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It was also reported that this procedure was performed at Yorkville Endoscopy in New York City.
Just based on this limited information released to the public, I suspect the following...
1) The endoscopy procedure was probably an EGD which actually is an endoscopic procedure performed to check the esophagus and stomach, typically to evaluate for reflux damage. It is doubtful that the endoscopy was done specifically to evaluate the vocal cords mainly because sedation is not required to look at vocal cords alone.
Furthermore, Yorkville Endoscopy does not have listed laryngoscopy (endoscopy to check the vocal cords) as part of its services. Click here to see their list of services. Also if you look at the list of physicians at Yorkville Endoscopy, they are all gastrointestinal (GI) specialists... it's the wrong medical specialty if a vocal cord procedure was being performed. With vocal cord procedures, it's the ENT doctors and not the GI physicians who do them.
2) If respiratory arrest occurred during sedated endoscopy, it could be due to one of several factors:
- Aspiration (that's why patients are instructed to eat and drink nothing after midnight before the procedure)
- Severe laryngospasm
- Over-sedation from the anesthetic (propofol is the typical anesthetic agent to sedate which also happens to be the drug that led to Michael Jackson's death)
As more information is provided, the answers to questions that ultimately lead to Joan River's respiratory arrest will become apparent.
Stay tuned!
September 9, 2014: NEW INFORMATION REGARDING WHAT HAPPENED CAN BE READ IN THIS UPDATED BLOG POST HERE!!!
Sources:
'Please pray': Joan Rivers, 81, rushed to hospital after she stopped breathing during surgery as her daughter asks for prayers. MailOnline 8/28/14
Joan Rivers Hospitalized Following Throat Surgery, Reportedly In Stable Condition. Huffington Post 8/28/14
9 comments:
Thanks for your post. Having had 3 EGDs myself, and being a biology student, I had wondered about the possible catalyst for her respiratory/cardiac arrest. I was convinced that her age put her at a higher risk from the sedation, but did not consider the aspiration or laryngospasm.
Thank you for clarifying this. I was wondering why she would be having her vocal cords checked out at a GI clinic. I realize we don't have all the information yet, but you provided a very good explanation of the possibilities, given what we know so far. I'm still confused as to why she would be deprived of oxygen for any length of time, as I assume a clinic that does these procedures would have the necessary life saving equipment at hand, and be able to implement any emergency devices immediately, since these are known risks.
There is a great deal that's troubling about this case. The Endo Center can't say for how long Joan was hypoxic. That likely implies she was not being monitored. I have trouble believing an anesthesiologist or CRNA was involved in such a misadventure. Or maybe I'm just in denial.
The most likely answer is excessive sedation with a slightly lower likelihood to laryngospasm (usually easily treated with a tiny dose of succinylcholine, airway reflex obtundation with IV xylocaine or deepening the anesthetic). Clinically significant aspiration is vanishingly rare with elective cases, assuming NPO guidelines were followed, and compliance should have been checked repeatedly before the procedure commenced. A heart attack could have happened at her show the prior night or any time. GI endoscopy isn't particularly hemodynamically stressful. It's not an abdominal aortic aneurysm repair, exploratory laparotomy, open heart surgery or other procedure particularly associated with that complication.
Still we're left with a brain damaged or dead patient, the clinic telling us she "stopped breathing" and them telling us they do not know for how long she was without oxygen. And that's troubling.
New York City Endoscopy Centers are well known to present significant dangers to patients. I ask myself why would a gastroenterologist associated with the Yorkville Endoscopy Center be doing a procedure on Ms. Rivers. Playing with the vocal cords can lead to laryngospasm and negative pressure pulmonary edema. Endoscopy centers do not carry the drug required to break laryngospasm, succinylcholine. They do not have the drug in the possession because having it also requires that you possess the drugs required to treat Malignant Hyperthermia and the machinery to diagnose the disorder as well. Endoscopy centers do not carry these drugs because of the expense of the ones to treat and diagnose Malignant Hyperthermia.
There is another Endoscopy Center in Manhattan that has been under both Federal and State investigation for almost three years related to a False Claims Act filing in a Manhattan court. That case related to the owners of the Endoscopy Center dictating to anesthesiologists that they should lower ASA risk assignments so as to increase business by performing procedures on patients who are excluded by NY State law from being treated at the specific facility. There was another prominent patient, Mr. Elie Weisel, injured who was also sent to Mt. Sinai Hospital. Mr. Weisel was downgraded from ASA 4 to ASA 3 at the insistence of the Chief Medical Oficer who also preformed the endoscopic procedure which resulted in Mr. Weisel going to Mt. Sinai Hospital in cardiac distress.
Moral of the story--don't get operated on, unless at death's door, or brought in unconscious.
My guess is she was undergoing an EGD with the use of Propofol. The following is a recent account of a GI patient that could possibly be what happened to her (he was having a colonoscopy not an upper GI).
"I recently had a colonoscopy for the second time. The first time I was given Versed and Phentnyl with no issues. This time I was given Propofol by a CRNA and when the procedure started I vomited and aspirated it. My BP dropped dramatically and my 02 sats and then I had a laryngospasm. I had to be intubated. Does this type of reaction happen often or does someone think that the CRNA did something wrong?"
That's possible, but unlikely. Aspiration of gastric contents in a fasted elective case is vanishingly rare (1 in 15,000 or so if memory serves). What happened to your friend is rare, but assuming the CRNA clued in on the situation promptly, it sounds like the care rendered was appropriate.
As far as whether this is what happened to joan rivers, yeah it's possible, but again unlikely. And beyond that, the most important question in a circumstance like this is what was the response to the bad stuff. That's what makes the difference between surviving and not.
All the authors on this position paper advocating endoscopist-directed administration of propofol practice at Yorkville Endoscopy.
http://www.gastroenterologistnewyork.com/webdocuments/pubs-propofol-for-endoscopic-sedation.pdf
Cohen, the principal author is a principal at the center. This leads me to the strong suspicion propofol was administered to Joan Rivers at the direction of the endoscopist with no participation by anesthesia trained personnel.
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