER

A colonoscopy involves inserting a half-inch-wide tube bearing a camera into the rectum and large intestine so doctors can detect bowel tumors, which are treatable when caught early – and fatal if found late.

Dr. Sidney Wolfe, director of the consumer advocacy group Public Citizen’s Health Research Group, said skipping or delaying the procedure out of fear of infection creates its own community-health crisis.

"Colonoscopies are a very effective procedure for cancer prevention. Anything that tarnishes the importance of it and makes people afraid is very serious," Wolfe said. "An important public-health measure is being put on a chopping block because people have raised legitimate concerns about some people who did the procedure."

There’s no hard data available to deter­mine whether fewer colonoscopies are being done in Las Vegas since the scandal. But doctors say patients ask about the Desai case every day, even though it’s been four years since workers at Desai’s Endoscopy Center of Southern Nevada on Shadow Lane and Desert Shadow Endoscopy Center on Burnham Avenue were accused of reusing vials and syringes to reduce costs, in­advertently spreading hepatitis C.

County health investigators tied nine hepatitis C cases to the clinics and called 106 others "possibly linked."

The case resulted in the largest syringe-reuse patient notification in U.S. history and prompted investigations by police, the state medical board, the FBI and the IRS. More than 50,000 patients needed tests for hepatitis and HIV. More than 150 have filed lawsuits.

Before the outbreak, colonoscopy patients would ask about the dreaded laxative preparation or whether the procedure could damage their bowel, said Las Vegas gastroenterologist Dr. Frank Nemec. Now, questions revolve around safe injection techniques and infection-control protocols. What happened at Desai’s clinics comes up once or twice a day, and Nemec said patients have told him they don’t want a colonoscopy because they don’t want hepatitis C.

"It’s very common," said Nemec, adding that many patients say they won’t use any doctor who worked for Desai.

Not all of Desai’s doctors, however, were implicated in the scandal. The Nevada State Medical Board filed formal complaints against just three: Desai, co-owner Eladio Carrera and clinic manager Clifford Carrol.

The state Board of Medical Examiners didn’t investigate – or even interview – all 14 doctors in the practice because "it wasn’t necessary," Cooper said.

"When you gather evidence, sometimes you gather evidence that eliminates people,” Cooper said when asked why investigators didn’t talk to all 14. He wouldn’t elaborate on that evidence, saying investigative results are confidential if the board doesn’t file charges.

Dr. Joseph Thornton, a gastro­enterologist and associate professor at the University of Nevada School of Medicine, said the stigma that follows Desai’s former staff isn’t always fair. Some doctors were closer to Desai than others, he notes, and not all of his clinics followed the same procedures.

"They should not all have been tainted by it, because they worked at locations that weren’t involved," Thornton said. "They were doing things correctly and the majority of them were just as surprised by what happened as the rest of us."

Nemec said some of Desai’s doctors were "very conscientious and careful."

Still, Nemec said he’s never hired a gastroenterologist who worked for Desai, because of "what they knew or should have known."

THINGS WEREN’T RIGHT AT PRACTICE

Attempts to reach the dozen doctors who still practice in Las Vegas were unsuccessful. Only Carrol, Carrera and their partner, Vishvinder Sharma, responded at all, with a letter saying their attorneys advise against commenting because of ongoing litigation.

Prosecutors say a number of doctors in Desai’s practice might have known what was going on, and they’ve warned most that they could be called to testify at Desai’s trial in October.

Desai’s employees "knew that the level of patient care was not good, that it stressed people working to such a degree that mistakes could be and were made," said Michael Staudaher, the Clark County chief deputy district attorney prosecuting Desai.

Evidence will show that Desai’s staff felt things weren’t right with the practice, Staudaher said.

"People could not waste anything and items were reused wherever they could do so," Staudaher added. "Whether that means every individual, or some of them, participated in such behavior, we don’t know."

What is clear is that at least two doctors in addition to Desai were in a position to know of problems – Carrera, a part-owner of the practice, and Carrol, manager of the Endoscopy Center of Southern Nevada.

The state medical board in 2008 filed a complaint against Carrera alleging that he failed to use reasonable care during colonoscopies despite "knowing or being in a position to have known" that the clinic’s practices could endanger patients. The complaint cited three patients who contracted hepatitis C from a proceedure performed by Carrera, and said he violated patients’ trust, exploited the physician-patient relationship for financial gain and "brought the medical profession into disrepute."

But the board backed off on Carrera, who testified to a grand jury after prosecutors agreed not to charge him. In the end, the board dropped all but the professional-disrepute claim.

Cooper did not respond when asked why the most serious charges against Carrera were dropped.

Carrera has met all requirements the board set in his settlement, and now practices with no special conditions or restrictions on his medical license.

The board dismissed its complaint against Carrol because Desai’s trial has tied up evidence needed for an investigation. A board attorney said the group could still go forward with a complaint against Carrol, who also has testified against Desai. For now, though, he practices with no limits or conditions on his medical license.

HOW SAFE IS NEVADA?

What does that say about the outbreak’s impact on health care in Southern Nevada?

"It’s fine," Cooper said. "People should not fear their doctor."

That’s not necessarily so, public advocate Wolfe said. For starters, the medical board should have interviewed every doctor to determine who knew what, Wolfe said. Plus, Carrera and Carrol seem to have gotten off easy.

Wolfe said he doesn’t know if medical care in Las Vegas is up to par, but he said residents should be concerned that doctors implicated in the hepatitis C crisis are practicing unconditionally today.

"Beyond gastroenterologists, that should make people in Nevada concerned about the oversight of the medical profession in their state," Wolfe said.

The Nevada State Medical Board has a record of going easy on errant doctors, Wolfe said. He pointed to a Public Citizen report showing that more than 70 percent of Nevada doctors with hospital credentialing problems never face discipline. In many other states, that number is below 50 percent, Wolfe said.

Public Citizen in May ranked Nevada No. 44 in the nation for its rate of serious discipline, such as license revocation or suspension, per 1,000 doctors.

"It’s not an accident that Nevada has been languishing at the bottom of medical boards. The state is not doing adequate numbers of disciplinary actions, and this case is just a vignette into that larger problem," he said.

But local doctors say colonoscopy practices are under a microscope in Las Vegas, so patients have little to worry about. Thornton, for example, said he believes Las Vegas is the safest place in the nation to get a colonoscopy, in part because clinic inspections have become common.

The government now inspects local colonoscopy practices twice a year – one announced and one a surprise – to ensure that single-use items are used only once, Nemec said. Compare that with Desai’s clinics, which were not inspected in 13 years.

The outbreak also spurred creation of the Safe Injection Practices Coalition, which aims to increase awareness among doctors and nurses of proper needle and syringe use. Nemec has worked with the group, which includes patient advocates, health care foundations, federal law­makers and officials with the Centers for Disease Control and Prevention.

Wolfe said none of that means patients here are home free.

"Yeah, there’s oversight, but the concern I have gets to the larger issue of bad judgment," he said. "People who had bad or dangerous enough judgment to let the outbreak happen could exert that judgment in other areas. Checking on the one-use-only aspect, that’s fine. It addresses what happened here. But who’s to know the doctors involved in (Desai’s) clinic don’t have some other element of bad judgment they may act on?"

Asked if he could advise Nevadans how to spot doctors who may be willfully cutting corners or endangering patients, Cooper had little to say.

"No, I don’t have anything. I don’t believe that’s going on," he said. "I’d have to sit down and write you a report on it."

Contact reporter Paul Harasim at pharasim @reviewjournal.com or 702-387-2908. Contact reporter Jennifer Robison at jrobison@reviewjournal.com or 702-380-4512. Follow @J_Robison1 on Twitter.