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What Killed Joan Rivers? Piecing Together a Medical Mystery

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There are minor operations and procedures, but there are no minor anesthetics.  This could turn out to be the one lesson learned from the ongoing investigation into the death of comedian Joan Rivers.

Ms. Rivers’ funeral was held yesterday, September 7.  Like so many of her fans, I appreciated her quick wit as she entertained us for decades, poking fun at herself and skewering the fashion choices of the rich and famous.  She earned her success with hard work and keen intelligence–she was, after all, a Phi Beta Kappa graduate of Barnard College.  Ms. Rivers was still going strong at 81 when she walked into an outpatient center for what should have been a quick procedure.

So when she suffered cardiac arrest on August 28, and died a week later, we all wondered what happened.  I have no access to any inside information, and the only people who know are those who were present at the time.

But the facts as they’ve been reported in the press don’t fully make sense, and they raise a number of questions.

What procedure was done?

Early reports stated that Ms. Rivers underwent a procedure involving her vocal cords.  A close friend, Jay Redack, told reporters at the NY Post, “Her throat was bothering her for a long time. Her voice was getting more raspy, if that was possible.”  In a televised interview, Redack told CNN that Ms. Rivers was scheduled to undergo a procedure “on either her vocal cords or her throat.”

However, the Manhattan clinic where Ms. Rivers was treated, Yorkville Endoscopy, offers only procedures to diagnose problems of the digestive tract.  All the physicians listed on the staff are specialists in gastroenterology.  Any procedure on the vocal cords typically would be done by an otolaryngologist, who specializes in disorders of the ear, nose, and throat.

So it may be that acid reflux was considered as a possible cause of Ms. Rivers’ increasingly raspy voice, and she may have been scheduled for endoscopy at the Yorkville clinic to examine the lining of her esophagus and stomach.  Endoscopy could reveal signs of inflammation and support a diagnosis of acid reflux.

Upper gastrointestinal (GI) endoscopy involves insertion of a large scope through the patient’s mouth into the esophagus, and passage of the scope into the stomach and the beginning of the small intestine.  It’s a simple procedure, but uncomfortable enough that most patients are given sedation or, less commonly, general anesthesia.

Was sedation given?

Three types of medication are commonly used for sedation during endoscopy:

1.  Midazolam, diazepam (Valium), or other medications in the benzodiazepine family are often used to help patients relax before the start of the procedure and to produce amnesia.

2.  Narcotics such as Demerol and morphine are often used to provide pain relief and make the procedure less uncomfortable.

3.  Propofol, a potent sedative and hypnotic medication, may be used to induce sleep and prevent awareness.  Many people first heard of propofol as the medication associated with the death of singer Michael Jackson in 2009.

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