Joan Rivers Underwent Unplanned Vocal Cord Biopsy Without Consent

Image by David Shankbone of Wikipedia

When it was first reported 8/28/14 that comedian Joan Rivers suffered some type of respiratory arrest during some type of sedated endoscopic procedure, it was unclear exactly what was done and what happened. According to initial reports, the endoscopy was done to "check her vocal cords."

Media reports have emerged citing an anonymous source that state an unplanned, un-consented vocal cord biopsy was done during the planned endoscopy procedure, most likely an EGD.

Of course to add mud to an already murky situation, Yorkville Endoscopy released a generic public statement that contradicted these reports stating "A biopsy of the vocal cords has never been performed at Yorkville Endoscopy."

However, should media reports be believed that a biopsy WAS performed and laryngospasm did occur, I suspect the following happened.

Joan Rivers had a planned, consented procedure to check her upper digestive system, most likely an EGD that was performed by a Yorkville Endoscopy GI specialist.

During the EGD, the vocal cords were checked and something abnormal was seen on the vocal cord. An ENT who apparently accompanied Joan Rivers that day decided to perform a vocal cord biopsy that was not planned for nor consented for.

When the vocal cord biopsy was attempted/performed, Joan Rivers' vocal cords apparently seized and closed up (condition called laryngospasm) which prevented her from breathing which eventually led to her cardiorespiratory arrest. A breathing tube was eventually able to be placed. The cardiorespiratory arrest may have occurred due to lack of airway not being obtained quickly enough OR the stress of the laryngospasm triggered a heart attack regardless of how quickly airway was obtained.

In any case, she unfortunately suffered anoxic brain injury and later died after life support was withdrawn a week later.

Assuming media sources have provided accurate information, what could have prevented this tragedy from happening???

Never mind the legal no-no's that occurred here:

1. Consent SHOULD have been obtained PRIOR to the vocal cord biopsy
2. No procedure should have been performed by anybody without proper credentialing and privileges for that facility (that's why doctors have privileges with certain hospitals and can not practice medicine in any other facility without such privileges.

What about the multiple medical lapses that occurred?

1. With vocal cord biopsies, general anesthesia with endotracheal intubation (breathing tube placement) is typically required. With full airway control, the breathing tube can be temporarily removed, but this is only done while patient is paralyzed under full general anesthesia.
2. Vocal cord biopsies CAN potentially be performed without intubation or general anesthesia ONLY if the patient is completely awake without sedation and has had adequate local anesthesia applied to the voicebox area. I suspect that Joan Rivers only had twilight anesthesia without any local anesthetic application to the vocal cords.
3. IF vocal cord biopsies are performed, whether under sedated general anesthesia or completely awake, a local anesthetic must be applied to the vocal cord region before any biopsies to minimize risk of laryngospasm as well as post-biopsy coughing.
4. IF laryngospasm occurs with airway loss, an anesthesiologist (if present) would have attempted forced high pressure mask ventilation. If airway is not able to be quickly restored (key word being quickly), a muscle paralytic agent (i.e. succinylcholine) would have been administered. This drug would have relaxed the vocal cord muscles allowing for a breathing tube to be placed. It should be mentioned that according to the New York Times, there is a good possibility no anesthesiologist was present during the case.
5. IF for some reason airway is not able to be secured quickly via intubation, an emergency tracheostomy or cricothyroidotomy should have been performed. This procedure essentially is cutting a hole in the neck directly into the breathing pipe which would bypass the vocal cords completely.

One can argue that perhaps an emergency trach or cric was not performed because the facility lacked the tools/instruments (again, never mind that the vocal cord biopsy should not have even occurred in the first place in this facility). However, here's a story where an infectious disease doctor without formal surgical training performed an emergency trach in a restaurant with congressmen looking on.

Certainly if an untrained surgeon can perform a lifesaving trach in a restaurant, it surely could have been done in a medical facility.


Sources:
Joan Rivers had surprise throat biopsy that cut off her air supply, source claims. Daily News 9/9/14

Source: Spontaneous Biopsy Caused Joan Rivers to Stop Breathing. OutPatient Surgery 9/10/14

At Surgery Clinic, Rush to Save Joan Rivers’s Life. NYT 9/9/14.

Doctor Present at Joan Rivers’s Procedure Wasn’t Authorized at Clinic. NYT 9/11/14

Joan Rivers' Endoscopy Clinic, Yorkville Endoscopy, Denies Performing Throat Biopsy on Late Comedienne. US Weekly 9/10/14.

Settlement Reached in Joan Rivers Malpractice Case. NYT 5/12/16