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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83 replies »

  1. 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.

  2. Where do you bring CRNA’s into this discussion, other than to make a political point. There is no evidence a CRNA was present. Stick to the facts an anesthesiologist was present. There was a bad outcome. Facts stick to the facts instead of trying to make political hay of something.

  3. 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

  4. So tyred dock, now that we know it was an anethesiologist at the helm it appears you have more donuts than dollars.

  5. 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 like to clarify a few things for you. Nursing education is not now and never has been considered a “medical education.” There are many paths to become a nurse. Your opinion of nurses not withstanding, the nursing profession has a long history of dedicated but thankless service to mankind. Physicians in general have no understanding of the nursing profession but are often the first in line to heap criticism and blame on the nurses caring for their patients.
    The average patient does not have a clue about the credentials of the person providing their anesthesia. They do not know the difference between a physican anesthesiologist and a nurse anesthetist. The question of who was first to practice anesthesia is widely documented in the history of the practice. It was dentists. As far as the safety of the practice I afraid much of the improvement in that area again falls to nonanesthesia providers. Safety improved as modes of monitoring the patient were developed and better drugs were developed. I am afraid to report that neither CRNAs nor anesthesiologists can claim much contribution to the development of either. It is hard to believe your report of nurse anesthetist “killing 90%” of their patients. I doubt nurse anesthetists would enjoy a 150 year history of respected service while killing off 90% of the patients under their care. They would have gone the way of the barbers as medical providers. As far as being arrogant and cocky I think we can both agree that the world of medicine is full of arrogant and cocky care givers. As for dirty politics and buying politicians, I am not sure either CRNAs nor MDs is in any position to point fingers. You are either not a member of either profession, or you are VERY new and perhaps in training. The fight between CRNAs and Anesthesiologists is basically about money and security. I have always believe there was enough of both for all of us. Neither profession benefits from these attacks, but if you are going to buy into them please by all means do it with some integrity. Get your facts straight or shut the fuck up. Your disjointed rantings and poor execution of basic english grammar and writing skills leave me wondering which nursing school rejected your application.

  6. 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.

  7. 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.

  8. 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:)

  9. 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 Doctor CRNA’s. But hold onto your ass my friend. It’s coming!!!

    Don’t even know why I reply to your asinine comments. Your ignorance speaks for itself!!

  10. 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 of the easiest and most basic medical education there is. You guys feel that by going to a PhD program that everyone is going to want you. We’ll wake up dr. Nurses, a PhD doesn’t make you better anesthetists, because it’s still nursing school. You saturate the market with thousands of incompetent practitioners every year. If it wasn’t your dirty politics and buying politicians, you would not have the power you do. I never understand how you guys say you were the first to practicie anesthesia from the beginning of time while killing 90% of the patients. It wasn’t until MDs came into the picture and actually made it a science. Your going to love this.. My neighbor just got into an online nursing school. The best part is that he didn’t graduate high school. They accept anyone and everyone who applies. He wants to be a CRNA too. This Joan rivers debacle got way off track, but as you already know from your comments you guys are arrogant and cocky. As a profession you guys need to be humbled by an outsider who knows a lot about anesthesia and training. good night and let the replies begin! Ready ,set ,go…..

  11. Ha! Anesthesiologists are THREATENED by CRNAs b/c CRNAs take their jobs! An AA must be supervised by an anesthesiologist. This all started when the anesthesiologists got lazy and someone got greedy. Same thing with primary care docs and NPs…now the NPs are opening clinics and taking their patients with them. IT’S ALL ABOUT GREED AND FEAR OF COMPETITION!

  12. Well, does it surprise you that an ANESTHESIOLOGIST was in charge of sedation? Who knows, she might still be alive if a CRNA had been in charge.

  13. 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

  14. 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.

  15. Dollars to donuts (sic) huh? So now from further reports it was an anesthesiologist there, guess your doughnuts were wrong, or maybe your dollars? Where’s your apology for professional slander? I would never wish this situation and outcome on ANY anesthesia provider, and I’m not in any way implying that this anesthesiologist was not competent. Unfortunately you, tyred dock, didn’t feel any qualms about accusing a CRNA of incompetency without even knowing who the provider was.

  16. Anesthesiologists are NOT liable for CRNAs’ mistakes, that is a matter of settled case precedent after case after case. Perhaps you are confused and thinking of Anesthesiologist Assistants? You ARE liable for any mistake they make, because they work only under YOUR license. But it’s understandable that you could be confused, after all, the A$A insists it is the same. But perhaps you will do your own investigation of evidence and case law, you sound like a smart enough person.

  17. No you are wrong. No CRNA was present. Just an md anesthesiologist. Don’t tell me she must have been ‘a difficult airway’ at least 50 providers had been there before. This isn’t CRNA vs MD. This is incompetence. In my mixed CRNA and MD practice all the MD’s were speculating this was CRNA. They talked very loudly for about 5 minutes. Now they say nothing. Shit happens. This is a dangerous profession with the only thing between life and death is training and judgement.

  18. How did you segue from this horrible tragedy to a diatribe about nurse anesthetists. Multiple studies on multiple anesthesia practice models have repeatedly come to the same conclusion. The anesthesia care team practice model is much safer than either anesthesia professional practicing alone. Imagine this tyred dock, and I do not expect an honest response. I’m assuming you are a general surgeon, but it if not the message is still the same. You have a case you want to do tomorrow afternoon. We’ll keep it simple, and say that it is a laparoscopic cholecystectomy. You want to know when you can do your case, so you called the holding area to ask for an estimated start time. The charge nurse tells you that you are number five on the list of add on cases, and it will be a few hours before an anesthesiologist is available to put your patient to sleep. However, we have a CRNA that can start your case immediately. You, me and every CRNA and anesthesiologist in practice knows how you will most likely respond. “Hell yeah send for the patient; I’m leaving my office right now.” Here is how it proceeds. Your history and physical which is on the chart documents a patient assessment by system. Every system is negative until you get to the GI system whereby you extensively detail your workup of the patient’s cholecystitis. In the preanesthesia assessment performed by the CRNA it turns out that the patient has a documented history of CAD having suffered two MIs that were treated with multiple PCI stent placements and an angioplasty a month ago. The patient is still on plavix and ASA, but has missed the past five days due to his nausea and vomiting and you never ordered it for him on your admission orders. All of which you discover during a phone conversation with the CRNA who is concerned that the patient is in very real danger of developing an instent stenosis and suffering another MI. Your response to the CRNA on the phone is something like this. I don’t give a damn he has to have his gallbladder out now. Take him to the room, and I’ll be there in 5 minutes. Upon arrival to the holding area the patient is anxious and in pain. Suddenly he complains of incredible chest tightness just like he had with his heart attacks. You see where I’m headed with this all too familiar scenario. The nurse anesthetists that you so thoughtlessly disparaged with impunity is now helping you fix your fuck up. You call cardiology to come see the patient immediately. The patient gets Reopro immediately which stops his chest pain. He goes to the CCU for two days. He returns to operating room on day three to undergo an uneventful lap cholecystectomy which you now insist must be done by an anesthesiologist. You never thank the CRNA for his/her efforts to help you care for YOUR patient. Then you decide to respond to a blog about the tragic intraopertive death of comedic icon, Joan Rivers’. In a GOD LIKE declaration from a surgeon no less you publicly bash an entire medical specialty with particular attention and effort to place blame on those wicked nurse anesthetists. With absolutely not a shread of evidence and no public discussion of a CRNA participating in the care of Joan Rivers’, you can sum it up for America. “The CRNA did it, and the lazy ass anesthesiologist was no where to be found.” Of course in your universe, the surgeon saves the day.

  19. Pseudocholinesterase deficiency is more prevalent in segments of the Jewish population most notably in the Persian and Iraqi origins. I would hope that the administration of succinylcholine would be closely followed by efforts to secure an airway or at the very least some kind of ventilatory support. When I hear hoofbeats, I usally think of horses not zebras. I suppose anything is possible.

  20. Hey Doc who are you kidding here. These corporations are usually owned by anesthesiologists. I am certain that your corporation would gladly pay you the salary they offer to their nurse anesthetists and allow you to have your own room sans supervisory responsibilities. The number of rooms you are permitted to supervise is regulated by multiple stakeholders. We both know your “uber-group” has no say about the maximum number of anesthetizing locations you can legally supervise and bill for your services. You really do sound miserable. May I suggest you take a trip to Thailand and get that vagina created since you’ve obviously already suffered an apparent orchiectomy. Stop whining!!

  21. 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 infact a board certified anesthesiologist. Like you it was her wish that only a doctor provide her anesthesia. Do not take my word for it just read the report released by the New York state agency reviewing the facility following this tragedy. You may not understand all the jargon, but the message is clear.

  22. Nadia I think you’re missing the point. No amount of preparation would have prevented this tragedy. This level of arrogance, ignorance and incompetence will always prove to be a lethal cocktail. These clowns could not respond to something they did not recognize as a problem. Finally when they did recognize the arrythmia, ventricular tachycardia with a pulse per the state’s report, it was so grossly mismanaged that it further delayed a return to spontanous circulation. She and her heart had to have been in fairly good health for her to endure and successfully stave off so many attempts to kill her. It was not simply a failure to prepare that proved lethal to Joan. It was according to New York’s definition, murder. The unlawful killing of another human being with malice aforethought. Malice aforethought in this instance refers to a level of intent or RECKLESSNESS.

  23. Dittos Robert!!!

    After thirty years at the head of the table myself, great to see another ball bearing CRNA not afraid to say it like it is. Seems like Joan Rivers tragic death has turned into a forum to let folks know that CRNAs are here to stay and that the MDA’s don’t have the market cornered on providing competent care to patients.Wonder how their attitudes will change after 2025 when all CRNA programs will be at Doctorate level.

    Now retired blame the AANA for not letting people know we exist. The most closely guarded secret in the medical world. They need to do a much better job at coming out of the closet with who we are. Less meetings and more action.

    Kudos to you Robert.

  24. You guys I’ve been a CRNA for 26 years. I”ve saved an anesthesiologist’s ass about as many times as one has had to save mine in all these years. The ones I’ve been fortunate enough to work with were sincerely greatful to have me in the operating room with them. It was about the patient not our egos. This sounds like a star struck bunch of idiots who happen to be physicians that could not find their own asses with both hands. Problem number one is as physicians you guys have this miss guided notion that the rules do not apply to you. There has NEVER been any mention of a nurse anesthetist being involved in the debacle that resulted in the death of Ms. Rivers’. I am sure this was exceptionally disappointing news for the American Society of Anesthesiologist’s membership. About as disappointing as the fact that it has also reported that an anesthesiologist working for pop star Michael Jackson was the first to administer bedtime propofol infusions as a medical treatment for his chronic insomnia. I guess that is one use of propofol they only teach you anesthesiologists in anesthesia residency.
    As anesthesia professionals we all know that the lack of a time out, the lack of a surgical consent, the lack of weighing Ms. Rivers’ that morning, the snapping of a selfie during the procedure,the lack of documented credentials for the visiting physician staff, nor lack of labeling on a specimen had much to do with what caused Joan Rivers’ death. For all intents and purposes there was no preanesthetic assessment. I believe the propofol dosages are more than likely correct as documented. The story of a propofol documentation error was likely concocted to deflect attention away from what was undoubtedly a fatal oversedation and a desire avoid professional opprobrium. Which we all know anesthesiologists possess in abundance. If no other sedatives were administered namely midazolam and/or fentanyl, and the anesthetic was propofol alone as reported. It very unlikely Ms. Rivers’ would have tolerated the introduction of a laryngoscope blade into her airway after the administration of just 50mg of propofol. She would have coughed and gagged violently. She also very likely physically resisted by reaching or moving around on the table. The documented vital signs do not support a light level of sedation anesthesia. The documented vital signs, if they are to be believed at all, are more much more consistent with an anesthetic overdose scenario. The first dose,propofol 100mg, while being a relatively large dose for age and weight particularly if other agents had been administered would be adequate to induce a state of general anesthesia. This would explain the lack blood pressure and pulse rate response. Direct laryngoscopy which is plainly described in the detailed report of the facility is classically considered to be a potent physiologic stressor for any patient. It results in elevated levels for blood pressure, heart rate, as well as workload on the heart at a time when it may be experiencing lower oxygen delivery. The body responds to this intense physiologic stress by releasing potent stress hormones and catecholamines. Despite this relative anesthetic overdose it is likely that the patient would still have a cough reflex and possibly gag. The vocal cords would spasm in response to being manipulated resulting in a closed airway known as a laryngospam. This is particularly plausible since we know that Joan Rivers’ came to the clinic complaining of hoarseness that was thought to be secondary to chronic acid aspiration. It is also conceivable that she regurgitated some residual stomach contents and suffered a pulmonary aspiration which should have been a particular concern in this particular situation. So we have given this 81 year old lady that weighs about 50 kilograms and induction dose of propofol. The ENT physician attempts to do a laryngoscopy but is met with a resistant patient who is moving around and coughing. The anesthesiologists quickly administers a second 100mg dose of propofol at a time when there is an abrupt decrease in the procedural stimulation. Many patients tolerate a simple EGD with topical anesthetic alone or in combination with minimal levels of sedation. Now you have a profoundly oversedated patient who is not able to maintain her own bodily functions which goes unrecognized and therefore unaided. The result is a patient which has limited breathing ability and is oxgenating poorly. Her cardiovascular system which has been severely depressed by the anesthetic agent. She suffers further assault as her bodies oxygen levels drop. Her carbon dioxide levels would climb to higher levels also due to the depressant effects of the anesthetic drugs on her ventilartory capability. This would have caused an acid/base disturbance from two differenct sources resulting in a serum acidosis. All this is going on and she is given yet another two doses of propofol. Finally her heart is overwhelmed resulting in the development of an arrythmia in this case ventricular tachycardia albeit reportedly with a detectable pulse. A very treatable, if recognized, arrythmia which to great surprise is treated inappropriately. Ms Rivers’ arrythmia is grossly mismanaged by the administration of medications which would actually worsen the arrythmia. She should have been cardioverted immediately with synchronized cardioverson. Manually ventilated to correct her acid/base and ensuing electrolyte disturbance. And you guys have the unmidigated effrontery to turn this medical debacle into a discussion about your selfish, self serving interprofessional battles with CRNAs. Can you even see the irony in this mess? In a blog which essentially presents a case of a comedic icon dying at the hands of one of your anesthesiologist peers. A surgical procedure and anesthetic so poorly executed that calling it negligence belies the incredible dereliction of your sworn oath of primum non nocere. I would go so far as to describe this as second degree murder. Joan Rivers’ would have been the first to say, “fuck you all.”

  25. 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…

  26. 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 present – despite the reports?

    3) Isn’t anyone who presides over this type of airway manipulation w/o sux in their pocket is in the wrong business.

    4) Is Yorkville hiring?

  27. 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.

  28. 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!!

  29. 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!!

  30. Here we go again with the CRNA VS MDA BS!!

    Too bad that MD.s can’t accept the fact that in many, many cases a CRNA will outperform MDA’s

    After thirty years of practicing as a CRNA could describe volumes of times having to bail out incompetent MDA’s.

    Would love to be around after 2025 when all CRNA’s will have PhD programs.

    As usual any chance to downgrade CRNA by MDA’s with the inability to admit CRNA’s are extremely capable anesthesia providers. We really don’t have to take a back seat to any MDA’s.

    Studies by ASA to try and downgrade CRNA’s as second rate providers have ALWAYS failed.

  31. 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.

  32. You are such a scumbag for spreading your non-sense propaganda. The wrongful death of Joan Rivers is simply the failure of the Medical Team and the MDA to take action and to provide a simple airway by any means. As far as anesthesia outcomes, the appalling disaster that led to the death of a person is and will be in the MDA’s hall of shame. Go and practice medicine and let anesthesia providers do what they have been doing without your needless supervision for over 100 years. Please………..

  33. 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.

  34. 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

  35. 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.

  36. 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 hand!

  37. Interesting to read that Anesthesiologists do not like supervising CRNAs for the sake of patient safety but they currently support AAs (anesthesia assistants) whose training is not to the standards of the AANA(Amer. Assoc of Nurse Anesthetist). Is there a double standard here.

  38. Dr. Cohen wrote extensively about the safety of gastroenterologist-directed-propofol administration. Bet neither a CRNA. or anesthesiologist was present or surely they would have been named and blamed instantly. Payback is a b÷+€£, huh Dr. Cohen?

  39. 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 stimulating job we have.

  40. 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.

  41. 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 anesthesia providers know: Propofol is not a drug to be messed around with unless you are VERY comfortable handing airway emergencies. There is a reason why the package insert says Propofol should only be used by a person “trained” in General Anesthesia. Although I have no idea what the exact details are that led to Joan Rivers unfortunate outcome, one of the scariest cases I ever had with an airway problem had to go with probable unrecognized laryngospasm, in a patient in the prone jackknife position,(so it was very difficult to assess the patient’s airway) and also where the patient was obese and had sleep apnea. I regularly provide anesthesia in the outpatient setting, some of which involves endoscopies and patients try to laryngospasm on me everyday. If I had to guess as to what happened to Ms. Rivers, with the limited info I have, I’d put my money on laryngospasm.

  42. 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 and asystole to follow. Laryngospasm is an acute event that probably would have been recognized more promptly. Most likely, anesthesia support was called for the code, but not before.

    Speaking personally, I do not draw up succinylcholine for every case, but it is always in the top drawer of the anesthesia cart. You can probably get a patient’s vocal cords to relax sufficiently with a combination of IV propofol and lidocaine if that’s what you have readily at hand. The key is to recognize laryngospasm and manage it BEFORE the O2 sat goes too low and/or negative pressure pulmonary edema occurs if the patient is struggling to breathe against a closed glottis. True laryngospasm is not going to respond to positive pressure alone, though inspiratory stridor may.

  43. This center did NOT employ crna’s for this upscale clientele.
    It was the perception that a DOCTOR would be superior.
    Stop spreading lies and using this terrible tragedy to advance your greedy selfish political agenda.

  44. They don’t employ crna’s……
    Stop using this terrible tragedy to advance your political agenda.

  45. I absolutely agree. All of the facts of this case should be known. If for no other reason, it can be a teachable moment for everyone.

  46. This center did not employ ANY “physician extenders”. If there was a provider there it would be a DOCTOR ANESTHESIOLOGIST responsible for this AIRWAY disaster. A simple minor case case on a 100 pound patient.
    Stop trying to blame the crna’s and using this tragedy to advance your political agenda. It is truly inappropriate and Tacky!!! DOCTOR!!!!

  47. FYI. Yorkville did not employ ANY CRNA’s. In addition, Ms. rivers is on record in saying that she wanted a DOCTOR to give her anesthesia.
    So we know it was NOT a Crna and if there was an anesthesia provider in attendance it would be an ANESTHESIOLOGIST. Kindly stop implying that the provider was a nurse!!! This was a terrible tragedy, and so sad that it happened on such a simple procedure on a patient who was about 100 pounds. Stop trying to blame the crna and put the blame for this AIRWAY disaster where it belongs.

  48. If you’re going to correct initials, it’s actually TJC (The Joint Commission); they changed their name from JCAHO in 2007

  49. Endoscopy procedures are not to be taken lightly… I’m a new practitioner and I always have an LMA, ETT and laryngoscope ready to go for every single case… Takes 5 minutes to be prepared for a day at the endoscopy lab… A sux syringe is on top of my airway set-up… That’s the standard of most nurse anesthetists and I’m sure most anesthesiologists… We need to use this tragic event as a lesson in never practicing in surgery centers without proper back-up… We want to do what’s best for our patients and safety is always our primary concern.

  50. Right you are. It appears to be a case of a doctor or doctors caught up with being a doctor to the stars. If a celebrity asks for inappropriate scheduling of surgical procedures, you just have to resist.

  51. Nice article. If anyone does a Google search of the GI doc, Laurence Cohen and endoscopist given Propofol anesthesia, you will see that he published a good deal on this subject, so I doubt a Crna or an Anesthesiologist was present. What I have not heard mentioned at all is that in the state of New York, it is well known that the medical insurers will not pay for anesthesia for endoscopes ( EGD and colonoscopies). So what about the fact that the cheapo insurers, by virtue of this policy, pressure doctors and patients to use other providers of anesthesia. They helped to create the whole mess. I practice on a state close to New York and a few of our insurers have tried to do the same (Aetna) but thankfully came to their senses days before the policy was to start.

  52. Excellent explanation Dr. Sibert.

    It’s hard for me to understand how Ms. Rivers could not be rescued with an anesthesiologist or CRNA was present. Possible certainly, but laryngospasm is Anesthesia 101.
    I can only surmise that for some insane reason, the Gastroenterologist or a RN was administering Propofol.

  53. This is a better link for my article
    https://medium.com/@MdGotham/the-intersection-of-greed-and-medicine-1726b017facb
    I think Dr Sibert did a much better job than I did. But I wanted to be provocative and since there aren’t many facts known I wanted to speculate and start a dialogue and lift the veil of silence in this case! This should be a teaching moment for the country and not a legal stonewall and wall of silence. I hope the NY State investigation is thorough, transparent, public and clear in assigning appropriate blame to all involved physicians in this fiasco. This episode, in my mind, is a direct result of putting greed and arrogance ahead of patient safety and good medicine.

  54. What is an “MDA”? Is it like an MDO (MD orthopedist) or MDGS (MD General surgeon)? What school do you go to to get an MDA degree? And more importantly, are osteopathic physicians “DOA”?

    If some are unable to use the appropriate nomenclature, perhaps they should desist from posting. Free speech is free speech, but MDA is insulting.

  55. If there was an anesthesia provider , MDA or CRNA, don’t you think they would have been blamed by now? Everyone wants to blame anesthesia for everything, when this appears to be a cascade of bad judgements on many levels. Maybe she went into flash pulmonary edema after laryngospasm. I doubt they employ CRNAs …the clientele would only want an MDA. I don’t think there was an anesthesia provider in the room.

  56. Anesthesia doc, you stated it quite well. As anesthesiologists, we are “assigned” to cover too many extenders by $$-minded groups. You are so right about the rise of these uber-groups. They thrive upon maximizing the number of extenders (nurse anesthtists) a given MD.is made to supervise, as the corporation can bill more that way. The individual MD, often or usually on a set salary, does not generally benefit from this, but the corp does. And the corp usually winds up kissing surgical ass over attending to patient safety. I have worked as an employee for such a group. The good old days of doing your own cases without overextension by nonphysicians “providers” are sadly over…

  57. I agree with you that it is very cavalier to leave a CRNA to his/her own devices, but you can’t blame the majority of anesthesiologists. We are controlled by corporate medicine now. I would prefer that we don’t use CRNA’s at all. I would much prefer to just do my own surgeries and only have to worry about 1 patient at a time. I think this goes for the vast majority of anesthesiologists. Things are much different now then they were back when I started. Our goups are now owned by MBA’s, who only see dollars and cents. These giant anesthesia groups take over entire areas at a time, like locusts, so you don’t even have a choice but to work for them. If they haven’t taken over your area yet, just wait, because they are coming. If you are a surgeon, consider yourself lucky that private, independent practice is always going to be an option for you. I would gladly take a cut in pay to work for myself, and take care of my own patients, but that is not even an option for me unless I move. And even then, it will only be temporary until they infest my new location and take away all the hospital contracts. I love the days when I am assigned to cover a room by myself and loath the days I am assigned to cover CRNA’s. And don’t forget, we are held liable for their mistakes, you have to worry about an anesthesiologist that is not on top of his CRNA’s. But then there are also times when you have emergencies, so you can’t cover them as well as you would like.

  58. dollars to donuts this was a CRNA at the helm with the anesthesia MD not in the room. Anesthesia is a poorly structured service accross this nation. I am an MD and a Surgeon and I KNOW. The anesthesia MD’s are not available except when things get hairy. The CRNA’s are very good, dont get me wrong, but the “game” unfortunately is for the MD’s to “oversee” and bill for multiple cases that they barely participate in. Anesthesia MD’s are notorious for this widespread structural problem in medicine today. They are among the highest paid, laziest, most cavalier, medical entrepreneurs ever. The physician extender model is deeply flawed, most of us in medicine know it.

  59. Obviously at that center the anesthesiologist role was minimized and probably kicked out by GI doctor who naively think that anesthesiologist should not be always present during this minor sedation procedure. Anesthesiologist job is to protect airway. Their propaganda that propofol can be safely given without anesthesiologist is only driven by poor greed and money that they obtain by doing such unprofessional services. It is sad day for US healthcare.

  60. Please don’t speak at all if you don’t know what you’re talking about. Pseudocholinesterase deficiency didn’t kill her. We don’t yet know if EMS or a provider at the facility intubated her. And there’s no such thing as JACO. If you’re referring to the joint commission its JCAHO

  61. As many surgeries that Joan Rivers presumably had, I am sure the providers would be aware if she had a pseudocholinesterase deficiency. Also curious if the providers bill anesthesia under MAC or General???

  62. They may have used succinylcholine but about 4% of people have inherited or acquired deficiencies in pseudocholinesterase which begins to degrade the drug in a few minutes. They can then get diaphragmatic paralysis and become anoxic therefrom before suitable aeration can occur.

  63. I hope ASA puts pressure on this kind of practices and JACO revises their policies and make sure any places even they say it is light sadation ,that has to be treated as a gen.Aneshesia as anything can go wrong from light sedation and patient devoloping allergic reactions to Lidocaine spray specially on airway or accidental intravasular injection of large amount of local aneshetics with Epi causing severe arrythmia.All these factors makes patient at high risk even though actual procedure may be very simple,as it is explained to patients in Drs offices

  64. Great article, much appreciated. I too am a retired anesthesiologist with extensive experience with both airway and office based endoscopy procedures. This tragic case illustrates many problems, some of which are already discussed. I always was upfront about depth of sedation/ anesthesia. This procedure can not be performed under sedation (unless the airway is treated with local anesthetics, too time consuming usually). An improper consent is a violation of patient rights. I would expect this procedure to be performed with a syringe of succinylcholine prepared in advance. Cost containment may have affected the outcome here, as Dantroline would be required to be present, and it is very expensive, and almost never used! Anesthesia machines are expensive as are preventive maintenance of them. It will be interesting to see if the clinic here met even any standards for such equipment. Sad and tragic as the outcome here is, I hope that NY state will tighten regs for such freestanding clinics.

  65. When will we find out if there was an anesthesia provider at all?

    When will we find out if there was Sux available or not?

    When will we find out if she had a vocal cord biopsy under improper anesthetic technique?

    If Joan Rivers is not safe from this level of shitty care, then who is?

    The government cannot protect us…

    If there was no anesthetic provider, and there was improper availability of rescue medicines and airway equipment, and there was an unconsented procedure done in an unsafe way, I hope Melissa sues the SHIT out of them and wins!

  66. Dr.Sibert
    Many times endoscopist drs do not even discuss with patients about aneshesia and its complications.many patients also do not ask any questions regardind Aneshesia which plays most important role in any procedures performed under aneshesia.I cannot even believe any nurse administering propofol and team of aneshesia and ENT who is airway management expert is hard to beleve they could not even perform emergency cricothyrotomy or emergency tracheostomy and if they did not have proper difficult airway cart when they are doing procedures specially where airway is concerned and aneshesia machine.We are not in some third world country.Patients safety has become secondary issue in most of the surgicenters.Also performing two procedures where there is already airway is irritated from one procedure ,puts patient at more risk of Laryngeal spasm.I have seen one case performed at one surgery center for biopsy of laryngeal tumor where that patient also died .I was in another room ,but could not leave my patient .It also good learning expierence when surgeon tells it is small polyp we are just look at it ,but some times these polyps have grown deep inward and they cannot see that in routine office examinations.I learned my lesson from coupe of such cases that first do awake laryngoscopy either using regular laryngoscope or video assisted laryngoscpoe and asses your airway first before administering any aneshetic agents.This is my personal coclusion.i am retired for 5trs now so things may have changed I hope so ,but in big city like NY this is happening then you can imagine what is conditions in border town surgery centers

  67. Steve–I’m glad that you did stick to your principles. I rarely use succinylcholine, and certainly don’t draw it up for every case. But I always make sure it’s in the drawer and immediately available. There is still no other muscle relaxant that works as fast, and nothing else that can treat laryngospasm so easily.

    The other problem with outpatient centers is that the physicians and staff there get too used to dealing only with simple cases and relatively healthy patients. When a true crisis arises, it may be way too long since they have dealt with a critically ill patient. Emergency medications in a refrigerator, and emergency equipment in a crash cart or a storeroom–not accessible enough when you really need them NOW.

  68. We don’t know the details, but to me it suggests one of the inherent problems with a surgicenter. It truly places the profit motive and the needs of the patient in opposition. You are correct, unfortunately, that some surgicenters doing endoscopies do not stock succinylcholine (sux) as a means of saving money. When we opened a new GI center last year they brought in a person to run it who had managed another GI center. She told us we didn’t need sux since they didn’t have at it where she came from. We refused to work there until we had the drug available. We risked losing that contract by standing on our principles. The thing is that we knew there is always someone waiting in the wings who would have worked under those conditions.

  69. A sage attending once warned me- “Special medicine will give you special problems”. In this case, the ‘special medicine’ is trying to perform two procedures at once to accommodate a VIP. Thanks for the explanation…

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