Her uneasiness began when she walked though the door.
There was the standing room-only waiting room. There was the ground-in dirt on the floors and the "filthy chairs," Barbara Zufelt said.
There was the general discontent among the patients and the bickering, disorganized employees.
It all told her to get up, leave and never return to the Endoscopy Center of Southern Nevada.
"It was that gut feeling, like, 'Get out of here,'" the 64-year-old said.
After an employee showed her around the clinic and explained the procedure, Zufelt decided to stay.
"They convinced me that it was me. That I was anxious," she said.
She went through with the preventive colonoscopy and was surprised by how quickly it was over. But the experience felt more like a "cattle call" than a medical procedure, she said.
Behind the standing room-only waiting room and assembly-line procedures was a moneymaking mentality that frequently trumped patient care, some doctors -- including a witness in a malpractice case -- have said.
The profit motive led administrators to push the limits of the clinic's capacity, the doctors said, scheduling colonoscopies and other procedures as little as 15 minutes apart -- a time frame that can lead to rushed exams and missed diagnoses.
The penny-pinching also led administrators, mainly majority owner Dr. Dipak Desai, to order the reuse of syringes and single-use vials of sedatives on patients.
Both are substandard practices that triggered a hepatitis C outbreak and potentially exposed nearly 40,000 patients to life-threatening blood-borne diseases, health officials told a city of Las Vegas administrator.
Desai "had willfully chosen, until he was caught, to mortally hazard his patients for profit," Las Vegas business services director Jim DiFiore wrote in a letter suspending the clinic's business license.
Now, with a community questioning its medical professionals, health officials bracing for more infected patients and authorities digging for criminal evidence, a full accounting of the outbreak's cost has only just begun.
CROWDED WAITING ROOM
When Cecilia Avila walked into the Endoscopy Center the morning of Feb. 27, the announcement of a hepatitis C outbreak and public health investigation was just hours away.
The waiting room was "crowded, dark and dingy," and paper towels were strewn across the bathroom floor, the 72-year-old said.
As the 21/2-hour wait wore on, Avila grew more miserable.
"I had been fasting since midnight, so I was starting to get hungry. I couldn't drink anything. It was very uncomfortable, and it appeared as though everyone there was in the same predicament as me," said Avila, an executive assistant for the Nevada Health Care Association, a nonprofit organization representing long-term care facilities.
Avila said she asked the receptionist three times how much longer she would have to wait. Each time she was told, "It's going to be a little longer because we're short. The doctor is out on an emergency.' "
By the time Avila's procedure was done, the Southern Nevada Health District had announced the outbreak, the unsafe injection practices at the clinic and the largest patient notification of its kind in U.S. history.
PARTNERS SPLIT PROFITS
At the time of the announcement, Dr. Dipak Desai ran the Gastroenterology Center of Nevada, Southern Nevada's largest medical group specializing in disorders of the digestive system. The group's 14 doctors worked among six medical offices and two endoscopy centers in the valley and controlled 60 percent of the local business.
The doctors who owned the offices and their associated clinics, the Endoscopy Center of Southern Nevada and the Desert Shadow Endoscopy Center, split the profits based on their ownership stake, according to a deposition given by one of the clinic's owners, Dr. Clifford Carrol, in a medical malpractice case filed last year.
Desai, the majority owner, was the clinic's administrator. Drs. Vishvinder Sharma, Eladio Carrera and Carrol were also part owners.
Dr. Julian Lopez, a Las Vegas gastroenterologist unaffiliated with the troubled clinics, said the business made its money not by pinching pennies on syringes and other medical supplies, but by churning through a high patient load.
"The media keeps saying, 'Why would they be doing this to save a few pennies?'" he said. "They're missing the point. The point is to speed it up so that you could do more cases, because that's where the money is."
Demand for colonoscopies has grown steadily in the past decade, thanks in part to public education campaigns about the value of preventive colorectal cancer screening.
In 1997, 42 percent of Nevadans over age 50 had undergone a colonoscopy.
In 2006, that number was 55 percent, according to the U.S. Centers for Disease Control and Prevention.
By inserting the scope -- a camera mounted on a flexible tube -- into the 6- to 8-foot-long organ, doctors can spot polyps and remove them before they become cancerous tumors.
Colorectal cancer is the second leading killer among cancers, but it's also one of the most treatable, with a five-year survivability rate of 90 percent if caught early.
Desai and his fellow owners took advantage of the growing demand.
In March 2004, the Endoscopy Center of Southern Nevada expanded to two beds and doubled its capacity for procedures.
Two years later, Desai and Sharma opened a second clinic, the Desert Shadow Endoscopy Center at 4275 Burnham Ave. Health officials have linked six hepatitis C cases to the Endoscopy Center and strongly suspect a seventh case is linked to the Desert Shadow clinic.
To meet the demand, the Endoscopy Center scheduled colonoscopies and other procedures 15 minutes apart.
On a typical day, doctors performed between 50 and 60 procedures between the two rooms, Carrol said during his deposition.
Carrol testified he typically performed about 30 procedures a day, and he once did 50 in a day when a fellow doctor called in sick.
The clinic at one time used two doctors to cover the two procedure rooms, but by June 2007 administrators scheduled just one doctor for both rooms because it was more efficient, he testified.
In an expert opinion filed in the malpractice case against Carrol, a professor at the University of Southern California's school of medicine said the clinic's high-volume operation came with a price.
"While scheduling and performing so many procedures in a single day allows the physician to maximize his profit, it sacrifices quality patient care," Dr. Russell D. Yang wrote.
PATIENT NEVER SAW DOCTOR
During Abana Stephenson's three-hour wait at the Endoscopy Center, she noticed an odor, chipped paint on the walls, and dried blood dotting the floor.
She worried that the lack of cleanliness might go beyond the waiting room.
"We were crammed in there like sardines. There were at least 70 people waiting. Some were sitting down. Others were standing. There were even people standing outside in the hallway," the 43-year-old said. "I went up to the receptionist and said, 'Look at all these people. How can you assure me that the equipment will be clean for all of us?'"
Her question was ignored, she said.
As she was being prepped for her procedure, the hairstylist asked to talk to the doctor. A nurse told her he was unavailable.
Later, after her IV was in, she again asked to speak to the physician who would be doing the procedure.
"This nurse just stared at me,'' she said. "The next thing I know, I was waking up. The nurse said, 'You're done.' They put me out before I had the chance to speak to the doctor."
Speedy colonoscopies were Desai's specialty as far back as the early 1990s, when he worked at Valley Hospital, said Lopez, who worked with Desai at the time.
Desai often bragged about being "the fastest endoscopist in the country," Lopez said.
"He has been forever and a day talking about his two-minute colonoscopy skills," he said.
That speed didn't equal better care, according to Lopez and Wendy McMurray, a registered nurse who worked with both doctors between 1991 and 1992 as supervisor of Valley Hospital's gastroenterology lab.
"He (Desai) would go as far as he wanted to go (with the scope into the body), and then he would just yank the scope out," Lopez said. "I mean, you had to have a catcher's mitt to get the scope."
"Like a bull-whip," McMurray said as she made a whistling sound and whipped her right hand back.
"The first time I worked with him and he did this, I was appalled," said McMurray, who has also been one of Lopez's patients.
McMurray said Desai's exams were incomplete because he did not insert the thin, flexible scope through the entire colon.
Along with how far the scope is inserted into the colon, how long a doctor spends looking inside the organ largely determines the effectiveness of a colonoscopy, Lopez said.
He believes Desai, for competitive reasons, pressured nurses to fabricate complaints against him that resulted in his suspension from Valley Hospital. A spokeswoman for Valley said late Friday she could not comment on the suspension.
McMurray said she was approached by Desai when she was at Valley about making up a complaint about Lopez, but she refused.
Dr. Douglas B. Nelson, a gastroenterology expert at the Veterans Administration Medical Center in Minneapolis, said the standard length of a colonoscopy exam is the subject of research, with overall procedure times averaging between 15 and 30 minutes. But the most important part of the exam, the endoscope withdrawal, should be at least six minutes to adequately find and remove polyps, Nelson said.
Many clinics schedule endoscopic procedures every 30 minutes, Nelson said.
At Sunrise Hospital and Medical Center, colonoscopies are scheduled an hour apart.
At the Endoscopy Center, some colonoscopies appeared to have taken only a few minutes, according to a March 28 memo penned by Dr. Lawrence Sands, chief health officer for the Southern Nevada Health District, which was presented to the health district's board to update the investigation.
On Sept. 21, a day when at least five patients contracted hepatitis C, patient records show one colonoscopy lasted two minutes and another two lasted three minutes. And records from that day indicate that on four occasions the same doctor was performing two procedures at the same time, according to the memo.
"You must take at least six minutes of your exam time on the way out," Lopez said, citing industry standards. "And this guy clearly wasn't doing that."
Desai's lawyers did not return calls for comment.
FORMER PATIENT SUES
One former clinic patient, Kevin Rexford, believes the frenetic pace of procedures at the Endoscopy Center is killing him.
In his medical malpractice lawsuit against the clinic and Carrol, Rexford claims the doctor missed a tumor growing in his colon during a colonoscopy in January 2005.
Rexford, then 43, had a history of colon cancer in his family and was showing warning signs of the disease, including abdominal pain and blood in his stool, according to court documents.
After the colonoscopy, which lasted eight minutes including sedation, Carrol diagnosed Rexford with hemorrhoids and recommended the fiber supplement Citrucel, the documents said.
The symptoms continued, and after Rexford was hospitalized in December 2005 because of long-term blood loss, doctors found the cancer growing in his colon. By then it was incurable, court documents said.
"Due to the scheduling pressures and the desire to perform (as) many procedures as he could, Dr. Carrol sacrificed Kevin's chance for proper diagnosis and earlier detection of his cancer," Yang wrote in his expert opinion.
In an opinion written on Carrol's behalf, Dr. Bennett Roth of the University of California, Los Angeles school of medicine, said Carrol performed a complete colonoscopy and that the necessary time for a complete exam varies by patient.
Also, colonoscopies are not 100 percent accurate diagnostic procedures and can miss small lesions hidden in the folds of the colon, Roth wrote.
The case was settled last week. Terms were not disclosed.
"The discovery in the case revealed a medical center obsessed with profit at the expense of quality care," Rexford's lawyer, Dan Carvalho wrote in an e-mail to the Review-Journal. "Through the sworn testimony of employee-witnesses, it became apparent that the center was operated in 'mill-like' fashion with an exorbitant number of patients scheduled for endoscopic procedures in very short time frames."
Rexford's lawsuit also claims the clinic overbilled him for anesthesia. Although his procedure lasted eight minutes, he was billed for 31 minutes of anesthesia, the suit says. Anesthesia is generally billed in 15-minute blocks, so the clinic charged for three blocks instead of one, the lawsuit claims.
According to the memo by Sands, the health district chief, clinic nurses said during interviews with health district officials that they incorrectly recorded anesthesia times to boost billing.
Several staffers also told investigators the clinic reused single-use biopsy equipment on as many as three patients before throwing it away.
Clinic management denied reusing biopsy forceps, but business records showed the clinic in 2007 purchased only 6,200 biopsy forceps or polyp removal wires for the 7,800 biopsies and polyp removals performed there in 2007, according to the memo.
In addition, no purchases were made in 2007 before March 20, although more than 1,500 biopsies or polyp removals were performed in that time period.
The clinic's staff also reported reusing bite blocks, which hold the mouth open during endoscopies of the throat and stomach, according to the memo. One staff member reported that they were only allowed to use four bite blocks per day per procedure room, despite the number of procedures performed.
Purchasing records from 2007 showed the clinic bought approximately 2,000 bite blocks, while procedure logs showed the clinic performed 5,800 upper endoscopy procedures, according to the memo.
Health district spokeswoman Jennifer Sizemore said the possibility of equipment being on hand from previous orders was taken into consideration, but that there still would have been a reuse of equipment considering the volume of patients undergoing procedures.
Health investigators ruled out reuse of such equipment as the source of infections confirmed so far. Anesthesia was the common factor, not biopsies or bite blocks.
Nelson said, however, that doesn't mean that improper reuse of devices might not be implicated in yet-to-be discovered cases of transmission.
"Although the reuse of bite blocks, if sterilized, probably did not pose a significant risk, if they were labeled for single use and reprocessed, this would be contrary to FDA policy,'' he said.
Like the nearly 40,000 fellow clinic patients who visited the clinic between March 2004 and Jan. 11 of this year, Zufelt received a health district letter urging her to get tested for hepatitis and HIV.
Her initial test was negative.
The court clerk said she wishes she had trusted her gut and walked away, but she had always been taught to trust the medical profession.
Now Zufelt can't visit a medical office without wondering if the nurses and doctors are doing the right thing.
"You're taught you can put your life in their hands and they would take care of you as they would their wives or their children. But it's not true."
Review-Journal writer Lawrence Mower contributed to this report. Contact reporter Brian Haynes at firstname.lastname@example.org or 702-383-0281. Contact reporter Annette Wells at email@example.com or 702-383-0283.