The finding occurred during a time period when Nevada's ranking for serious discipline of doctors, meaning an action was taken against a physician's license, slipped from 33rd in the nation to 47th, according to a health advocacy group.

The Washington, D.C.-based Public Citizen does not consider the action taken against Ezeanolue to be serious, and thus it wasn't included in the rankings. Pappa's family has filed a lawsuit against Ezeanolue, and Pappa's brother, Erik, thinks Ezeanolue should no longer be practicing. But medical board members disagree that the punishment was light, saying it was appropriate under the circumstances and enough to get the Las Vegas physician's attention.

Dr. Sidney Wolfe, director of Public Citizen's health research group, said when a state shows low rates of actions against doctors, it means they're underdisciplining.

"This is not some random fluctuation," Wolfe said. "That's what people should worry about and ask their legislators to investigate. ... Whenever we see something like this, there are always reasons."

Alaska was the state most likely to take serious disciplinary measures against doctors with a rate of 7.30 actions per 1,000 physicians; Nevada's rate was 1.68 per 1,000 physicians. Serious actions include license restriction and probation as well as revocations, suspensions and surrenders of licenses. The national average was 3.18 serious disciplinary actions per 1,000 physicians, Public Citizen found.

But Drennan A. "Tony" Clark, executive director of the Nevada board, called the rankings "very misleading."

Protecting the public, he said, is "our No. 1 job."

Though Wolfe said the difference in the disciplinary rates of boards across the nation can stem from staffing and funding rates or whether a board is proactive in investigations, Clark believes his board has just those attributes: It's proactive and is adequately funded and staffed.

Clark said there are two main reasons for Nevada's latest ranking. One has to do with when the survey was taken. The latest numbers are compiled from the three-year period 2004-06. The previous rankings came from the 2001-03 period.

In 2004, he noted, the board lost traction when it lost its general counsel and changed executive directors, causing the board to take less than half the actions it did in both 2005 and 2006.

Clark also said board actions that allow the state to correct behavior without taking action against a physician's license are not recognized in the rankings.

Dr. Javaid Anwar, president of the Nevada board, agrees.

"There is no objective data to support the contention that the more doctors who have their licenses revoked, the better care will be," Anwar said. Directing a doctor to take further education or giving a physician a public reprimand can be just as effective as action against a license.

Seldom, Clark said, are malpractice complaints against physicians clear cut.

Those that are, he noted, can be promptly dealt with, often in emergency sessions.

In June, for instance, the board held an emergency meeting and summarily suspended the medical license of Las Vegas physician Dr. Harriston L. Bass Jr. Authorities allege Bass, whose murder trial is scheduled for later this year, sold prescription drugs illegally to a patient who overdosed and died in 2005.

Most malpractice complaints that come before the board are far less straightforward, Clark said, often involving dueling interpretations of what constitutes proper care. This, he said, makes revocation of a license difficult.

Ezeanolue's is one case, he said. In 2006 the board found him guilty of malpractice for failing "to use the reasonable care, skill or knowledge ordinarily used under similar circumstances."

Ezeanolue, who didn't return phone calls, is appealing the ruling. Ezeanolue's attorney, John Cotton, declined comment.

Medical board attorney Edward Cousineau said at a May 16, 2006, hearing that Ezeanolue failed to diagnose "a condition that could have easily been corrected and reversed by standard medical treatment."

Pappa was admitted to MountainView Hospital on Dec. 27, 2001; he died New Year's Day.

Dr. Philip Goodman, a Reno physician asked by the board to review a complaint against Ezeanolue, noted during proceedings by the medical board on May 16, 2006, that Ezeanolue made two diagnoses regarding Pappa: "One, abdominal pain, possible food poisoning. Two, new onset of diabetes mellitus."

Diabetes mellitus is a disorder in which blood sugar becomes high because the body fails to make enough insulin.

According to Goodman, Ezeanolue misdiagnosed Pappa. Results of his examination and lab tests, Goodman said, should have led Ezeanolue to a diagnosis of diabetic ketoacidosis, or DKA, a serious complication of diabetes mellitus that includes the buildup of substances called ketones in the blood.

Left untreated, DKA leads to coma and eventual death.

"He (Pappa) had unrecognized and untreated diabetic ketoacidosis for a period of at least two days, that eventually went into an irreversible multi-organ dysfunction syndrome and SIRS, which is systemic inflammatory response syndrome, that leads to a series of complications and death," Goodman said.

The case, Clark said, illustrates the challenges the board faces.

At the hearing and in court documents, Cotton, Ezeanolue's attorney, stressed that only one of the six physicians that Ezeanolue called in for a diagnosis as Pappa's condition worsened even mentioned DKA as a possible diagnosis. That physician, Dr. Elyiahu Rubin, did "not get a very clear examination" of Pappa because he saw him four days after he entered the hospital while he was "quite terminal," Cotton said.

Cotton also noted that one doctor who examined Pappa at the hospital, Dr. Joaquim Tavarez, wrote of his condition: "Doubt DKA is the main component."

An expert who testified before the board on Ezeanolue's behalf, Las Vegas physician Dr. Russell Neibaur, said Pappa died of a severe pancreatic condition. Four of the consultants called in by Ezeanolue on the case concluded Pappa had pancreatitis, Cotton said, citing their reports.

Brian Pappa's medical history shows he had been treated successfully for Hodgkin's lymphoma. He also had told MountainView emergency room physicians he had, in the past, consumed up to 20 beers per day, but had not had any alcohol for weeks.

"You can see why it's so difficult to come up with rulings when doctors can't even agree on what caused a death," Clark said.

Still, transcripts from a closed Sept. 15, 2006, board meeting show Pappa's diagnosis was discussed, and board president Anwar said Ezeanolue and his team of specialists "all missed it."

"To me, it was DKA the minute he walked into the emergency room, straightforward," Anwar said.

But Anwar said he has no quarrel with the discipline the board gave Ezeanolue. The public reprimand showed up in the board's winter 2007 newsletter. That newsletter, Clark said, is sent primarily to medical organizations and institutions.

"I am sure the action we have taken will protect the public," Anwar said. "It is the kind of action that makes a physician more careful."

Erik Pappa, a public information spokesman for Clark County, isn't sure the board's action protects the public.

"I'm not sure many people know what he (Ezeanolue) did, so I don't understand how the public is being protected," Pappa said.

On Sept. 19, 2006, the board's malpractice action against Ezeanolue was referenced in six lines of a three-page news release, which mentioned actions against five other doctors as well. No mention was made of where Ezeanolue practiced, the fact the patient died, or what specific malpractice was involved.

"We don't have time to write a 480-page press release," Clark said.

Erik Pappa finds it incredible that his brother's death wasn't mentioned in the release.

"If you're trying to protect the public, you can't attract the attention of the press by leaving out the most salient point," he said.