Joan Rivers patient safety
Joan Rivers - she made us laugh for years

It is often said that a death is meaningful if it serves as lessons for others to learn from and increase awareness so they “speak up” when found in a similar situation. So, what can be learned from the death of Joan River?

As reported by CNN, the facts surrounding the death of Ms. Rivers were as follows:

Comedian Joan Rivers lost her life after having an apparently minor elective procedure at a Manhattan medical clinic last week.

The routine surgery was on her throat, according to the New York Fire Department. She apparently suffered cardiac and respiratory arrest during the procedure at Yorkville Endoscopy. She was transferred by ambulance to Mount Sinai Hospital and died on Thursday…

Rivers’ autopsy was inconclusive, the medical examiner’s office said.

Although there are still many questions—the answers to which are not known or have not yet been made public, such as, what was the exact procedure that was being performed or whether a sedative, opioids, or anesthetic was given—here are 4 lessons learned from the death of Joan Rivers.

 

Four lessons learned

1. Even “minor” procedures can have major risks and “hidden harm”

The American Society of Anesthesiologists reminds us that although “anesthesia is safer than ever before, every person scheduled for a procedure or surgery must have a serious conversation with their physician anesthesiologist about their anesthesia care delivery plan ahead of time… Even ‘minor procedures’ are not risk-free.”

 

2. Ask questions to fully understand the medical procedure you are to undergo

Physicians must communicate and patients need to fully understand the full nature of the medical procedure. It is often helpful to have a family member, friend, or significant other with you to check if you asked all your questions and another set of “ears” to listen to what is being told or explained to you.

U.S. Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) believe “clinicians and patients [need] to engage in effective two-way communication to ensure safer care and better health outcomes.”

This type of patient engagement and education should be told to the patient, and then have the clinician ask for verbal or written feedback from the patient on the level of understanding. This is termed “readback feedback”.

AHRQ encourages patients to ask their medical providers questions as illustrated in this humorous video, which shows how patients ask many questions everywhere (such as in a restaurant) but not in the doctor’s office (please click on the image to view the video):

 

3. Make sure you are monitored electronically, with both pulse oximetry and capnography, if you are to receive sedation, opioids, or anesthesia

Even “routine” procedures may entail the use of a sedative, opioids, or anesthesia. The endoscopic procedure performed on Ms. Rivers, which would have likely involved insertion of a large scope into her mouth, is a simple and common procedure, but, as noted by Dr. Karen Siebert, “uncomfortable enough that most patients are given sedation or, less commonly, general anesthesia.”

The Anesthesia Patient Safety Foundation believes that clinically significant drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality.

Continually evaluating and monitoring respiratory and circulatory status prior to, during, and following the procedure is essential. As a recent video released by the APSF provides, continuous electronic monitoring of oxygenation (the adequacy of oxygen in the blood) with pulse oximetry and ventilation (adequacy of breathing) with capnography, when combined with traditional in-depth nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life-threatening, opioid-induced respiratory impairment and distress.

Virtually all proceduralists use pulse oximetry to measure blood oxygen levels. Assessing ventilation is another story. Being able to tell by simple observation if a patient is breathing adequately or not during a procedure can be tricky. Surprisingly, standards for capnography monitoring are not the same for all medical specialists. Anesthesiologists, the recognized experts in administering sedation and anesthesia, are required by the American Society of Anesthesiologists to measure the adequacy of ventilation using capnography (a device which measures exhaled carbon dioxide) to provide breath-by-breath monitoring. Other specialists, such as gastroenterologists and dentists, are not required to use this technology. Without capnography, several critical minutes can elapse after a patient stops breathing before medical professionals are alerted to the situation. Unfortunately, by this time, a serious problem, or even a cardiac arrest may occur.

 

4. Equipment and resources at an outpatient clinic may be different than at a hospital

If your procedure is scheduled at an “Outpatient Clinic”, be sure to ask about available emergency equipment at the clinic. Just because your procedure is scheduled in an outpatient type of clinic, do not take this lightly and ask about code cart availability, emergency drugs to manage your condition, and any adverse events and lastly trained clinicians available and knowledgeable about handling potential life threatening emergencies.

Exactly what procedure was performed and how that procedure was performed are facts that the public still does not know about the death of Joan Rivers. However, keeping these 4 simple points in mind could save the life of you or your loved one.

20 COMMENTS

  1. These are all very crucial points. But I am disturbed that your recommendations leave the safety measures up to the patient herself. Seriously, how am I supposed to “make sure” I’m monitored in the way you describe while under anesthesia? Sure, I can ask them if they will do this, but exactly how am I going to be monitoring this when I am UNCONSCIOUS? How can you place all the responsibility at the feet of the consumer? What about the medical providers themselves, to raise the standard and reduce complications proactively? I’m not saying we consumers do not have responsibility, but there is an end to what we can do, at some point, we place our lives and wellbeing in the hands of health professionals, at whose mercy we remain.

    • Stefani raises some excellent points. We wish there were some easy answers to these concerns. The goal of our article was to provide patients with information that would allow them to have a meaningful pre-procedure conversation with their providers that would clarify the quality of care that is to be provided. To your question, before the procedure, ask your physician how you will monitored when sedated – is oxygenation (the adequacy of oxygen in the blood) with pulse oximetry and ventilation (adequacy of breathing) with capnography going to be used? Ensuring safe care is certainly not the sole responsibility of the patient. In a perfect world, all providers would offer the safest, highest quality care. Until that happens, however, patients will need to be educated consumers in order to make the best choices for their continued healthcare and well being.

      Ken Rothfield, Lynn Razzano, and Michael Wong

  2. The following is from an endoscopy patient describing his recent experience with an outpatient clinic and anesthesia, published here with the hope that it might help someone:

    “The issues here [with the Joan Rivers death] are that insurance companies are making ‘outpatient procedures’ almost mandatory due to the expense of alternatives($100 or $300 vs $ 500 or $ 1000 on co-pays–depending on how good the insurance is). The medical profession around here [in Tampa] just buys into the ‘safety’ of these procedures without advising you of the risks vs. alternative measures. Some of this is innocent since they experience so many ‘safely done’ procedures gone well and statistics are in their favor, however, it is clear to me the fatality statistics go down dramatically when patients have such a procedure in a hospital where an experienced anesthesiologist and a better trained cardiac team is present. The anesthesiologist is actually the doctor who saved my life on the table when I had a need to be compressed 30 times after a heart stimulant drug was injected, in a resuscitation event. For all practical purposes, I was virtually dead for about 45 seconds! The technicality of the issue is related to the differences between GENERAL anesthesia and DEEP SEDATION anesthesia which I believe the public is just not well-versed. The first one is when your completely ‘out’ and have no motor functions (as close to actual death without dying you can be!) while the second is when you are still unconscious (usually having no recollection of what happened to you at all) but retain some motor functions, such as coughing, which is what I did. When I coughed with tubes down my throat, it drove water into my lungs, which stopped my breathing, which eventually stopped my heart! As far as I know, outpatient procedures are mainly (or totally?) performed under a form of SEDATION anesthesia. Joan’s [Rivers] experience was even more incredulous after I heard the dubious credentials of the outpatient facility she went to considering the amount of wealth she had. I assume that it was probably privacy she was concerned about considering that the paparazzi would be all over a public hospital. My opinion is to not have an endoscopy if it is just a preventative, ‘comfort zone’ diagnostic procedure with no connection to a symptomatic event you’re having. Otherwise, I wouldn’t avoid a procedure that is deemed helpful or necessary to evaluate a condition you may be experiencing or feel you may be at risk for. In that case, just DEMAND that you have it in a hospital or at an outpatient center immediately connected to a hospital (this was my case) where the personnel are trained, hospital staff and then pay the co-pay difference to be safer. BTW, the GI doctor who was performing the endoscopy during my mishap said he would NEVER try to do this again without it being a General Anesthesia event where I am COMPLETELY out and I’m intubated and have mechanical breathing present.”

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