Opioid Safety, Respiratory Compromise

4 Lessons Learned from the Death of Joan Rivers

By Kenneth P. Rothfield, M.D., M.B.A., Chairman, Department of Anesthesiology, Saint Agnes Hospital (Baltimore, MD), Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant, Physician-Patient Alliance for Health & Safety), and Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

It is often said that a death is meaningful if it serves as lessons for others to learn from and increase awareness so they “speak up” when found in a similar situation. So, what can be learned from the death of Joan Rivers?

Joan Rivers - she made us laugh

Joan Rivers – she made us laugh

As reported by CNN, the facts surrounding the death of Ms. Rivers were as follows:

Comedian Joan Rivers lost her life after having an apparently minor elective procedure at a Manhattan medical clinic last week.

The routine surgery was on her throat, according to the New York Fire Department. She apparently suffered cardiac and respiratory arrest during the procedure at Yorkville Endoscopy. She was transferred by ambulance to Mount Sinai Hospital and died on Thursday

Rivers’ autopsy was inconclusive, the medical examiner’s office said.

Although there are still many questions the answers to which are not known or have not yet been made public – such as, what was the exact procedure that was being performed or whether a sedative, opioids, or anesthetic was given – here are 4 lessons learned from the death of Joan Rivers.

Four Lessons Learned from Joan Rivers Death

1. Even “minor” procedures can have major risks and “hidden harm”

The American Society of Anesthesiologists reminds us that although “anesthesia is safer than ever before, every person scheduled for a procedure or surgery must have a serious conversation with their physician anesthesiologist about their anesthesia care delivery plan ahead of time … Even ‘minor procedures’ are not risk-free.”

2. Ask questions to fully understand the medical procedure you are to undergo

Physicians must communicate and patients need to fully understand the full nature of the medical procedure. It is often helpful to have a family member, friend or significant other with you to check if you asked all your questions and another set of “ears” to listen to what is being told or explained to you.

U.S. Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) believe “clinicians and patients [need] to engage in effective two-way communication to ensure safer care and better health outcomes.”

This type of patient engagement and education should be told to the patient, and then have the clinican ask for verbal or written feedback from the patient on the level of understanding. This is termed ”readback feedback”.

AHRQ encourages patients to ask their medical providers questions, as illustrated in this humorous video which shows how patients ask many questions everywhere (such as in a restaurant) but not in the doctor’s office (please click on the image to view the video):

AHRQ Restaurant Ad

AHRQ Restaurant Ad

3. Make sure you are monitored electronically, with both pulse oximetry and capnography, if you are to receive sedation, opioids or anesthesia

Even “routine” procedures may entail the use of a sedative, opioids, or anesthesia. The endoscopic procedure performed on Ms. Rivers, which would have likely involved insertion of a large scope into her mouth, is a simple and common procedure, but, as noted by Dr. Karen Siebert, “uncomfortable enough that most patients are given sedation or, less commonly, general anesthesia.”

The Anesthesia Patient Safety Foundation believes that clinically significant drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality.

Continually evaluating and monitoring respiratory and circulatory status prior to, during, and following the procedure is essential. As a recent video released by the APSF provides, continuous electronic monitoring of oxygenation (the adequacy of oxygen in the blood) with pulse oximetry and ventilation (adequacy of breathing) with capnography, when combined with traditional in-depth nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment and distress.

Virtually all proceduralists use pulse oximetry to measure blood oxygen levels, Assessing ventilation is another story. Being able to tell by simple observation if a patient is breathing adequately or not during a procedure can be tricky. Surprisingly, standards for capnography monitoring are not the same for all medical specialists. Anesthesiologists, the recognized experts in administering sedation and anesthesia, are required by the American Society of Anesthesiologists to measure the adequacy of ventilation using capnography (a device which measures exhaled carbon dioxide) to provide breath-by-breath monitoring. Other specialists, such as gastroenterlogists and dentists, are not required to use this technology. Without capnography, several critical minutes can elapse after a patient stops breathing before medical professionals are alerted to the situation, Unfortunately, by this time, a serious problem, or even a cardiac arrest may occur.

4. Equipment and resources at an outpatient clinic may be different than at a hospital

If your procedure is scheduled at a “Outpatient Clinic”, be sure to ask about available emergency equipment at the clinic. Just because your procedure is scheduled in an outpatient type of clinic, do not take this lightly and ask about code cart availability, emergency drugs to manage your condition and any adverse events, and lastly trained clinicians available and knowledgeable about handling potential life threatening emergencies.

Exactly what procedure was performed and how that procedure was performed are facts that the public still does not know about the death of Joan Rivers. However, keeping these 4 simple points in mind could save the life of you or your loved one.

(This article was first posted on The Doctor Weighs In.)

5 thoughts on “4 Lessons Learned from the Death of Joan Rivers

  1. Pingback: Four Lessons Learned from Death of Joan Rivers: Physician-Patient Alliance for Health & Safety Advises Patients Even “Minor” Surgery Can Have Major Risks | North Fork Vue - North Fork Vue

  2. 1.As a Coroner years ago, I saw a patient that was scheduled to have a hernia repair the next day. He died suddenly from a heart attack the night before. He could have easily died from the heart attack while having the hernia surgery. Sometimes coincidences happen.
    2. Older people are more fragile than younger ones and don’t tolerate allergic reactions or vagal-vagal reflex reactions as well as the younger people. Older people are more sensitive to cerrebral anoxia than younger ones. Was Joan Rivers death possibly preventable? We like to think so, but accidents do happen.



  4. The world is still surprised at the death of Joan Rivers and will grieve this loss for a long time to come. If we all learn a couple of lessons from it, then it will be even more significant. Certainly we are reminded even minor procedures can be dangerous.

  5. Pingback: Death of Joan Rivers a Wake Up Call for Surgical Centers and Patients

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