“Twilight! She has to have twilight,” insisted the adult daughter of my frail, 85-year-old patient. “She can’t have general anesthesia. She hasn’t been cleared for general anesthesia!”
We were in the preoperative area of my hospital, where my patient – brightly alert, with a colorful headband and bright red lipstick – was about to undergo surgery. Her skin had broken down on both legs due to poor circulation in her veins, and she needed skin grafts to cover the open wounds. She had a long list of cardiac and other health problems.
This would be a painful procedure, and there would be no way to numb the areas well enough to do the surgery under local anesthesia alone. My job was to figure out the best combination of anesthesia medications to get her safely through her surgery. Her daughter was convinced that a little sedation would be enough. I wasn’t so sure.
“Were you asleep the last time your doctor worked on your legs?” I asked the patient. “Oh, yes,” she said. “Completely asleep.”
“But she didn’t have general,” the daughter interrupted. “She just had twilight.”
New York Post reporter Susan Edelman revealed on January 4 the name of the unfortunate anesthesiologist allegedly present on August 28 at Yorkville Endoscopy, during the throat procedure that led to the death of comedian Joan Rivers. She is reported to be Renuka Reddy Bankulla, MD, 47, a board-certified anesthesiologist from New Rochelle, NY.
Having her name made public will be a nightmare for Dr. Bankulla, as investigators will certainly target her role in Ms. Rivers’ sedation and the management — or mismanagement — of her resuscitation.
When the news of Ms. Rivers’ cardiac arrest and transfer to Mt. Sinai Hospital became public, many of us guessed that there might have been no qualified anesthesia practitioner — either anesthesiologist or nurse anesthetist — present during the case. The gastroenterologist and then medical director of the clinic, Dr. Lawrence Cohen, argued famously that the sedative propofol, which Ms. Rivers received, could be safely given by a registered nurse under his supervision, and that no anesthesiologist is necessary.
However, with the publication of the Centers for Medicare & Medicaid Services (CMS) report of September 5, it became clear that an anesthesiologist was definitely present. The anesthesiologist was identified only as “Staff #2″ in the report. She was interviewed by the CMS surveyors four days after the event, but said she was “advised by her legal representative not to discuss the case.”
Key pieces of information about what happened still haven’t been made public. Nonetheless, the surveyors gathered enough information to reach this conclusion: “The physicians in charge of the care of the patient failed to identify deteriorating vital signs and provide timely intervention during the procedure.”
By any standard of care, the anesthesiologist clearly would be one of the physicians in charge.
With a physician who is an expert in airway anatomy at her side, and all the technologic advantages of a modern clinic in Manhattan’s upper east side, the 81-year-old Ms. Rivers must have anticipated an uneventful procedure. Instead, she stopped breathing and suffered cardiac arrest. The question remains: What went wrong?
In fairness, the credentialing process at a hospital or ambulatory surgery center (ASC) simply reviews documentation that the physician is qualified to perform procedures, and grants the physician privileges to practice there. Physicians choose where they want to work, and don’t necessarily maintain privileges at more than one hospital or ASC. A lack of privileges doesn’t imply a lack of experience or training; it simply means that the physician hasn’t gone through credentialing steps at that facility.
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.
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.
The Wall Street Journal recently contacted me regarding an upcoming article on Sedasys, the new gadget that is supposed to be able to infuse propofol by computer while monitoring vital signs.
If you’ve read anything I’ve written previously, you’ll know that I am NOT a big proponent of technology as a means of “improving” patient care. To me, the more technology you put between the patient and the caregiver, the less medicine you’re practicing, and the more data-entry and computer programming you’re doing.
Sedasys is designed specifically to administer propofol. Propofol is a milk-like substance that produces a range of effects from sedation to general anesthesia. For sedation you just use less, for general anesthesia you use more. Its very quick onset and very quick recovery make it great for outpatient sedation. It has to be given in a continuous drip because its effect goes away so fast. GI docs love it because its so effective. I suspect they also love it because propofol comes with an anesthesiologist to give it.
The only problem is the one Michael Jackson encountered: it has this pesky side effect of causing you to stop breathing. And you can’t tell by looking at a person how much will sedate them and how much will make them stop breathing.
A little old lady with a million health problems might sedate at, say, 40 mg and stop breathing at 60 mg, while an 19-year-old could probably take 150 mg and still be fighting you. It’s not necessarily weight-based.
It has been over two years and the tragedy of Michael Jackson’s death has finally been laid to rest. The verdict of accidental manslaughter highlights how dangerous medications of any kind can be. A couple of years ago I wrote about the events surrounding Michael Jackson’s death and tried to look at why Dr. Conrad Murray was being tried for manslaughter rather than some other charge like murder. I also took a look at what happened and how.
Now that the verdict is in, it looks like Dylan Schaffer was right and the verdict does match what we knew publicly. There are a great many lessons that can be learned from the whole saga, but the biggest one is that people really need to try to understand what the medications prescribed for them do, why they should and should not take them and most importantly, really know what the right dosages are. And please do not be fooled by the fact that the drug in question is a rare and powerful one that requires prescription and careful administration.
It is all too easy to die from taking simple over the counter medications in the wrong amounts and at the wrong time. And mixing and matching medications and other substances makes things worse. Probably the easiest way to get yourself in trouble with medications is something like getting a headache and the flu, taking a heavy dose of paracetamol, then a couple of stiff drinks and a big slug of something like Nyquil. Suddenly you are getting awfully close to liver damage or death.