Against the odds in Las Vegas

Socioeconomic factors

These were not isolated incidents of illness or injury for the city of Las Vegas, in Clark County, Nevada. The city has suffered more than most during the recession because of its dependence on casinos, just like the 8% of its residents who are compulsive gamblers. Las Vegas now has the highest suicide rate in the US.5 Before Obamacare, Nevada had the second highest proportion of patients without health insurance and the second lowest rate of public health funding ($41 (£26; $33) per person per year, less than half the national average of $95).6 Of the 50 US states and the District of Columbia, Nevada ranks 46th for the number of primary care physicians per person, 50th for psychiatrists, 51st for orthopaedic surgeons, and 50th for nurses.7 The only specialty with more doctors per patient than the US average is forensic medicine, which is useful, as the state has the highest rate of violent crime in the country. Las Vegas is also the largest metropolitan area in the US without a medical school, although it has an osteopathic school.

One doctor, Zubin Damania, said, “There’s a joke in town: where is it that most patients go for their complex medical care? The answer is McCarran [the airport].” He thinks that a perfect storm of factors has led to poor healthcare in Las Vegas: the lack of a big academic medical centre, an excess of for-profit hospitals, a perception that the city is only about vice, a large number of transient uninsured workers, and a lack of local investment in healthcare. Yet not all hope is lost for “Sin City.”

Damania is a fitting showman for Las Vegas, though he moved there only in 2012 after giving up his post at Stanford University. His alter ego, ZDoggMD, has been called the “jolliest doctor on the west coast” for parody rap videos about healthcare, viewed over 1.5 million times on Youtube. Now he works two blocks away from the Heart Attack Grill and has set up an innovative clinic called Turntable Health. Downtown residents pay a flat monthly fee ($80) to use it, much like a gym. They can attend the clinic for appointments within a working day or talk to a doctor at any time of day or night for no extra charge. In addition, he has set up free exercise classes, a studio kitchen with nutrition advice, and a team of life coaches to maintain healthy behaviours. Contrasting it with his previous work, Damania said, “When I’m paid fee for service, I’m incentivised to do a lot of unnecessary stuff and spend as little time as possible with each patient and try to see as many patients as possible. That’s a recipe for treating people when they’re sick. That’s sick care, not healthcare.”8

World’s “fight capital”

Unlike Damania, Charles Bernick moved to Las Vegas 20 years ago. He is a neurologist at the Cleveland Clinic’s Lou Ruvo Center for Brain Health, where Manny Pacquiao was examined after his concussion in the boxing ring. Bernick studies chronic traumatic encephalopathy, “the newest neurodegenerative disease,” also known as dementia pugilistica in boxers. He says that Las Vegas’s status as the “fight capital” of the world makes it a great place for such research.

He has set up the Professional Fighters Brain Health Study to follow current fighters, retired fighters, and matched controls over five years, by using neuroimaging, neuropsychometry, and plasma biomarkers. Baseline cross sectional analysis has already shown that the number of professional fights is correlated with volume reduction in two brain regions, the caudate and putamen, and decreased connectivity between regions—possibly seen six years before any clinical cognitive impairment.9 The American Medical Association, like the British Medical Association, has called for a ban on boxing, but in the meantime Bernick is seeing whether the sport can become safer by warning boxers when irreversible brain damage begins to occur.

Defibrillator success

Even casinos are saving lives after spearheading a major public health initiative: public access defibrillators. Back in 1995 a Las Vegas paramedic, Richard Hardman, realised that death rates from cardiac arrest were much higher in Clark County than neighbouring counties and that about two thirds of cardiac arrests occurred in casinos. Gamblers with cardiac arrests that happened in Vegas too often stayed in Vegas. He knew that paramedics were made to pull up discreetly by side entrances to casinos and then had to negotiate the casino floor. One paramedic said, “It all looks the same. You go up and down elevators, there are no direct routes, the carpets lead you around and around, you lose your sense of direction.”10

This is despite casino video cameras spotting most cardiac arrests and casino security guards arriving within seconds. So Hardman persuaded casinos to install automated external defibrillators and train security staff as part of a study. The results were published in a landmark paper in 2000: 53% of all witnessed ventricular fibrillation patients survived to discharge from hospital, with a mean time interval of 4.4 minutes to defibrillation, which is a better success rate than among people visiting US hospitals.11 12 Previously, paramedics in Las Vegas casinos had taken 10.7 minutes to perform defibrillation after a 911 call, with 29% surviving to discharge.13

More doctors—and not just at conferences

Survival to hospital discharge also requires doctors. To recruit them, there are now finally proposals to build both a public and a private medical school in Las Vegas. The hesitation has been about money. A medical school needs $30m in state support annually. Projections suggest that for every $1 invested Nevada would receive $12 from benefits to the local economy, but the state is reluctant to take a chance. The dean of the University of Nevada school of medicine argues that without a school in Las Vegas the city will find itself “woefully bereft of physicians.”14

Doctors do in fact often come to Las Vegas, but they do so for conferences. The lasvegascme.com website listed 32 medical meetings happening in September 2014 alone, from fetal echocardiography to food allergy. The reasons are obvious. There is a 24 hour airport receiving passengers from 150 cities and sending them to Las Vegas Boulevard, which has over 100 000 hotel rooms and some of the largest convention centres and resorts in the world. Conference attendance supposedly increases by a sixth when a conference rotates to Las Vegas from another city.

The utility of conferences is questioned by John Ioannidis, professor of health research and policy at Stanford University. He says that doctors leave behind substantial carbon footprints and mediocre research in abstracts, while they promote the perpetuation of opinion leaders and conflicts of interest involving industry.15

If more doctors stayed on to work in Las Vegas instead, then maybe the city’s luck would start to turn.