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Legendary Comedienne Joan Rivers’ Death Leads to Medical Safety Questions at Outpatient Facilities

3 comments

The world lost iconic comedienne Joan Rivers today following a complication with what should have been a routine outpatient procedure performed on August 28. Now, the question everyone is asking is “What went wrong?” and the New York State Department of Health has announced it will investigate to determine if medical errors or medical malpractice occurred.

Last Thursday, Ms. Rivers underwent an elective procedure on her vocal chords at Yorkville Endoscopy. At some point during the medical procedure she stopped breathing and was transported to Mount Sinai Hospital, where she went into cardiac arrest. Doctors placed her in a medically-induced coma and started life support. On Sunday, they started lifting her out of the coma and on Wednesday daughter Melissa Rivers reported that she had been moved out of the intensive care unit into a private room.

The obvious medical questions involve whether a preventable anesthesiology error occurred.  When a patient is not conscious and under anesthesiology medications, control of the patient’s breathing and vital signs are exclusively controlled by the anesthesiology doctor.  When medical surgeries occur outside the hospital setting, the anesthesiology physician must assure that all necessary equipment is available—including a “crash unit” in case of sudden trouble with the patient.  Time and time again, disastrous patient “crashes” occur at outpatient or ambulatory centers that lack all the equipment of regular hospitals.  Elective surgeries can become catastrophes, which may be the case with Joan Rivers.

This afternoon, Melissa Rivers announced the death on JoanRivers.com, stating in part, “My son and I would like to thank the doctors, nurses, and staff of Mount Sinai Hospital for the amazing care they provided for my mother.”

Hospital mistakes have been the subject of extensive research and regulation, but outpatient facilities have for the most part flown under the radar. People assume “outpatient” means minor, when in fact many outpatient procedures, including Ms. Rivers’ procedure, require anesthesia. Anesthesia carries with it serious risks, and these risks increase with the patient’s age. When a patient suffers complications during a “routine” outpatient procedure at a hospital, the hospital has trained staff and equipment to handle the emergency; an outpatient facility does not.

Outpatient facilities, also called ambulatory care facilities or surgicenters, are offering more procedures every day as updated equipment and expanded pharmaceuticals now make it economical, feasible, and profitable. A JAMA study found that outpatient visits outnumber hospital discharges at a 30:1 ratio. The authors of the study warned in an editorial that these statistics should alert doctors in outpatient facilities that the “absence of risk management programs in ambulatory care settings across the country, is a cause for concern.”

Our Virginia medical malpractice lawyers have written about lawsuits brought by patients who were injured or killed when outpatient clinic doctors negligently performed medical procedures like Lap-Band and plastic surgery. We know how victims and their families suffer when complications arise without the equipment to respond to them. Hopefully, Ms. Rivers’ death will shine light on the dangers of undergoing medical procedures at outpatient facilities and prompt legislative action. With its soaring popularity not likely to level out anytime soon, it’s time to fix existing state regulations – cobbled as they are – and expand on them to require standard emergency equipment and expanded patient safety requirements at these facilities.

AM

3 Comments

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  1. RIP Joan says:
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    Are you even certain that a physician anesthesiologist was present for her procedure? Many outpatient endoscopy centers employ nurse anesthetists, many without the supervision of physician anesthesiologists in order to lower costs.

  2. Rick Shapiro says:
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    This is an excellent point, thanks for the comment. Yes, it is true that not every outpatient surgical center even has a licensed anesthesiologist at every procedure. Some do not have a licensed anesthesiologist magnifying the need for safety regulations.

  3. RIPjoan says:
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    In my opinion an incident like this is fairly straightforward and highlights several important issues. These questions must be answered. What medications were administered? Who administered the medications and what is their level of skill/training/experience with administration as well as rescue/resuscitation if there are problems? In other words, if the airway is lost due to over medication/under medication or surgical complication there must be personnel available to deal with this scenario. What monitoring was used? Did they monitor the ETCO2 which would allow for almost immediate recognition if the patient is not breathing? What rescue equipment was immediately available in the center and who was trained to use it and what did that training consist of? What level of pre operative evaluation did she have and was it adequate? Of course, even if all of these questions are answered appropriately and meet current OR standards an incident like this can still happen. It may have just been her time (ie arrhythmia). I suspect however that propofol was used without intubation and monitoring of CO2. She likely stopped breathing and it was not immediately recognized and the person responsible was unable to respond in the necessary window to save her brain from lack of oxygen. In my opinion medicine needs to continue moving in the direction of the airline industry. Strict safety standards should be universal.