The news reports of Joan Rivers' death appear to place blame and raise lots of questions.
Here's my take on what went on based on the available public information from news reports and speaking with anesthesiologists and gastroenterologists...here's an inside look at the likely sequence of events that occurred in Joan Rivers tragic and untimely death...
Here are the facts that are publicly available:
- Joan Rivers went to have an endoscopy done
- The endoscopy was to be performed by a gastroenterologist
- It was to be performed at an endoscopy Center on the upper East side of New York City
- (We don't know the precise reason why the endoscopy was being performed-that has not been made public)
- After the gastroenterologist finished his portion of the endoscopy, he allowed an ear nose and throat doctor, Joan Rivers' personal ENT, to perform a surgical procedure while under anesthesia.
- This ENT had no privileges to perform any procedure at this endoscopy Center.
- Joan Rivers was NOT intubated for this endoscopy.
- The ENT decided to obtain biopsies of growths, known as polyps, on her vocal cords.
- According to news reports, Joan Rivers never gave consent for such a biopsy to be performed.
COMMON RISKS OF VOCAL CORD BIOPSY...
One of the common risks associated with obtaining a vocal cord biopsy is that the vocal chords will now swell or go into spasm. That is known as a laryngospasm. When that happens, it becomes extremely difficult to keep the airway open. Literally, what happens is that the airway and the tissue surrounding the airway become very swollen.
We know that during an endoscopy, the patient receives IV sedation, almost always administered by an anesthesiologist. The anesthesiologist is supposed to be monitoring the patient's vital signs as well as her oxygen saturation level.
During an endoscopy procedure where light sedation is used by intravenous methods, the patient is never intubated.
What that means is that now if a doctor attempts to obtain a biopsy from the vocal cords and the tissue surrounding the vocal cords swell, it will prevent air from traveling through from the mouth/nose into and out of her lungs. That passageway becomes blocked.
Working with an unprotected airway
That's what happens when you do not have a protected airway or a tube that is already inserted in anticipation that this can occur.
Where the doctors are working with an unprotected airway, if they fail to recognize that swelling and spasm of the vocal cords can cut off the patient's airway, that may be a violation from the basic standard of medical care. Even though an argument could be raised that an endoscopy Center might have the available surgical tools to intubate a patient, it's highly unlikely that you will find many patients being intubated for the purposes of an endoscopy in an endoscopy center.
I have talked with various medical experts and here's what they said...
Speaking with various anesthesiologists and gastroenterologists, they point out the following key findings from the available news reports:
(1) The gastroenterologist permitted and allowed a doctor who was unaffiliated with this endoscopy center to come in and be present during the endoscopy procedure.
(2) The gastroenterologist permitted and allowed this same uncredentialed ear nose and throat doctor to perform a surgical procedure when she in fact was not credentialed at this facility.
(3) The ear nose and throat doctor failed to take into account that she was working with an unprotected airway and that there was a very likely chance that if biopsies were obtained, the patient would experience swelling and laryngospasm.
(4) Once the patient's airway was cut off, in all likelihood, the ear nose and throat doctor who performed the biopsy would not recognize that there was a diminished or decreased amount of oxygen getting through to the patient's brain. Instead, it would be the responsibility of the anesthesiologist to recognize that the patient's oxygen saturation level decreased tremendously and that her respirations were labored and rapid.
(5) If there is delay in recognizing that the patient is not getting sufficient oxygen, that is a medical emergency.
(6) Once the anesthesiologist recognizes that he's got a medical emergency on his hands, the next step is to establish and secure an airway in order to prevent the patient from going into respiratory arrest.
(7) The anesthesiologists I spoke to told me that this becomes a nightmare scenario specifically because once the airway is now closed off it becomes difficult if not impossible to then try and get a tube down the patient's throat to open up her airway.
(8) If attempts to intubate the patient are unsuccessful, then the next question is why wasn't a tracheotomy performed? A tracheotomy is an emergency surgical procedure done to establish an immediate opening in the patient's trachea in her throat. That would allow her to get air into her lungs. It's often messy and done under extreme emergency circumstances where the patient is either choking or their throat has closed up.
(9) The endoscopy Center has issued statements saying that they are fully credentialed as an endoscopy facility and have all the available emergency equipment and crash cart equipment necessary for medical emergencies.
(10) If true, that raises the question about why an immediate emergency tracheotomy was not performed. An anesthesiologist should be able to perform this procedure without problem. There is nothing in the news reports to indicate that anyone considered or actually performed an emergency tracheotomy.
(11) Even if an emergency tracheotomy had been performed, the question becomes how much time had elapsed where Joan Rivers was receiving a diminished amount of room air into her lungs and whether she had already experienced significant brain damage.
(12) In a patient whose throat has closed off because of swelling and spasm, you can give the patient as much oxygen as you want by facemask, but if that oxygen is not getting down into her throat and into her lungs, it means that her brain is being deprived of oxygen. That can and will lead to cardiac arrest.
(13) Lack of oxygen is described by doctors as “Hypoxia.” If there is a total cutoff of oxygen going to the brain, then the doctors use a medical term known as “Anoxia.”
(14) We do know from the news reports that Joan Rivers was in cardiac arrest and transported to Mount Sinai Hospital via ambulance. She remained in a comatose state for approximately 8 days before her daughter finally removed her from life support and she tragically died.
Again, if we look critically just from what is available publicly the sequence of events are:
An otherwise healthy patient went in for a diagnostic look down her throat into her stomach to see what if anything was going on. After the look-see was done, the gastroenterologist performing the procedure allowed an ear nose and throat doctor to remove polyps on Joans' vocal cords.
Since Joans' airway was not protected, and the ENT apparently did not anticipate vocal chord swelling, the vocal cords and surrounding tissues went into spasm. Now they were faced with an emergency situation where they could not gain access to an airway causing the patient to go into respiratory arrest and then cardiac arrest.
As a result of a prolonged lack of oxygen, Joan suffered significant brain damage. After eight days being on life support, she died.
Why do I share this with you?
Why do I take you through this timeline? Because Joan's untimely and tragic death has been in the news a lot and many people wanted to know how this could occur to an otherwise healthy patient.
I've received a number of inquiries from people who wanted to understand how a medical malpractice lawsuit works as well as how a wrongful death lawsuit worked and I thought I would share this information with you to give you an insider's look at what happens when an attorney begins to evaluate a tragic case like this.
Because Joan Rivers was a prominent celebrity, there has been an intense look at the events surrounding her medical care as well as an immediate investigation done by the New York State Department of health-which by the way is highly unusual. Normally an investigation by the New York State Department of Health takes months to get up off the ground and to proceed forward.
It's my guess that because of Joan Rivers celebrity and intense curiosity by the public about what happened, that the New York State Department of Health decided to investigate immediately to make sure that other patients were not at risk of a similar thing happening.
Obviously, as more details emerge the timeline of events may clarify some of the unknown questions that have been raised.