Another violation, many clinics

Anesthesiologist admits risky practice

Published Tue, Mar 11, 2008 (2 a.m.)

Updated Tue, Mar 11, 2008 (7:34 p.m.)

Gibbons: Inspections sufficient

FBI, Metro and AG serve clinic search warrants (3-10-2008)
How the culture of cost-cutting in Nevada’s capital contributed to the Endoscopy Center scandal (3-9-2008)

Hepatitis scare

American Society of Anesthesiologists – Patient Safety

A Las Vegas anesthesiologist told health inspectors he used injection practices similar to ones that have triggered the nation’s largest hepatitis C scare, adding a new wrinkle to a still-developing infectious disease crisis.

The doctor’s admission complicates the investigation because he has worked at hospitals and clinics throughout the valley.

Sources identified the physician as Dr. Scott Young, an independent contractor at the Gastrointestinal Diagnostic Clinic.

Health inspectors in January linked the hepatitis outbreak to the Endoscopy Center of Southern Nevada, where they said certified nurse anesthetists were using syringes multiple times on patients — a practice that could allow vials of anesthetics to be tainted with infected blood from the first patient and then passed on to other patients.

Authorities announced their findings Feb. 27, notifying about 40,000 clinic patients that they should be tested for infectious disease. Six patients contracted hepatitis C at the Endoscopy Center.

Before the announcement, authorities had launched inspections at other medical practices, including at the Gastrointestinal Diagnostic Clinic on Feb. 14, where they observed Young’s risky injection practices.

When reached by the Sun, Young said only that he could not talk about it.

The revelation came Monday as about 45 federal, state and local investigators, including Metro Police’s entire intelligence section, served search warrants on six valley clinics owned by the Endoscopy Center of Southern Nevada and the Gastroenterology Center of Nevada.

The state Health Division’s inspections of the Gastrointestinal Diagnostic Clinic, at 3196 S. Maryland Parkway, were not related to the emerging criminal probe.

Young, who is not named in the state document, told inspectors he changed the needles when administering anesthetics to patients — but thought it was OK to use the same syringes on individual and multiple patients because of where he introduced anesthetics into the IV line, documents show.

Brian Labus, senior epidemiologist for the Southern Nevada Health District, said syringes and vials of single-dose medicine should never be reused under any conditions because they can transfer tainted blood.

The Health District is trying to identify his patients, both at the clinic where he was observed and elsewhere. Because the investigation is ongoing, authorities say they don’t know whether more patients will need to be tested.

At their Feb. 14 surprise visit, inspectors observed Young using a syringe multiple times on the same vial of Propofol, an anesthetic, and then using that vial multiple times on other patients, according to the report.

Contamination warning

Propofol, also known as Diprivan, is made by the pharmaceutical company AstraZeneca and has strict guidelines for use. It’s for individual patient use only because it can “support the growth of microorganisms.” It is not to be used if “contamination is suspected,” the manufacturer’s guidelines say.

Young told inspectors it was OK to use the drug on multiple patients because the procedures were conducted so quickly, one after another, that there was not enough time for bacteria to grow. He initially said that when he switched to new patients he changed the needle, but reused the syringe on multiple patients, which he said was OK because a “high port” was used on the IV line.

In a separate interview a few minutes later, Young said he would discard the needle and syringe after each use, but not the vial of medicine.

Dr. Chris Millson, a Las Vegas-based board member of the American Society of Anesthesiologists, said Monday that while Young was not following the recommended practices, his case appears much different from what occurred at the Endoscopy Center of Southern Nevada, because Young was injecting into a “high-port” IV line, relatively far from the patient’s vein, minimizing the risk of blood backflow. In comparison, the Endoscopy Center patients’ injections were occurring in IV ports at the arm, he said.

Also, Millson said, while it’s not recommended to reuse Propofol, the likelihood of its hosting infection is extremely slim if the vial is consumed swiftly.

Labus said the risk to patients would have been about the same at both clinics. “They’re single use items, plain and simple,” Labus said.

Anesthesiologist dismissed

Young works throughout Las Vegas, including at University Medical Center. Health officials said they don’t know whether Young used the same injection practices at other sites.

Doctors at the gastroenterology clinic, a source said, dismissed Young after learning of the claims against him.

The unrelated criminal probe by federal and state authorities of the Endoscopy Center and the Gastroenterology Center of Nevada was launched Monday morning.

“This has the potential of being one of the largest criminal investigations into the medical field we’ve ever had in Nevada,” Clark County District Attorney David Roger said.

According to a copy of a five-page search warrant, investigators sought a wide range of business and medical records at the clinics from March 2004 through February.

FBI spokesman Joe Dickey described the investigation as a “high priority.”

Among other potential violations, federal and state agencies have the ability to pursue cases of Medicaid and insurance fraud in this investigation.

Attorney Richard Wright, who represents Dr. Dipak Desai, one of the owners of the clinics, declined to comment.

This story has been corrected. In an earlier version, Young was incorrectly associated with Summit Anesthesia.

On Tuesday, Millson said he wanted to clarify the impression he gave that he was condoning or minimizing the threat of using vials of propofol for multiple patients. He said the use of syringes or propofol on multiple patients is completely unacceptable.

Sun reporter Jeff German contributed to this article.

Discussion: 16 comments so far…

By morpheus

3/11/08 at 7:39 a.m.

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I find it ironic that The American Society of Anesthesiologists made statements in the Washington Post recently condemning nurse anesthetists as if their anesthesiologist members would never commit such a horrible act. Well, it looks like one of their own has been caught red handed reusing syringes on multiple patients. I think perhaps this anesthesiologist should surrender his license as did the nurse anesthetists in Las Vegas. This is not the first anesthesiologist to be accused of reusing syringes on pateints. Recently in New York City, Dr. Finkelstein anesthesiologist) was accused and responsible for infecting patients with Hep C. This is outrageous and I can't believe practitioners are doing this in this day and age. Come on, you know better.
By barrelmakers

3/11/08 at 9:33 a.m.

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I believe Dr. Chris Millson (a BOARD MEMBER of the American Society of Anesthesiologists), has already forgotten the mental anguish and anxiety the patients of these clinics and providers are experiencing. For Millson to state that not reusing of syringes is the “recommended practice” is shameful. I would venture to guess from his comments that Dr. Millson would allow himself and his mother to be treated with the same syringe that has been used on multiple patients. Well this is Nevada, go ahead and take that gamble Doctor, as for me I would like a clean syringe, needle and vial. And for all you medical practitioners out there, all I can say is “follow your STANDARDS OF CARE!!!!!”
By gtnla

3/11/08 at 10:25 a.m.

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The individuals involved in this practice should lose their licenses, spend some time in jail and be made to pay the states additional cost for investigation, trials etc. This is nothing more then pure greed, trying to save a buck at their patient's expenses. Everyone knows you do not reuse syringe on mutilpal patients.
By morpheus

3/11/08 at 1:46 p.m.

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So far we have not heard whether the Nevada State Medical Board has asked or is going to ask Dr. Scott Young (anesthesiologist)at the Gastrointestinal Diagnostic Clinic to surrender his license. In contrast, the Nevada State Board of Nursing stepped up to the plate immediately and asked the nurse anesthetists involved to surrender their licenses pending the outcome of the Hep C investigation. It seems there is a lower standard applied when the doctors in Nevada are involved in substandard care. The Nevada State Board of Nursing should be commended and the Nevada State Board of Medicine should be shamed.
By morpheus

3/11/08 at 2:32 p.m.

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"ASA Encourages Patients to Ask for An Anesthesiologist Qualifications of Anesthesia Providers Key for Patient Safety and Infection Control."CHICAGO – Following the notification of 40,000 Nevada endoscopy center patients of possible exposure to hepatitis C due to the reuse of syringes and vials for anesthesia administration, the 42,000 members of the American Society of Anesthesiologists (ASA) want to stress that contrary to many reports in the media, the “providers” administering the anesthesia with improper infection control techniques were NOT anesthesiologists. Anesthesiologists were not involved in the care of these patients. While outbreaks and notifications of this size are extremely rare, it brings to light the need for physicians and patients to be aware of the safety standards in place at all facilities,” said Jeffrey L. Apfelbaum, M.D., ASA President. “Before undergoing any procedure involving sedation or general anesthesia, patients need to be aware of what type of anesthesia they will be receiving and most important--- who will administer their anesthesia.”ASA encourages patients to ask the following questions before undergoing any procedures requiring anesthesia:"Who will be administering my anesthesia medication? Do I have an option to request an anesthesiologist? What type of anesthesia care will I be given?Do you throw out needles, syringes and vials after every patient use?"It seems they were all to eager to profess that an anesthesiologist would NEVER be involved in such practices. Looks like they spoke to soon. They must have also forgot about the other recent events where anesthesiologists were involved in the same practice as Dr. Scott Young.On 15 November 2007, 628 patients were notified that they should be tested for Hepatitis B, C and HIV. Doctor Harvey Finkelstein, 52, a physician anesthesiologist in Plainview, New York, was found to be reusing contaminated syringes. Finkelstein had more malpractice settlements than any other pain-management specialist on Long Island and was sued, on the average, once or twice yearly.Joanne Doroshow, director of the New York-based Center for Justice and Democracy and a member of a state task force on medical malpractice, said the case illustrated “a too-cozy relationship between the medical profession and the people who supposedly regulate them.” It is no surprise they would be all to quick to crucify nurse anesthetists when a couple bad apples surface. However, they will go to great lengths to hide their own bad apples and act as if all there members are clean and unspotted. Shame on the American Society of Anesthesiologists (A$A). The statements made by the A$A are no surprise; Certified Registered Nurse Anesthetists are in direct competition as equal providers held to the same standards of care.
By whitewater

3/11/08 at 3:52 p.m.

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Nice defense of the CRNA industry! Sounds like CRNAs are quite culpable on their own in this story however, as all reported cases of hepatitis C transmission in this outbreak have been linked to CRNAs failing to adhere to safe injection practices. Crying "the doctor made me do it" is certainly not exculpatory, but is rather an indictment of poor professional autonomy, judgement, and ability to put the patient's safety first. We need a new standard of care. The old one failed our patients, and failed us.
By hrstoll

3/11/08 at 10:31 p.m.

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There is a TV commercial where the doctor says something to the effect of " cut below the 3rd rib", and the guy says " shouldn't you be doing this"! Ironic, this ad has been running before all this. I had a procedure done at UMC and called my doctor to ask one question, who was the anesthesiologist who administered my sedation. The answer was no need to worry it was a "DR" and not a nurse. I asked what his name was and it was Dr. Scott Young. Relieved I went about my business until I read the news. Now I too am on the damn list of these bastards. I applaud no one. The city, county, state and fed have acted to slowly in this and all the pundits giving excuses and reasons will not diminish the reality of it all. A comment to Richard Wright: Is there any high profile case you WON'T take on moral or principle grounds?
By morpheus

3/12/08 at 9:38 a.m.

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hrstoll,

Your comments appear to be biased and uninformed. Not surprising because most of the general public is uninformed by about Certified Registered Nurse Anesthetists (CRNAs). CRNAs were the FIRST organized specialty in anesthesia. They have been administering anesthesia since the mid 1800s.It was NOT medical doctors to first specialize in this area. Anesthesia in its infancy was not looked upon as a glorious service, but somewhat as a handmaiden to the surgeon. The medical community and especially now the American Society of Anesthesiologists (A$A)have done a great job of deceiving the general public and minimizing the contributions of CRNAs in the field of anesthesia. The true fact is that CRNAs solely administer about 65% of all anesthesia in this country and about 85% is CRNA only in rural america. That's what the ASA does not want you to believe. That is a fact. Rarely are there only anesthesiologists practicing alone in a medical center. In fact, a great number of CRNAs are employed by anesthesiologists so the 'ologists can sit in the lounge, surf the internet and drink coffee. This is how they can maximize there income. I am sure that statement will engulf rage among the anesthesiologists, but it is a cold hard fact and they know it, so bring the flames. Las Vegas is unlike most of the country in that there are few CRNAs working in any of the hospitals down there. Would I worry that a CRNA was going to administer my anesthesia? No, not for one minute. In fact, I have only had anesthesia by CRNAs. They are highly educated, qualified, and licensed to perform this function. Anesthesiologists are held to the same high standards of anesthesia care that CRNAs are expected to uphold. It is sad that there always will be a few bad apples out there in all medical professions. Does it mean that one particular group is less professional or more incompetent? NO. The vast majority of CRNAs and anesthesiologists practice a high level of care. Our military warriors are provided anesthesia care almost exclusively by CRNAs. Our government and military brass understands the high level of care and competence of CRNAs. Want to know the facts about CRNAs and who they really are? Visit www.aana.com
By whitewater

3/12/08 at 11:21 a.m.

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Yada Yada...more CRNA self promotion when all of us should be directing our attention to patients injured by our sloppy practices and to elevating the standard of care to ensure the safe delivery of medical care...

FACT: Sedation for the overwhelming majority of endoscopic procedures performed by gastroenterologists can be safely delivered by trained RNs (not CRNAs) working under the gastroenterologist's direction at NO ADDITIONAL COST to the patient. The extra $500-1,000 in anesthesia charges resulting from having a CRNA give the drugs does not provide a safer procedure and only serves to inflate the costs of care by employing high priced professionals to do tasks that do not require their expertise. Morphus' concern over anesthesiologists in the lounge is laughable. What about a nurse charging $500 to give 100 mg of propofol for a 15 minute colonoscopy? Not a bad way to drink a latte.

Gastroenterologists and RNs who choose to become proficient in airway management can manage deep sedation with propofol (the same drug used incorrectly by CRNAs and at least one anesthesiologist in LV) safely and at no charge to the patient. Over 450,000 such sedations have been reported and will be presented at the annual gastroenterology meetings in May.

FACT: CRNAs earn $150,000-$200,000 annual medial incomes in the U.S., depending on the environment of care. That income exceeds what a hard working and highly trained family physician or internist can command. It is out of line with the training and expertise required. But if I had it I would shout out and defend it as assertively as Morpheus is doing.
By mab5238

3/12/08 at 4:58 p.m.

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Well whitewater, maybe those "highly trained" family physicians and internists should quit and go back to nursing school. Stop crying about how much CRNA's make and take some responsibility for what I assume is your profession. Your organization should step up to the plate and discipline this individual. Let's keep it on subject. By the way, it is in the Nurse Practice Act that RN's can't give propofol. They can, however, administer versed and demerol, as there are antagonists for those drugs. You should really do your homework before you start making comments about subjects you know nothing about. Talk to the GI docs who employ CRNA's at these places if you have a problem with it. Unbelievable...
By morpheus

3/12/08 at 10:13 p.m.

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Whitewater, by the way, your CRNA salary quote is actually low. Many CRNAs make SIGNIFICANTLY more than what you quoted. The national data is "outdated," especially those who own their own practices."Out of line with the training and expertise?" Laughable!! Tell that to the many CRNAs who work in CRNA only practices in rural Nevada and throughout the country! Tell that to the families of trauma victims, pending rupture of an abdominal aneurysm who would not be alive today had there not been a CRNA there to provide emergency anesthesia services. All done without any anesthesiologist in sight. A CRNA doing what they are trained to do and very capable. Tell that to the surgeons and other physicians in rural american as well as large tertiary care centers who actually respect the knowlege, expertise and skill CRNAs possess. I am sorry the pediatricians, family practice, and internal med doc's don't make what the average CRNA makes. Well to damn bad! Maybe they should have thought about their career path if money is that important to them. Why do you think CRNAs get payed what they do? Expertise, service in high demand, and liability. Hell, even insurance companies think CRNAs should get payed well.
Yea, It would be laughable to take a "highly trained" family doc or internist in the OR to provide an anesthetic for even the easiest surgical case. We would be talking to next of kin and calling a lawyer.
By CAS

3/15/08 at 1:13 p.m.

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Dr Chris Millsons comment makes me wonder... tubing once attached to the patient is considered CONTAMINATED. That's standard, even basic Infection Control.Period.
Ignaz Semmelweis (physician, 1818-1865)(please look up his name, discovery and fight for Infection Control, while being rejected by the "medical establishment" - Physicians and Nurses alike, if you do not know who he is) would turn in his grave listening to this "reasoning".
By moon117

3/18/08 at 2:45 p.m.

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whitewater- I am not a CRNA, am an RN and have several Physicians and nurses in my family. I feel It is important that the public is educated about the roles and responsibilities of different medical professionals. It seems that Morpheus is only trying to educate the public and stand up for his profession--and so he should. CRNA'a are very capable and i would trust a good CRNA equally to that of a good anesthesiologist. At this point, the public is like an angry mob who seems to just want to fry everyone and anyone who is associated with medicine. There are a lot of good medical personnel who are not guilty and it is important to realize that. The responsibilities of Nurses and doctor's grows with each passing year due to nation wide shortages. It takes courage and conviction to dedicate oneself to medicine. It is outrageous that a handful of nurses and doctors would do such a horrible thing but this situation has undertaken a snowball effect. I agree it is the publics right to know what is happening, but The media really should be more careful (less biased/more objective) when reporting. Now we have patients who are having trouble finding medical care and How many people will die from colon cancer as a result? How will this effect the recruitment of nurses and doctors in Nevada and potentially nation wide? How many people will die because there isn't a doctor or nurse around because hospitals are having trouble finding coverage? I think that the fact that elections are coming up may be influencing some of these decisions. I agree with the bloggers who have said to Let the guilty people fry but fry the right people.
By atrxnasd

3/21/08 at 3:05 p.m.

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Doctors and nurses are not the same. Unfortunately both have their share of poor providers. Dr. Young is NOT a member of the ASA. On the AMA web site he is not listed as having his boards in Anesthesiology. An anesthesiologist without boards and membership in a professional society should have sent up red flags to patients and his employers. Without Boards he may have been trained as an anesthesiologist but he is not recognized as a consultant in Anesthesiology. A consultant in Anesthesiology would know the difference between 1970's medicine and 2008. ASA members are informed with current up to date literature (Dr. Finkelstein was not an ASA member and was not practicing anesthesia but pain management).
Its too bad that because some CRNAs use any excuse no matter how poor to make up for their mistaken belief that because they are not doctors they are unimportant. Most CRNAs I know are happy to be nurses, are proud of their knowledge, training, and skills and are smart enough to realize that medical knowledge is important and therefore they work within an anesthesia care team. Others who feel inadequate that they don't have medical training are alway looking for reasons to say they are as good or better than doctors. That just isn't the case. Nurses and doctors are different with different training!!

Just get over it!!!!
By moon117

3/24/08 at 3:56 p.m.

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Who said doctors and nurses were the same? Yes, both have their share of poor provoders, but both have theirs share of good providers too. Good nurses and doctors work as team members on the same side (that of the patient). Their roles aer different but their goals ultimately the same - OPTIMAL CLIENT OUTCOMES. There is too much destruction and not enough construction towards and within the medical profession. I don't even know what to say when i hear a generalized statement "get over it".
By morpheus

5/16/08 at 4:34 p.m.

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atrxnasd,

Many CRNAs work in ALL CRNA groups in this country. I happen to be an owner/partner in one myself. We don't need anesthesiologists to provide quality and safe anesthesia care period! Unlike anesthesiologists, CRNAs must pass their board exam within a short specified time period or they don't practice anesthesia.