The Intersection of Greed and Medicine, An Opinion Piece
Why did Joan Rivers die? Let’s connect the dots...
I loved Joan Rivers. I never met her, but I loved listening to her on the Howard Stern show. She was an amazing guest. Listening to her over the years, I came to feel — as so many of her listeners did — that I actually did know her, that she had became almost a friend. I consider myself a humble but highly caring and ethical surgeon, and I cannot stop thinking about what killed Joan Rivers. I am convinced that she did not have to die. If things had been done in a proper and prudent fashion, she would still be alive and kicking.
I had to try to figure out what went wrong in Joan’s care.
I think the answer is that the clinical decisions regarding her care were not made in her best interests. Instead, her care was designed to make the most money for her doctors. Gone are the days when I can say, “Trust me — I’m a doctor,” because too many of my fellow doctors can’t be trusted. Greed has warped their decision-making. Patients need to be better informed about how economic decisions affect their care.
Dr. Karen Sibert has written two excellent articles analyzing the Joan Rivers case, “Anesthesiologist’s Review of the Facts in the Joan Rivers Case” (http://thehealthcareblog.com/blog/2014/09/15/an-anesthesiologists-review-of-the-facts-in-the-joan-rivers-case/). “Joan Rivers’ death: What went wrong?” (http://www.kevinmd.com/blog/2014/09/joan-rivers-death-went-wrong.html). But what really happened is still a mystery.
What follows includes some speculation, but it is my educated guess regarding what took place at Yorkville Endoscopy on 8/28/14 around 0930.
Yorkville Endoscopy is in a miserable location on 2nd Avenue in New York. The construction of a new subway line is underway there. The subway construction and scaffolding erected at the entrance make it difficult to even get an emergency stretcher into the endoscopy suite!
Why did Joan have her procedure there? Because Dr. Lawrence B. Cohen did not want to share his fees with Mount Sinai Hospital. Joan’s procedure should have been done in the hospital, NOT in the ambulatory center. She was old and fragile and precious.
Dr. Cohen is a super-smart doctor, but probably also an arrogant one. By all accounts, he is a great gastroenterologist. But he is also the main national proponent of having gastroenterologists capture the anesthesiology fees that would ordinarily — and properly — go to the anesthesiologist. These fees are a tempting target because the anesthesia provider will quite often be reimbursed at a higher rate than the gastroenterologist.
Dr. David Dies has written a good analysis of Dr. Cohen’s effort to eliminate anesthesia personnel, “How Joan Rivers Might Save Your Life” (http://www.shreveporttimes.com/story/opinion/guest-columnists/2014/09/18/joan-rivers-might-save-life/15793599/ ). Dr. Dies understands Dr. Cohen’s mindset.
Even though an MD anesthesiologist was in the room with Dr. Cohen during Joan’s entire procedure, that anesthesiologist was most likely an employee of Dr. Cohen’s and totally subservient to him. In such a relationship, the anesthesiologist could not have any independent judgment and had to do whatever Dr. Cohen commanded. The administration of anesthesia was a process owned by or dominated by Dr. Cohen. Therefore the anesthesiologist couldn’t cancel or reschedule the case.
There may have a three-way decision (or conspiracy) among Dr. Cohen, Joan, and Joan’s good friend Dr. Gwen Korovin to have her vocal cords “checked out” while she was under anesthesia so that Joan would not feel any pain during the procedure. Dr. Korovin took a now-notorious selfie while Joan was under anesthesia. Why was Dr. Korovin even allowed to participate in the procedure? Well, Joan had given verbal consent to let her check out her raspy voice and to perform any indicated procedures. No truly independent MD or Certified Registered Nurse Anesthetist (CRNA) would have permitted Gwen to take a selfie and then participate in the endoscopy. But there was no strong independent advocate for Joan at the head of the bed.
From here on the rest of the story was inevitable. Joan most likely had a vocal cord spasm that couldn’t be broken. The reason it couldn’t be broken might have been economic.
The only drug approved in the US to break a vocal cord spasm is an intravenous medication known as sux (succinylcholine or suxamethonium chloride). Sux itself is not expensive, but having sux available is expensive. If you buy sux, then you must also buy an antidote for a rare sux reaction termed malignant hyperthermia (MH). An MH cart costs about $3000 and is only good for 3 years. My speculation is that Yorkville Endoscopy did not want to have sux in the building to save the MH cart costs.
But even without sux Joan could have been saved.
If a simple tracheotomy or cricothyroidotomy had been performed quickly it could have saved her life — but neither procedure was performed, and Joan died. Why didn’t Dr. Korovin perform a tracheotomy or cricothyroidotomy? My speculation is that there may not have been enough equipment available in the ambulatory center to do either procedure and that Dr. Korovin became panic-stricken when Joan arrested. She probably wasn’t prepared for the crisis. In her panicked state she probably couldn’t think or function effectively. She may not have done a tracheotomy or cricothyroidotomy since her training days decades earlier. She was the ear, nose, and throat specialist to the stars, but she could not secure the airway of her brightest star patient.
Joan probably consented to a very risky procedure. If so, her death was not really a case of “VIP syndrome” but rather an appalling lack of judgment on so many levels driven by greed and arrogance. Nobody had the courage or the incentive to stop the money train.
Let’s make Joan’s death a teachable moment. There are several lessons to be learned from what happened to her. Older and sicker patients should not be treated at an ambulatory endoscopy center. They should be taken care of in a hospital setting where there are abundant life-saving resources and there are always airway experts available within seconds.
Sux, an MH cart, and all possible life-saving equipment should be required and available whenever sedation is given for endoscopy or “minor procedures.”
The entrances and exits of any medical facility must accommodate an emergency stretcher.
The standards of care for ambulatory anesthesia should be the same as that in the stringently regulated hospital environment. When there are two highly qualified airway experts available to take care of you when you receive sedation (a board certified anesthesiologist and CRNA), then you are receiving true VIP care.
The anesthesiologist should be an independent and strong advocate for the patient and must be ever vigilant and stand up to a bullying or arrogant surgeon or gastroenterologist. Joan was the victim of poor care and terrible judgment and she had nobody to protect her when she went to sleep for her last time.
Rest in peace funny lady!
