THCB

Anesthesiologist’s Review of the Facts in the Joan Rivers Case

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Since the death of comedian and talk-show host Joan Rivers, more information has surfaced about the events on the morning of August 28 at Yorkville Endoscopy. But key questions remain unanswered.

News accounts agree that Ms. Rivers sought medical advice because her famous voice was becoming increasingly raspy. This could be caused by a polyp or tumor on the vocal cords, or by acid reflux irritating the throat, among other possible causes.

So Ms. Rivers underwent an endoscopy by Dr. Lawrence B. Cohen, a prominent gastroenterologist, to evaluate her esophagus and stomach for signs of acid reflux. At the same time, a specialist in diseases of the ear, nose, and throat (ENT) reportedly examined her vocal cords (also known as vocal folds).

We don’t know exactly how much or what type of sedation Ms. Rivers’ may have received, though several news sources have reported that she was given propofol, the sedative associated with the death of Michael Jackson. No physician who specializes in anesthesiology has been identified on the team taking care of Ms. Rivers, and we don’t know who was in charge of giving her propofol.

It seems clear that at some point during Ms. Rivers’ endoscopy and vocal cord examination, there was a critical lack of oxygen in her bloodstream.

Was laryngospasm the cause?

Giving sedation for upper endoscopy is tricky, as any anesthesia practitioner will tell you. A large black endoscope takes up space in the mouth and may obstruct breathing. Any sedative will tend to blunt the patient’s normal drive to breathe. But most patients breathe well enough during the procedure, and go home with no complaints other than a mild sore throat.

News reports have speculated that the root cause of Ms. Rivers’ rapid deterioration during the procedure could have been laryngospasm. This term means literally that the larynx, or voice box, goes into spasm, and the vocal cords snap completely shut. No air can enter, and of course the oxygen in the bloodstream is rapidly used up.

The most common situation that leads to laryngospasm is irritation of the vocal cords. Everyone knows that when a drop of liquid or a crumb of food goes down the wrong way, it’s highly irritating and provokes a fit of coughing. When the vocal cords are stimulated or even lightly touched, their natural protective response is to close up.

Every anesthesiologist is taught how to manage laryngospasm, because it can be a life-threatening emergency leading to brain damage or death if the patient is deprived of oxygen for too long. Sometimes the vocal cords relax and open up on their own, but often they don’t.

The appropriate treatment depends on the exact type of airway problem that is happening. Partial airway closure (inspiratory stridor) should improve after gentle positive pressure ventilation with a bag and mask.

True laryngospasm, though, won’t respond to simple bag-mask ventilation. In fact, positive pressure may make it worse. Positive pressure actually increases the anatomic ball-valve obstruction in the patient’s throat during laryngospasm. This scientific fact has been known for decades, though I fear that it’s often forgotten or underestimated.

The quickest and most reliable way to treat true laryngospasm is to give a medication called succinylcholine. This immediately paralyzes all muscles and relaxes the larynx, so that the patient’s vocal cords open and the lungs can be ventilated.

“Our anesthesiologists monitor the patient continuously”

The public statement issued by Yorkville Endoscopy claims that an anesthesiologist evaluates each patient before any procedure, gives only light to moderate sedation, and stays with each patient throughout the procedure and into recovery.

If this statement is true, and a physician anesthesiologist was with Ms. Rivers, it seems hard to believe that laryngospasm wouldn’t have been promptly recognized and treated.

It may be, though, that the appropriate drugs and equipment to manage the situation weren’t immediately at hand. Some endoscopy suites decide not to buy an actual anesthesia machine for every location. Some ambulatory centers no longer stock succinylcholine because they rarely use it. And if you keep succinylcholine in stock, you also need a supply of the medications needed to treat malignant hyperthermia, a rare and potentially fatal condition that can result from receiving succinylcholine.

Some news sources have speculated that it may have been difficult to insert a breathing tube for Ms. Rivers after she stopped breathing on her own. That seems unlikely if anesthesiology and ENT physicians were present, as both are expert at airway intubation. In addition, Ms. Rivers had undergone multiple surgical procedures and anesthetics before. Jokes about all her plastic surgery operations were part of her stock-in-trade. If she had unusual anatomy that made her airway difficult to manage, this would surely have been known to her doctors.

ABC’s of life support: Airway, breathing, circulation

My best guess—and it is only a guess—about what happened to Ms. Rivers is a hypothetical scenario along these lines. She was undergoing an endoscopy and evaluation of her vocal cords under a light to moderate level of sedation. Irritation of her vocal cords caused coughing, and the level of oxygen in her bloodstream started to drop. More sedation might have been given to stop the coughing, and she might have stopped breathing completely. Or, if the vocal cord irritation got worse, she might have gone into complete laryngospasm.

The realization that a high-profile patient was in trouble would certainly have added to the stress of the team. We can easily imagine that staff members rushed to bring a crash cart with drugs and equipment to rescue her. But as the minutes ticked by, the oxygen level in Ms. Rivers’ bloodstream would have deteriorated quickly.

Eventually, if a patient’s oxygen level drops low enough, the heart can’t function properly. Abnormal heart beats start to occur, followed by ventricular fibrillation and cardiac arrest. Ms. Rivers was known to have suffered from arrhythmias in the past, and at the age of 81 she could easily have had underlying heart problems such as coronary artery disease or aortic stenosis. These would have made resuscitation even more difficult.

At some point, the rescue attempts succeeded and a breathing tube was placed. However, it was too late to prevent irreversible damage.

Dr. Cohen steps down

It was a surprise to learn that Dr. Cohen no longer heads Yorkville Endoscopy, and it would be easy to interpret his departure as a tacit admission of error. Dr. Cohen has been outspoken in his opinion that nurses may administer propofol sedation safely for endoscopy, and that anesthesiologists aren’t usually necessary.

Many anesthesiologists expected that it would be only a matter of time until gastroenterologists learned how easy it can be to run into serious complications with propofol.

My overwhelming feeling, though, is sympathy. A complication or a death in the operating room is a tragedy for everyone concerned. Physicians and staff members will feel the emotional after-effects for months, comparable to the post-traumatic shock of a major accident or combat experience.

Some good may come out of a full report on the August 28 events at Yorkville Endoscopy. We can learn how risky even simple procedures can be. It’s important to understand that the bare-bones supplies of drugs and equipment in many ambulatory centers won’t be enough sometimes, and that no anesthesia is minor. Sadly, nothing can bring Ms. Rivers back to her family and her legion of fans.

Dr. Karen Sibert practices anesthesiology in Los Angeles. She is a frequent contributor for THCB. She can be reached at editor@thehealthcareblog.com  She blogs at apennedpoint.com.

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rachel
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rachel

WOW! GETTING READY TO HAVE SURGERY, I WANTED TO KNOW ABOUT PROPOFOL. CAME ACROS THIS CONVERSATION, AND IT MAKE ME SCARED. YOU GUYS ARE MEDICALAND YOU CAN NOT AGREE. NOW I AM SCARED TO BE PUT TO SLEEP.

Nadia CRNA
Guest
Nadia CRNA

Good point Judy.

judy
Guest
judy

The incident brings to light the inherent dangers of sedation outside the hospital setting. An upper GI series should only be performed in a hospital where adequate resources would have been available.
Over 30 years ago, as a teenager, I opted to have all 4 impacted wisdom teeth removed in the hospital. I did not feel the dentist nor his staff were experts at airway management, even though they insisted it would not be a problem to be sedated in a dentist’s office. Could any of those staff members perform an emergency tracheotomy? Doubtful.

Ron CRNA
Guest

Judy, Right on the button. When lecturing to student nurses regarding safe anesthesia always told them to NEVER go to sleep in a dental office. Know any dentist that could open a chest and massage a heart as a last resort? Even more doubtful. Reasons for having the dental procedure done in a dental office were always insurance coverage.

What cost a life lost? Have horror stories regarding dentists giving anesthesia after my 30 years at the head of the table.

Nadia CRNA
Guest
Nadia CRNA

Well said Ron CRNA. Where does fCRNA ‘Superior’ Anesthesiologist practices anesthesia? Let’s don’t work there! 🙂
The point remains:
Any anesthesia provider doing procedures at endoscopy centers ensure yourselves that the place is well equip and it follows acceptable standards…
Let’s keep our patients safe and let’s keep it cordial:)

FCRNAs
Guest
FCRNAs

Why did one conversation turn this into MD vs. CRnA? I love to read about CRNAs and their superior education to doctors and other practitioners. Did you know 30% of CRNAs have been grandfathered in and only hold a bachelors degree or less and practice anesthesia? I say we just stop every medical school in the country and just let nurses take over all of medicine. I realize that Putting in Foley catheters and wiping butts is a tough semester in nursing school, so I understand why you guys are the best option for anesthesia. Nursing school is so one… Read more »

Ron CRNA
Guest

Comments from fCRNA are only reinforcing what CRNA’s have been talking about for years. Hurling insults at Nurse ANESTHETISTS only adds to how MDA’s try to justify their so-called superior knowledge over CRNA’s, again unfounded, and always BS when study after study proves otherwise. Your insults prove your inferior intellect and as usual if you don’t know what else to do just hurl insults. Your neighbor who got into an ONLINE nursing school indicates that he/she COULDN’T get into an APPROVED school of nursing. He/She will NEVER get approved for any anesthesia program. Sorry you have such a problem with… Read more »

Robert
Guest
Robert

Well FCRNA your obvious disdain for nurse anesthetists leaves me wondering what we as a profession have done to warrant such a disparaging attack. Your rants demonstrate a complete lack of understanding of the world of medicine in general, but your disjointed ramblings about nurse anesthesia runs the gamut from an aloof flight of ideas to outright fabrication and heresy. You apparenlty are not secure enough in your criticisms to publish your statement with a legal name. I happen to be one of those 30% CRNAs grandfathered into practice, and I have no plans to pursue a doctorate. I would… Read more »

Deborah McClellan
Guest
Deborah McClellan

((((clapping))))

Karen Sibert MD
Guest

Please see today’s column for an update–it’s published both in The Health Care Blog and on my website:

apennedpoint.com

There’s no point in further discussion about who gave the sedation–that individual has been identified as Renuka Bankulla, MD.

gasser
Guest
gasser

ABSOLUTELY NO POINT IN BLAMING A CRNA AT ALL. CUZ IT WAS A BOARD CERTIFIED PHYSICIAN /MDA/Ollie…
when seconds count I want a CRNA THANK YOU VERY MUCH

خرید کریو
Guest

very good

Nadia CRNA
Guest
Nadia CRNA

Dr Drew just answered questions pertaining River’s case with diplomacy…
His #1 above is really the question to ask and then add: Really people, really?!!!
Drew #3 Sux has to be available… I think most of us MDA or CRNAs agree on that…

Drew
Guest
Drew

I am an MDA, and have worked along side CRNA’s for close to 30 years. The team approach has been shown to have the best outcomes. That being said, regarding this case, I cannot imagine a decent CRNA or MDA even breaking a sweat dealing with laryngospasm. Having read through the posts, I think anyone who provides anesthesia for a living must be asking the same questions: 1) Why on God’s green earth would anyone do anything to a vocal cord more invasive that just looking at it without an ET tube? 2) Was there an anesthesia provider ever really… Read more »

Deborah McClellan
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Deborah McClellan

Exactly!

Ronald CRNA
Guest

Last reply was to Rick Holmes not Nardia.

Nadia CRNA
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Nadia CRNA

Thanks Ronald! And i like your comment:)

Ronald CRNA
Guest

Like most uniformed you left out part of our title. We are nurse ANESTHETISTS. If you or anyone you know has had an anesthetic in the past it was 60% chance given by a CRNA Our training is in par with MD.s

Do the math. If you take the amount of surgeries given in this country and divide it by MD.s your going to have your surgery WITHOUT any anesthesia except local by your surgeon Try that with a chest or belly operation my friend. Wake up!!

Nadia CRNA
Guest
Nadia CRNA

Hi Rick Holmes: Let me clarify, we are not regular nurses! We are nurse anesthetists and we attend a master’s program in anesthesia… Most of us were top of the class students in our other degrees… I love my anesthesiologists and CRNA friends… I have worked independently and also under a Physician Anesthesiologist… I love both ways!
To all: Let’s continue to strive to provide safe anesthesia for all of our patients. We do this by continuing to study and research cases and also by being cordial to one another in the OR.

Independent CRNA
Guest
Independent CRNA

It was an MDA, don’t like the moniker? Get over it. Don’t like that we practice in 17 states without MD supervision? Get over it. And by all means please tell me the thing that you magically know about anesthesia that they won’t tell a CRNA. There are studies that show no difference in patient outcome between MDA and CRNA AND CRNAs are more cost effective. In closing, don’t me mad at me because I choose a different course that put me in the same position as you and lets move forward with the practice of this incredibly exciting and… Read more »

Rick Holmes
Guest
Rick Holmes

I don’t get it. There are places that let nurses give anesthesia without a doctor supervising them? I don’t care what anybody says, that can’t be safe. Why would anyone choose a nurse for such an important role? I respect what nurses do, but they never even went to medical school for crying out loud. Doctors are at the top of their class their whole lives, while a “C” student can get into nursing school. This discussion is a real eye opener. Next time I need surgery, I will be sure to ask who is putting me to sleep before… Read more »

Beckett Maxwell
Guest
Beckett Maxwell

Why an anesthesiologist would allow an ENT doctor to do two very stimulating direct laryngoscopies on a sedated, un-paralyzed patient, without protecting the airway with an endotracheal tube is beyond me. But what do I know, I’m just a highly trained Nurse Anesthetist. The ENT doctor may be an airway expert on awake patients, but anesthesia providers are the airway experts on patients who are asleep. She should have known better. That’s too bad.

Fairlogic
Guest
Fairlogic

Apparently, Joan Rivers specifically asked for a MDA (Physician Anesthesiologist) and she is dead now. I like this analogy better. My brother’s second surgey anesthesia was provided by a Doctorate level CRNA, better outcome than the first surgery which was provided by a MDA.

Ronald CRNA
Guest

Plus there’s no C student getting into nursing programs You really need to get informed if you’re going to comment on this kind of website.

Robert
Guest
Robert

Mr Holmes the facts in this case do not support your assertion that being anesthetized by a nurse anesthetist implies an inferior level of anesthetic care. There is only ONE standard of care regardless if you are being cared for by a nurse anesthetist, and anesthesiologist or both. Chances are pretty good that if you’ve been anesthetized in the United States in the past 100 years it is quite likely that you were cared for by a nurse anesthetist. Kel surprise you survived. Your knowledge and understanding of nurse anesthesia education not withstanding the provider in Ms Rivers’ case was… Read more »

Deborah McClellan
Guest
Deborah McClellan

Yes Rick Holmes. Make sure you have an anesthesiologist present by all means. Just like the one Ms. Rivers had. Educate yourself. CRNAs have been safely administering anesthesia in this country over 100 years. You are so very naive with your “doctors are at the top of their class their whole lives” comment. In med school Pass = MD

Beckett Maxwell
Guest
Beckett Maxwell

Why an anesthesiologist would allow an ENT doctor to do two very stimulating direct laryngoscopies on a sedated, un-paralyzed patient, without protecting the airway with an endotracheal tube is beyond me. But what do I know, I’m just a highly trained Nurse Anesthetist. The ENT doctor may be an airway expert on awake patients, but anesthesia providers are the airway experts on patients who are asleep. She should have known better. That’s too bad

Gasser
Guest
Gasser

Ummm it was a lady Anesthesiologist who was in the room and she gave conflicting amounts of PROPOFOL..
Too bad there wasn’t a CRNA in the room to ensure Ms Rivers was safe and alive.

Ronald CRNA
Guest

Ditto Gasser. Retired CRNA after thirty years. 1 death in Vietnam in 1967. He had all limbs and genitals blown off by land mine.

Would have intubated Joan in fifteen seconds when O2 sat started to dive. Her death we all know was incompetence by whomever was watching her airway. .She was performing on stage in good health the night before for Christ’s sake. If she wasn’t in good health what the hell was she doing in a store front endoscopy facility?

Hope her daughter sues the bastards!! They killed her!!

Karen Sibert
Guest

My best guess is that there was no anesthesia practitioner–physician or nurse–immediately involved in this case, otherwise a name would have become public by now. So this isn’t a political issue in terms of turf. Most likely laryngospasm wasn’t even the problem. The likely scenario IMHO is that Ms. Rivers became apneic, and it wasn’t noticed in time because everyone was focused on other things and the room lights were probably dimmed. She was slender, and it probably took tiime for her O2 sat to drop. By the time that happened, it wouldn’t have taken long at all for bradycardia… Read more »

Md gas passer
Guest
Md gas passer

Karen: I agree that I doubt there was any anesthesia personal in the room. The GI doc has published extensively about “Endoscopist-directed Administration of Propofol.” How do you like this title: Propfol for Endoscopic Sedation: A Protocol for Safe and Effective Administartion by the Gastroenterologist http://www.gastroenterologistnewyork.com/webdocuments/pubs-propofol-for-endoscopic-sedation.pdf He was also involved in the “Anesthesia Robot”-Computer Assisted Personalized Sedation Device http://www.gastroenterologistnewyork.com/webdocuments/article-computed-aided.pdf Is seems as if his life’s work was to prove a non-Anesthesiologist, either in the form of a GI doc or a “robot,” was just as safe as an Anesthesiologist when using Propofol and he now has finally realized what most… Read more »