According to the medical examiner's report, here is why Joan Rivers died...
"Anoxic encephalopathy due to hypoxic arrest during laryngoscopy and upper gastrointestinal endoscopy with propofol sedation for evaluation of voice changes and gastroesophageal reflux disease."
"...an autopsy was not performed on Joan Rivers at the instruction of the family and in accordance with Jewish law. Instead, the report was based on a noninvasive physical examination and a thorough review of her charts from Yorkville Endoscopy, where she was undergoing her procedure, as well as her medical history."
Some definitions first will help explain these findings:
Anoxia is a lack of oxygen.
Hypoxia is a decreased amount of oxygen.
Ischemia is a decreased blood flow.
Encephalopathy is essentially brain damage.
Laryngoscopy and upper GI endoscopy are procedures done using fiberoptic tools with a camera that is used to visualize her throat, her voiceobox and the tube that leads down to the stomach and in many cases, into the stomach.
When someone is deprived of oxygen, the brain will suffer injury. If the patient is not getting oxygen for a significant amount of time, in terms of minutes, it’s likely the patient will suffer irreparable brain injury.
A decreased amount of oxygen or a lack of oxygen going to the brain can result in both respiratory arrest and cardiac arrest.
If the patient’s lack of oxygen is significant, it can result in permanent brain injury causing the patient to go into a coma. If the injury is irreparable, the patient may experience brain death.
If brain death occurs, they will likely be kept alive only by artificial means; a respirator.
What does this have to do with Joan Rivers and her recent death?
The answer is everything.
Last month Joan Rivers had an endoscopy, which is an internal examination of her mouth, trachea, larynx and her stomach. A gastroenterologist does the exam with a fiberoptic tube and a camera attached to the tip.
Joan Rivers had this procedure under a local anesthesia known as propofol. It’s considered light sedation and is administered via an IV.
News reports suggest that Joan’s ear nose and throat doctor was also present, even though she didn’t have privileges and was not licensed to be at the endoscopy center or do any hands-on procedures. Those same news reports suggest that the ENT (an otolaryngologist) performed an unplanned biopsy of a polyp (a growth) on Joan’s vocal cords.
What’s not discussed in the news reports is that if you perform a biopsy on an unprotected airway, you run the risk that the patient will suffer a spasm of the vocal cords and the surrounding tissues. Swelling can occur and cut off the flow of oxygen down her airway.
If an anesthesiologist recognizes what has happened, there are medications available to try and break that spasm.
One medication used by anesthesiologists to break this type of spasm is succinylcholine.
It’s unclear from the news reports when and if an anesthesiologist was present. Also unclear is when an emergency with Joan’s airway was detected. Never discussed is if any doctor or anesthesiologist used succinylcholine to try and break the vocal cord spasm.
If you plan on doing a vocal cord biopsy, most anesthesiologists will have the patient intubated in order to protect the patient’s airway. This way, if the vocal cords go into spasm and become swollen, there is already a tube in place to prevent the airway from closing.
We also know from news reports that Joan was taken via ambulance to Mount Sinai hospital in cardiac arrest and she remained in a coma from the time she arrived at the hospital until her untimely death eight days later.
Interestingly, there were also news reports that indicated an autopsy would be performed to determine the precise cause of her death.
Yet, today, October 16, 2014, the medical examiner indicated that no actual autopsy was done because of Joan’s religious beliefs.
In the Jewish religion, we believe that a person’s body should not be desecrated after death. There are exceptions. One is if the death was due to a criminal act. The other is if there is some overriding medical concern that would allow the family to go forward with a clinical examination of her body after she died.
An autopsy is done by a doctor known as a pathologist. The entire purpose of an autopsy is to determine the cause of death.
What I find most remarkable and unusual in this entire scenario is that if the family, for religious reasons, chooses not to have an autopsy, then there is no reason whatsoever for the medical examiner to do anything.
Yet, the news reports today indicate that the medical examiner evaluated Joan’s medical records from the endoscopy center. Based upon only their review of her medical records and only an external examination, they determined that she died as a result of ischemic encephalopathy due to anoxia.
As discussed earlier, that means Joan Rivers experienced a lack of oxygen during her endoscopy procedure. The lack of oxygen caused significant injury to Joan’s brain.
As a direct result of significant lack of oxygen, she suffered permanent and irreversible brain damage.
Also, the news reports indicated the death was from ‘therapeutic complications’. That’s medical examiner speak indicating that the death happened while she was have some type of medical therapy. It does not indicate that there was wrongdoing or that the doctors or endoscopy facility departed from the basic standards of medical care.
The medical examiner’s ‘conclusion’ that this was a ‘therapeutic complication’ does not specifically help the family in reaching the conclusion that something was done wrong.
Getting back to the ‘autopsy’ that was never done...if there is no clinical internal examination of a person’s body after their death, then there is no way to definitively identify the precise cause of death.
However, based on the diagnosis of hypoxic ischemic encephalopathy or anoxic encephalopathy, you can work backwards and figure out how she suffered the lack of oxygen, the decreased oxygen in her blood stream and the permanent brain injury leading to her unfortunate and untimely passing.
But with all this talk about how Joan died, I keep coming back to this basic question and it has to do with conscious pain and suffering...
We know that Joan was sedated for this endoscopy. That means that she was not awake and aware of what was happening. If she went into cardiac and respiratory arrest during the endoscopy then again, she never awoke from the procedure.
Then, if she remained in a coma, attached to a respirator for the entire 8 day duration to the point where she was unconscious and unaware of what was happening, the family, should they choose to bring a wrongful death lawsuit, will have a significant challenge.
What’s the challenge?
In NY, in a wrongful death case arising out of medical malpractice, one of most important parts of such as case is the pain and suffering that the injured victim suffered before their death.
However, New York courts have held that in order to claim pain and suffering on behalf of the injured victim, we have to be able to show that the patient was conscious and aware of what was happening to them.
The theory is that if they were not conscious and aware, how then could the surviving family realistically claim that they experienced pain and endured some type of suffering before they died?
To get around this challenging issue, really smart attorneys will scour the medical record, especially the nurse’s notes, for evidence that might show that Joan had some level of conscious awareness.
What exactly does ‘some level of conscious awareness’ really mean?
It means that a patient who was moaning, was found to have some level of consciousness to justify a claim of pain and suffering. It means that in some cases, if a patient responds to touch or to a family member’s voice, that could mean there is some level of conscious awareness.
If Joan remained in a coma for the entire hospital stay, it would be important to know what the neurological testing revealed to determine if there was some cortical brain activity. Did she have deep tendon reflexes? Did she blink when her eye was touched?
Did she respond to any painful stimuli?
Was an EEG (electroencephalogram) done? An EEG is done to evaluate brain activity. We don’t know since Joan’s medical records have not been released.
In this type of wrongful death lawsuit, the defense will undoubtedly argue that if there were any findings of Joan responding to some stimuli that it was only reflexive and not truly indicative of a conscious level of awareness.
Remember, even if the defense acknowledges that they did something wrong, they will always argue that the value of her injuries and untimely death is certainly not what the family believes it is.
So what does a surviving family have to show in this circumstance like the one involving Joan Rivers?
In order to be successful, the surviving family must show that they are more likely right than wrong that a doctor or endoscopy staff violated the basic standards of medical care. In legal terms, that means we must show there was wrongdoing or medical negligence.
In addition to showing the violations from good medical care, we must also show that we are more likely right than wrong that the wrongdoing was a cause of the injuries and death.
Finally, we must have a medical expert confirm each of those things in order to justify going forward with a valid lawsuit against the doctor and hospital staff. Only then are we permitted to bring suit.
Another issue that often arises in these types of medical malpractice and wrongful death cases is whether Joan’s ‘therapeutic complication’ leading to her death could have been prevented.
In order to answer that question, medical experts are needed to evaluate the records and determine, based upon their clinical experience and medical literature whether this was a known risk of the procedure or whether this never should have happened.
Even if this was a known risk of the procedure, the mere fact that Joan signed consent forms to have an endoscopy, is not a license to any of her doctors or nurses to violate the basic standards of medical care.