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?

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.... Doctor friends tell me it might be the biggest medical malpractice case in recent history

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 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.

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

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.

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

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'.

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.

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).

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.

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.

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:

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.

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.

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.

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 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.

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.

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.

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

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

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.

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.

Obviously, as I guessed, I'm not the first person to have thought like that. They is even a journal dedicated to this research:

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).

Medical experts have been around for a long time.

"At the heart of the problem is the self-perception of the medical community as the next best thing to sliced bread."

This is a tremendously antiquated view of the medical profession. If you think that physicians fail to appreciate the problems with our medical system, then you have little understanding of the business of medicine.

"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. "

Modern medical training and practice has little resemblance to a pre-industrial Artisan class. Physician groups and hospitals are no different from any other modern business model. They are concerned with revenues and costs.

"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."

Modern healthcare is orders of magnitude more complex. Certain aspects of health care should be treated as a commodity. Access to preventative services should be available at every turn. The proliferation of outpatient clinics in suburban malls is an obvious example of how this has already occurred. Access to the Web is another example of how certain aspects of health care information can be considered commodities. The difficulty is when medical care demands hospital resources and technology. Complex medical or surgical conditions can not be made commodities purely based on the resources that go into diagnosis and treatment.

"The industrialization and standardization of medicine will both reduce costs, increase quality standards, allow for wider availability, and better troubleshooting of problems."

Medicine is industrialized and standardized. The problems with cost in the United States boils down to a simple fact.. Do as I say, Not as I do. Talking about reducing costs is all well and good until it's your wife, mother or baby that is at stake... then it's... "do whatever it takes, doc." It more complex then saying let's just make it more efficient like Intel does with microprocessor production.

"The ultimate goal would be that going to the doctor would be no more of a hassle than shopping for a cell phone."

This is a beautiful comment because it underlines the depth of misunderstanding of our medical system. The problems with healthcare have little to do with the interaction between a healthy patient and their primary care doctor. Although primary care physicians have been unfairly squeezed when it comes to reimbursement, they are not resposible for the problems with health care that center on our inflationary health care spending. WE ARE RESPONSIBLE. A public that demands high tech procedures and expensive medications simply because we can't draw boundaries. As a society, we can't eat healthy and exercize. As a society, we can't say "it's ok to let my 65 year old mother with metastatic cancer go to hospice care."

Don't trivialize the problem.

Speaking of checklists, there was a really nice article by Gawande in the New Yorker on how dramatically helpful they are, and how much they reduced the rate of infection when they were adopted, despite tremendous initial opposition from doctors to using them.

I am an anesthesiologist who practices in an outpatient surgicenter. I have also been a medical director of a surgicenter. Let me run some numbers. They did approximately 40,000 GI endoscopic procedures in four years. That is roughly 10,000 per year. They had two rooms. That is 5,000 procedures per room. Let us say they worked 50 weeks of the year. That is 100 cases per week per room. So on an average day they did 20 cases per room. In an eight hour day that is twent four minutes per case. This does not include the time it took to take one patient out and bring the next patient in. Let alone review history and prepare the room for the next case.

That endoscopy center was basically a production line. It is not possible to give good care to patients when you look at these numbers.

A few rotten apples reflect badly on the vast majority of desi doctors who work hard and give good care.

Desai was the medical director and majority owner. A surgicenter that does that kind of volume generates huge profits. Millions of dollars went into his pocket. It will be a malpractice goldmine for the lawyers.

I truly feel sorry for the patients.

Ennis, and Rahul: It wasn't physicians who resisted checklists, but a government agency called the Office for Human Research Protections. They shut it down for bizarre reasons. Most physicians I run into are for this sort of thing, as are hospitals.

Risk management and prevention is the way to keep medical malpractice away from medicine. This is one iniative, that I suspect will come back in a way to get around the goverment's concerns.

Ennis, and Rahul: It wasn't physicians who resisted checklists, but a government agency called the Office for Human Research Protections. They shut it down for bizarre reasons. Most physicians I run into are for this sort of thing, as are hospitals.

Interesting. Can you elaborate? That's not what Gawande indicates though in the article:

After the checklist results, the idea Pronovost truly believed in was that checklists could save enormous numbers of lives. He took his findings on the road, showing his checklists to doctors, nurses, insurers, employers—anyone who would listen. He spoke in an average of seven cities a month while continuing to work full time in Johns Hopkins’s I.C.U.s. But this time he found few takers.

There were various reasons. Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost’s evidence. So far, he’d shown only that checklists worked in one hospital, Johns Hopkins, where the I.C.U.s have money, plenty of staff, and Peter Pronovost walking the hallways to make sure that the checklists are being used properly. How about in the real world—where I.C.U. nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the idea of filling out yet another piece of paper?

Now, it might be that overwork is the biggest reason for seemingly justifiable corner cutting (although, at least in this case, the evidence seems to indicate otherwise), and that what the community needs is really many more doctors, but the shortage too seems to be a result of conscious efforts by the AMA to keep demand high.

To clarify: What I meant in my previous comment is that the evidence seems to indicate that corner cutting is not justified at least in ICUs. Another example (which I might not be recalling correctly) is how resistant doctors were to follow hand washing guidelines even after there was considerable evidence that it reduced the risk of MRSA.

Also, I am not saying that these examples are indicative of something fundamentally wrong about the US medical community because I certainly don't feel that way, but it seems like there is some reluctance to adopt measures that are focused more on diligence and meticulousness, because it is seen as an insult to the inherent skill and talent of doctors.

This desi doctor was greedy as hell and guilty as sin. Indians are at risk of becoming pariahs in America thanks to jerks like him:

http://www.lasvegassun.com/news/2008/mar/09/assembly-line-colonoscopies-clinic-described/

If you want to get a sense of the rushed medical procedures that patients encountered inside the clinic that triggered the unprecedented hepatitis scare, consider Duke Breuer’s experience.

After undergoing a colonoscopy at the Endoscopy Center of Southern Nevada, Breuer asked a nurse what he should do about the bandage on his right forearm.

“Take it off when you get home,” the nurse said.

Later, when the 78-year-old Breuer pulled up the tape, he started gushing blood. The IV needle had been left in his arm and he had accidentally yanked it out.

Blood spurted with each beat of his heart — “Poom! Poom! Poom!” is how Breuer describes it. The darkest blood he’d ever seen, covering his pants and ruining his beloved Chinese silk rug.

So Breuer was none too happy when he returned to the facility a few days later for a second procedure.

“I ought to sue you for ruining my rug,” he told a nurse.

Her response stunned him.

“You ought to sue us for a lot of other things that go on here,” Breuer says the nurse replied. “You don’t know what goes on here. I hate my boss.”
He dismissed her as a disgruntled employee.

Then, 10 days ago, the Southern Nevada Health District announced that 40,000 people might have been infected with hepatitis B, hepatitis C or HIV because of dangerous injection practices at the downtown endoscopy center.

Never, it seems, has the community been so collectively outraged as now, with the news that patients were put at risk of being infected with fatal diseases because of a doctor’s drumbeat to save money.

According to investigators, the nurses claimed that Dr. Dipak Desai, one of the state’s most powerful physicians and owner of the clinic, had ordered the dangerous practices. When patients needed more anesthetic, the nurses were using the same syringe to dip back into the vial. That tainted the medicine. Then, even though the vials were intended for single use, the nurses would reuse them on other patients. That passed along infection. Little money would be saved by reusing syringes, but reusing the medicine could save $5 to $10 per procedure, experts estimated.

Six people contracted acute hepatitis C because of the dangerous injection practices, health officials said, and now thousands more await the results of blood tests.

The clinic has been closed by the city.

Why did Desai apparently ignore established, fundamental medical safety?

Medicine is business. And in an era of rising health care costs and dropping insurance reimbursement rates, physicians balance the pursuit of profit with patient care. But those who know Desai and worked with him say his downfall was greed. Desai proudly proclaimed that he ran the most cost-effective clinic in the entire country.

A nurse who worked for Desai said his business plan called for extreme cost-cutting measures. A doctor who has worked with Desai said he was proud of churning through procedures at an impossibly fast pace. He said he witnessed Desai perform in a few minutes a colonoscopy that should have taken 15 minutes. And then brag about it.

“He’d say, ‘I’m the fastest endoscopist, the best endoscopist, in town,’ ” recalled the doctor, who like others asked for anonymity for fear of reprisals. “That was his pride and joy.”
By many measures Desai is a success. He attended medical school in India and completed his residency and an internship in New York before he and his wife, Dr. Kusum Desai, a pulmonary specialist, were licensed to practice medicine in Nevada in 1980.

Desai has been chief of gastroenterology at University Medical Center and Valley Hospital & Medical Center, and a professor at the University of Nevada School of Medicine. The couple owns a $3.4 million, 8,700-square-foot home in Summerlin.

A friend credits him for helping to found the Hindu Temple of Nevada and donating $250,000 to it.

But the friend asked not to be identified because of what else he had to say about the doctor: that Desai is aggressive, intense and preoccupied with business.

“If he cannot achieve something with you he will forget you in a minute,” the friend said.

The Endoscopy Center of Southern Nevada opened in March 2004 in a medical building at 700 Shadow Lane, between two of the city’s largest hospitals — and across the street from the offices of the Southern Nevada Health District, which launched its surprise inspections of the facility in January.

The business complements Desai’s Gastroenterology Center of Nevada, which has six valley locations.

Although other doctors worked at the high-volume facility, it was Desai’s domain.

Appointments were frequently double-booked, leading to two-hour waits in a standing-room-only waiting room, said a nurse who worked there in 2007.

In assembly-line fashion, patients were hurried among nurses who would admit them, start an IV in their arm, take them to the room for the procedure, and then walk them to a recovery area before sending them out the door.
“He would always say, ‘Time is money,’ ” the nurse said of Desai. “The faster we would go, the happier he was.”

The flow of patients sounds impossibly fast, said Phyllis McGregor, a nurse who for 20 years directed the gastroenterology department at Centinela Hospital Medical Center in Inglewood, Calif.

She ran three rooms where a total of 30 procedures a day were done, at the most. Desai was doing 60 procedures in two rooms — a pace that McGregor said compromised patient safety.

The rush of procedures took its toll beyond the forgotten IV needle in Duke Breuer’s arm.

Carrol Lathrop, a 70-year-old from Pahrump, says Desai perforated her bowels during a colonoscopy, and she was forced to wear a colostomy bag for a year before having surgery to fix the problem.

Lathrop’s records from the clinic show Desai performed the procedure on Sept. 6, 2006. The notes are contradictory, observing on the one hand that she was in “discomfort,” “tolerated the procedure poorly” and that the “quality of the prep was inadequate,” while also saying “the colonoscopy was performed without difficulty” and she was discharged in “satisfactory” condition.

The next day, Lathrop was in such agony that she went to Desert View Regional Medical Center in Pahrump where, according to hospital records, she was diagnosed with an “acute perforation” of the sigmoid colon.

McGregor, the California nurse, says she has seen only two cases of perforated bowels in 25 years.
In addition to hurrying procedures, Desai was a miser with supplies, his clinic nurse said. In a finding unrelated to the hepatitis C outbreak, the state Licensure and Certification Bureau found that technicians were not adding the proper amount of detergent to remove the blood, tissue and other body fluids from the endoscopes, nor were they discarding cleaning solution after each use.

In addition, clinic staff was ordered to save money by cutting in half the disposable underpads that protect the beds, she said. The pads cost about 21 cents each.

Desai also saved money — and made money — by using certified nurse anesthetists rather than anesthesiologists, who are medical doctors. Because the certified nurse anesthetists were salaried employees, unlike anesthesiologists, who would have billed insurance companies and Medicare independently, Desai was able to submit his own billings for anesthesiology.
The nurse who worked in the clinic said keeping the anesthesia services in-house offered opportunities to overbill for services. For instance, she said the anesthesia for all procedures was billed at 30 minutes when none ever lasted more than 15.

The Nevada attorney general’s office is investigating whether Desai defrauded insurance companies or Medicaid, the government’s insurance program for the poor.

Using employee-nurses versus outside doctors to administer anesthetics may have contributed to a culture of compliance with Desai’s demands — including the unsanitary injection practices.

Dr. Chris Millson, a Las Vegas-based board member of the American Society of Anesthesiologists, said an independent anesthesiologist would have gone “toe to toe” with Desai and prohibited the dangerous injection practices.

“It’s not that a nurse anesthetist can’t argue with a physician,” Millson said. “But none did in this case.”

On Wednesday, five certified nurse anesthetists voluntarily surrendered their licenses to the Nevada State Board of Nursing pending the outcome of its investigation.

And on Friday Desai voluntarily agreed to cease practicing medicine pending the outcome of an investigation by the Nevada State Board of Medical Examiners.

Interesting. Can you elaborate? That's not what Gawande indicates though in the article:

OHRP objected to the implementation of checklists as research that took place w/o informed consent of patients:

Such research, however, poses an apparent ethical conundrum: it is often impossible to obtain informed consent from patients enrolled in quality-improvement research programs because interventions must be routinely adopted for entire hospitals or hospital units. When, for instance, research on a quality-improvement initiative that affects routine care is conducted in an intensive care unit (ICU), surgical suite, or emergency room, individual patients have no opportunity to decide whether or not to participate. Can it be ethical to conduct such research without informed consent?

A nice assessment of OHRP's objections and how to better handle the situation in an NEJM article. This article provides a time-line of the situation as well, so you will see that the IRB halted the research after the study was published and of course, after Gawande wrote about it. If the checklists were not implemented as a part of a research study, the OHRP would have no say in the matter. But generally people think (from the NEJM article):

Is informed consent necessary for quality-improvement research? From both an ethical and a regulatory perspective, we believe that the OHRP's stated conclusion about the need for informed consent was erroneous. Like most ethical norms, the requirement to obtain informed consent has legitimate exceptions. In emergency settings, for example, it is even considered ethical to include patients in a randomized trial of an experimental treatment without consent, provided that appropriate safeguards are implemented.

Also : here is a snarky critique here of how human subject protections regulation are bungled and a general round-up of what researchers feel.

Ennis

You're right. It would be more correct to labeled them doctor/physician/provider error instead of patient errors, but that's how they are are referred to in the hospital. I guessing it does not refer to the patient actually committing the error, but rather the error being done to the patient by the physician.

Checklists are a good idea but at least when it comes to bronchoscopies, marking the outside of the body does not help you since it does not in anyway correlate with what one is looking at on the video monitor. I actually suggested to the JHACO inspector that a radiographic marker (i.e a lead L or R) should be used rather than signing my initials on the left or right side of the body since the radiographic marker would actually be seen on the fluoroscopy but the sharpie signature would not. The JHACO inspector told me that would not fulfill the requirement and I still had to sign the side of the body that I was going to bronch. The problem I have is that at times the focus becomes on the form itself rather than the reason the form was created.

Another example we have these SCORE IT forms designed to prevent deep venous thromboses (DVTs). I got called to fill out the form and check the appropriate form of prophylaxis since it was not filled out. The reason it was not filled out was because I admitted the patient with a DVT and had already placed him on anticoagulation. The nurse completely missed the point of the patients diagnosis in his zeal to check the box on the form.

Upon discharge patient's are supposed to be offered flu and pneumonia vaccines in most cases. I got called about a patient whom I did not order the flu vaccine for at discharge. The patient was being discharge after having been treated for influenza, so it would have been pointless to give her the vaccine, but the form still had to be filled out.

In the end however if it leads to better patient care then I'm all for it.

I'm a newbie on this board, and don't really know how to quote just yet (and don't have time, since I technically should be working already):

This is a response to Rahul regarding checklists:

The original plan was struck down by the aforementioned gov't agency. Google the agency, and you should find articles indicating.

Doctors, as a general rule, are usually divided over risk management. The doctors I've encountered (admittedly a very small sample) appreciate any ideas that will help reduce errors. But there are a significant number who don't. In NY state, physicians can get a 5% discount on their med mal premiums if they attend a RM class once every year or two. But many don't because a)they can't be bothered, or b)they don't have time or some combination of both. Usually these doctors make enough money that that 5% doesn't cut it.

But in this new litigious world, aka the USA, we live in, many hospitals are forcing their staff and attending physicians to attend classes or follow RM procedures.

Sure, there will always be arrogant doctors and nurses who resist. but look, we now have checklists to make sure that all surgical instruments are present and accoutned for after a procedure and before the patient is sewed back together.

After reading the link provided by Vyasa (57), I am surprised none of the clinic's techs, nurses or doctors (all of whom I consider to be highly educated and ethical) blew the whistle. Perhaps most were scared and are struggling to make a living, I don't know. Could any of the employees (or even patients) reported the non ideal practices anonymously to a public health department in the earlier stages before this thing got out of hand? Or does the public health department have too much bureaucratic red tape and much paperwork is involved and maybe it is not worth the trouble?

Regarding my previous post, I don't personally know any of the workers/professionals at the Las Vegas clinic. I meant to say I generally consider most all people in the health care field to be ethical and highly educated. There might be exceptions, of course. Sorry about the confusion.

I am a gastroenterologist (in training about a year from finishing my fellowship) in regards to the articel about desai and his practices. A colonoscopy is composed of two parts, this first is getting to the cecum (the area the appendix is and technically the starting point of the colon) and the second part is withdrawal which is the examination of the mucosa. Most experts say that the withdrawal time should be at least 6 minutes (in the most experienced hands) and upwards to 12 minutes if you are wanting to get a real good look. The time it takes to get to the cecum depeds on your skill etc, and it can be as fast as 1 minute and longer even an hour. A "colonoscopy" is actually the withdrawal. As with any surgical/procedural specialty there is a certain amount of machismo that goes along with it...(re Scrubs) It is not that unusual to here GI trainees brag about the speed in which they can do one...so the whole bragging part I get...do I agree? not sure...but I get it. Secondly mest surgi-centers employ CRNA (nurse anesthesists) because frankly they are cheaper...an MD anesthesiologist costs a lot more to employ than a CRNA. Do you need an anesthesiologist in GI? No..the problem (if you can call it one) is that everyone wants to be "knocked out" so you have to use propofol...which according to most places needs to be administered by an anesthesia practioner. You don't need propofol for a good quality exam...you do need it for a quick one sometimes.
In any case if you used infected needles and syringes, you were dumb, and you were wrong. Of course everyone is going to say he authorized the use, nut as someone else said, you can't control your employees. Also in our group we do quality improvement studies each year, and we routinely go over our practices, and I think most practices are asked to do this as well, but I am not sure about private practice as I am not in.
In terms of the volume of procedures this is an effect of medicare cuts. in the past if you for example did 100 procedures a week you made 100000 a year, now if you do 100 you get like 50000, but you your wife and your kids like the 100000 lifestyle so now you have do 150...its a vicious cycle (and befor anyone jumps on me these are not real numbers)

http://www.acg.gi.org/physicians/clinicalupdates.asp#guidelines

http://www.gastro.org/wmspage.cfm?parm1=4453

http://www.asge.org/PublicationsProductsindex.aspx?id=352

oops. It looks like 2 doctors (who worked in the clinics) already complained. For some reason, it looks like their concerns were ignored or was not a priority, etc.

As patient advocates, nurses are of course held accountable for infection control. They shouldn't blame this on staffing practices over holding each person accountable.

Should add to say that I meant staffing in terms of who is doing the tasks; of course being understaffed and overworked is never a good thing..

I received a colonoscopy at this Las Vegas endoscopy center (as did my parents). I'm not really the type to feel much pain and suffering; honestly, I doubt I'll feel any outrage unless I've actually contracted a disease. But I will say this:

The place was entirely a production line. You get there and find out that they're already 2 hours behind schedule. You complain in vain to receptionists and assistants who nod knowingly, because they've heard it all before. But what can you do? Leave? Let me remind you that you've just spent the previous day fasting and drinking about a gallon of disgusting liquids intended to clean you out. You don't want to do that again anytime soon. You are the very definition of a captive audience.

As a former retail business co-owner, I'm all about being greedy and cutting corners and taking any possible advantage over unsuspecting customers. So I understand what Dr. Desai is all about. The difference, though, is that my practices weren't creating a public health risk, and I never had to take a professional oath.

Stuff like this is why Indian people don't trust their own kind.

"68 · Vegas Patient said

Stuff like this is why Indian people don't trust their own kind.

Wow, thought I was the only one who had that idea. (By the way, I wish you good luck and hope all is well for you and all of the other clinic patients #68)

This really hurts me deeply say this. I have been to 9 Desi doctors/dentists over the past 30 years or so. I have only seen (a grand total of) one Desi physician who was helpful to me and unfortunately he relocated to another state. Be fully aware this is only my experience, but my non desi physicians & dentists are way nicer ,more competent and never make me feel rotten about myself. I believe in the patient doing whatever they can for their own health, so I am no overeating, drug abusing, smoking couch potato at all.

I have lived in six states and always changed physicians/dentists with every move. I treat everyone with proper respect and realize not everyone will act respectfully in turn, but most all of the Desi doctors/dentists I have consulted were rather brusque, condescending and even incompetent in some cases. This is one reason why I don't choose a brown physician, even though I am very much a brown person myself. I have had too many terrible experiences. Maybe the desi physicians don't want to look like they are giving extra help/favors to brown patients, i don't know (I never demand extra time/favors, services for nothing, + i always pay and show up on time, etc.) Just to reiterate, this is only my experience and it is a very limited sample. Maybe the "second generation" MDs etc are better. There are always two sides to every story, of course. However, I treat everyone the same and with respect regardless of color, status, but for some reason, i have better results with non brown medical professionals.

In one instance, there was one northie physician who often made fun of southies (indian), their names etc. I happen to be an andhra southie and it made me wonder if he had some bias against southies like me. For the record, I never brought up the issues of being a fellow Indian, north or south, or try to bond in some way when I saw the Indian physicians. I was very business like and refrained from any small talk out of respect for the physcian's time. I stopped going to that person and I later found out that three other patients (one non Indian included) did not care for him and a bad time too. Luckily, we have choices in this system and you are always free to look elsewhere.

Depending on type of anesthesia given, it is routine for RNs to push sedative drugs. It is standard practice in most free standing ambulatory surgical centers depending on what the specific drug is. Guidelines vary slightly from state to state. If a patient, however, needs sedation of a higher level than what RNs can push through a syringe AND this deeper sedation requires monitoring by an MD (as with Propofol), then the big guns are called in. What they use and who they use to sedate people is based on each individual patient's tolerance to sedatives ,difficulty and length of the case as well as other issues that vary from patient to patient.

Yes, everyone wants to be knocked out, but that doesn't happen unless big bad Propofol and an anesthetist are used. You don't get it if you don't ask your doc for it. Now, even if you ask for it you still may not get it. Major insurance companies,like Aetna, will not pay for your colonoscopy if you get propofol... unless you meet their requirements. They feel that using Propofol and an anesthetist drives up the cost of the procedure. So, as long as it is less money out of their pockets, they don't mind that you are writhing in pain (even moderately sedated) asking for your "Mummy" to make it stop. This is an uncomfortable procedure, people! Just because they can Versed away your discomfort during the procedure, doesn't mean that there was no pain.To compound this unpleasant experience, now you have to worry about weather you've got the last patient's Fentanyl backwash in your veins.

All this while six feet of scope disappears up your arse.

just to follow up on ebeth,

I did 300 of these last year and I only used propofol once in a non intubated patient, of the remainder i only witnessed 15 people who could not be sedated properly with versed, so I don't think you need proprfol. (that being said I ave only done these and never received one) Additionally, there are disadvantages to using propofol, the first is that the sedation is deeper, so you need more monitoring and the deeper the sedation the higher the risk. Secondly, blood pressures can drop to unsafe levels with higher doses and 3rd, one of the biggest and most dangerous complications of a colonoscopy is a perforation of the colon, this happens when there is a lot of pressure on the colon from the scope. Endoscopists can use the feel of the scope, and the reaction of patients to know when there is excess tension, with propfol patients can not let you know there is pain or discomfort so you have a higher chance of perforating. Of course as ebeth said, the insurance companies dont consider this when considering payment, they just look at money.

Oh and the scope is only 150 cm long and typically only 80 to 90 are in a person...not 6 feet

http://www.insurancejournal.com/news/east/2008/03/20/88412.htm

here's another malpractice award involving a desi doc--$19M.

Yes. I was exaggerating for effect. There are some 180s and 160s out there and that, my friend, is nothing to sneeze at.

I guess my point was that in addition to the feelings of fear, apprehension and embarassment a patient feels the last thing he should have to worry about is human integrity... Integrity of the insurance companies, center administrators, providers and most of all the GD nurse who should have know better.

Any medical professional that deliberately reused a needle on another person and also knew there are life-threatening diseases that pass from shared needles, should be put in prison just like a murderer and for every life they have harmed, the time increased.

And for all you absolutely insensitive boobs who believe, "oh it's not so terrible having HiV and Hep C," you must but OUT OF YOUR MIND! To even say such a thing is horrible much less infer it on the www.

I have Hep C thanks to the medical community giving it to me. I have spent the first 20 years of my adulthood tiring too easily and the last 8 years incredibly sick. Enduring doctor after doctor failing me and then the unethical doctor, who professes to be a Hep C expert, deliberately withholding medicine from me to protect her HMO corporate goals. I was too naive to think there are criminal doctors but it's true. Sin is an equal opportunity inevitability.

I hope it's possible that some of this is ignorance of how this needle can spread disease, but my intelligence says nope to that hope.

My experience has taught me that there is much that needs to improve in the practice of medicine. I have a very good suggestion on how to help the Hep C doctors due a better job of qualifying the danger there patient is in but I am not optimistic that I can penetrate the arrogance of the elitist system. I am open to rebuttle on my pessimism and forgive me if I am being unfairly harsh.

To all the victums of this tragedy, I am so happy you have each other for support and too fight this injustice and I pray there is fierce punishment if negligence is absolute.

regardless of if there death sentences they are still disease and infections that could have been prevented and ruined peoples lives... 1 question how would you feel if you had it and the possibilities of giving it to other people and your children you should really think before you say "They are not death sentences" because who wants to be sick or take medication for the rest of your life because a doctor which we trust with our lives was careless!!!