The death of Joan Rivers

The sudden passing of Joan Rivers during a routine outpatient procedure is tragic. While the events leading to her death have not been fully revealed, the information leaked or released is enough to draw some conclusions and learn from this terrible outcome. Formally reviewing cases in this manner typically takes place during morbidity and mortality (M&M) conferences, a tradition in the modern practice of medicine. The goal of these conferences is to learn from and change behaviors which led to complications or errors rather than to assign blame. Certainly we do not want to be critical of our colleagues who have the tremendous responsibility of caring for their patients daily, particularly since many facts are not known.

Within our specialty, the American Society of Anesthesiology (ASA) maintains a Closed Claims Database that collects information about adverse outcomes that may reveal systemic patterns of problems that, in isolation, would otherwise be difficult to discern.

What has been reported?

Ms. Rivers complained of acid reflux and worsening hoarseness. She visited Yorkville Endoscopy for an outpatient upper endoscopy, a procedure that uses a tube with a camera, to examine the upper portion of the gastrointestinal tract with her gastroenterologist, Dr. Lawrence Cohen. He invited Dr. Gwen Korovin, a private otolaryngologist to perform a laryngoscopy, a procedure using a similar instrument to visualize the vocal cords. Ms. Rivers developed a hypoxic cardiac arrest during the course of her treatment and then died the following week. It was later learned that Dr. Korovin did not have Ms. Rivers’ consent or privileges to work at the clinic.

What most likely happened?

The most likely cause of hypoxia, where the body is deprived of oxygen, is laryngospasm of the vocal cords. The vocal cords are exquisitely sensitive and easily irritated to prevent foreign matter from entering the lungs. In this case, saliva or touching the vocal cords with a scope can precipitate the closure of the vocal cords, or laryngospasm, and prevent air from entering the lungs and supplying the brain, heart, and other organs with oxygen.

Another cause is respiratory depression from administering increasing amounts of anesthetics, such as propofol—to keep a patient sedated or deeply asleep—opoids, and benzodiazepines.

What could have prevented this complication?

The treatment of the problem depends on the cause:

• Positive pressure ventilation with a manual resuscitation bag and face-mask or succinylcholine, a medication that can cause relaxation of the vocal cords, can restore a patent airway in the case of laryngospasm. Alternatively, the trachea can be intubated ahead of time to prevent laryngospasm during the procedure, but laryngospasm can also occur when the tube is removed at the end of the procedure.
• For respiratory depression, the patient could be supplemented with oxygen and airway devices or an antidote can be given for some of the medications to reverse their effects.

What does it mean that Dr. Korovin was not authorized to work in the clinic, even though she was invited to be present?

In order to work in a health care facility, the physician must have their medical credentials reviewed and be granted privileges to work at a center. The idea is to verify that an individual has the proper education, training, and experience. Additionally, the individual’s malpractice history should be reviewed to assess the ability of the health care practitioner to provide acceptable care.

What does it mean that Dr. Korovin did not have consent to perform the procedure?

Competent adult patients must give their physicians permission to perform a procedure on them through a formal process known as informed consent. In it, the physician is supposed to explain the risks, benefits, and alternatives of a procedure. While it is almost impossible to exhaustively discuss every possible risk, the discussion should include the most common and most serious complications such as heart attack, stroke, or death. The patient then must agree to the procedure. In the absence of it, the physician commits battery on the patient if a procedure is performed without proper consent. Patients of sound mind—that is to say they do not suffer from psychiatric disorders or effects of medications that impair judgment—have the right to refuse a procedure, even if it may be life-saving.

Is there any systematic method for ensuring that steps are not missed when a procedure is performed?

The World Health Organization has published a framework to ensure that the necessary steps are followed throughout a procedure.

Before induction of anesthesia

• Has the patient confirmed his/her identity, site, procedure, and consent?
• Is the site marked?
• Is the anesthesia machine and medication check complete?
• Is the pulse oximeter on the patient and functioning?
• Does the patient have a known allergy, difficult airway or aspiration risk, risk of >500ml blood loss (7ml/kg in children)?

Before skin incision

• Confirm all team members have introduced themselves by name and role.
• Confirm the patient’s name, procedure, and where the incision will be made.
• Has antibiotic prophylaxis been given within the last 60 minutes?

Anticipated Critical Events

To Surgeon:

• What are the critical or non-routine steps?
• How long will the case take?
• What is the anticipated blood loss?

To Anesthetist:

• Are there any patient-specific concerns?

To Nursing Team:

• Has sterility (including indicator results) been confirmed?
• Are there equipment issues or any concerns?
• Is essential imaging displayed?

Before patient leaves operating room

Nurse Verbally Confirms:

• The name of the procedure
• Completion of instrument, sponge and needle counts
• Specimen labelling (read specimen labels aloud, including patient name)
• Whether there are any equipment problems to be addressed

To Surgeon, Anesthetist and Nurse:

• What are the key concerns for recovery and management of this patient?

References
1. Barash P, Cullen B, Stoelting R, et al., eds. Clinical Anesthesia. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins.

2. Hartocollis, A. (9 September 2014). “Doctor Present at Joan Rivers’s Procedure Wasn’t Authorized at Clinic”. The New York Times. Retrieved at http://www.nytimes.com/2014/09/12/nyregion/doctor-present-at-joan-riverss-procedure-was-not-authorized-at-clinic.html on 9 October 2014.

3. Hartocollis, A. Goodman JD. (9 September 2014). “At Surgery Clinic, Rush to Save Joan Rivers’s Life”. The New York Times. Retrieved at http://www.nytimes.com/2014/09/10/nyregion/at-east-side-surgery-center-a-rush-to-save-joan-rivers.html?action=click&contentCollection=N.Y.%20%2F%20Region&module=RelatedCoverage&region=Marginalia&pgtype=article on 9 October 2014.

4. Miller RD, Eriksson LI, Fleisher L, et al., eds. Miller’s Anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone.

5. World Health Organization. 2009. Implementation manual WHO surgical safety checklist 2009Safe surgery saves lives. Geneva, Switzerland. Retrieved at http://whqlibdoc.who.int/publications/2009/9789241598590_eng.pdf on 15 October 2014.

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We are physician anesthesiologists (medical doctor / MD) who provide anesthesia to individuals with a phobia, fear, and anxiety for outpatient procedures in fields such as dermatology, plastic surgery, gastroenterology (upper gastrointestinal endoscopy, esophagogastroduodenoscopy, EGD, colonoscopy, otolaryngology (ear, nose, throat / ENT), and dentistry (deep cleaning, implant, all-on-four, root canal, and wisdom teeth extraction).

We provide various levels of anesthesia–from monitored anesthesia care (MAC) to general anesthesia. MAC is often used interchangeably with conscious sedation and twilight anesthesia. As it relates to dentistry, it is referred to as sleep dentistry, sedation dentistry, dental anesthesia, and intravenous, or IV, sedation.

We practice in Northern (Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, and Sonoma counties) and Southern (Los Angeles, Orange, San Bernardino, Riverside, Ventura, and San Diego counties) California.

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