Joan Rivers and you: Understanding risks when procedures require anesthesia

When someone famous dies, especially someone with a great talent like Joan Rivers, we would all like to learn something from the experience. But we must keep in mind that we may never know some of the facts about what happened to this great comedienne and we probably never will. And if we are to learn something from her experience we must not speculate but rather stick to what we do know:

According to sources at New York's Mt. Sinai Hospital where the 81-year-old was brought after an endoscopic procedure at Yorkville Endoscopy, (she was probably treated with an intravenous anesthetic agent such as propofol or possibly sedation from other drugs like Valium and Demoral), she sustained a cardiac arrest, was resuscitated, with damage to her brain from the period of insufficient oxygen to the brain.

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She was put into a medically induced coma to decrease swelling -- which may mean barbiturates to slow the brain’s metabolism, diuretics, over breathing on the respirator to decrease carbon dioxide, and possibly steroids.

She was subsequently transferred from the ICU but remained on life support.

Chances are great that the brain damage was too severe to warrant continuing her life with artificial means.

So what can we learn?

• The older my patients are, the more reluctant I am to support elective procedures unless they are absolutely necessary.

• If a procedure is essential, find out as much as you can about the doctor performing it as well as the anesthesiologist. Experience matters.

• Your internist or cardiologist plays an important role as a gatekeeper making sure that you are in good shape for the proposed procedure.

• I am reluctant to use free-standing facilities in elderly patients because of the greater risk of complications. Travel time matters. In the rare case of a cardiac or respiratory arrest, precious seconds before resuscitation matter.

• No procedure is risk free.

Elderly patients undergoing any kind of surgery have the highest complication and death rate by far. Assessing patients carefully before and during the procedure are crucial to decreasing the risks.

In terms of endoscopic procedures themselves, the procedure is generally quite safe for all ages, the greatest risk for the elderly comes from the anesthesia. The organs generally most at risk are the lungs, heart, and brain.

The American Society for Gastrointestinal Endoscopy issued guidelines in 2006 which state that “most diagnostic and therapeutic endoscopic interventions can be safely performed in elderly patients." But in terms of sedation, they are quite cautionary, stating that, “moderate sedation in the elderly requires heightened attention to dosing and the effects of standard sedatives. “ The guidelines add that initial doses of sedatives should be lower, and that “intensified monitoring is appropriate for many elderly patients.”

We don’t know for sure the kind of monitoring or sedation that Joan Rivers had.

We don’t know about her underlying health risks or even the exact procedure she had.

We don’t know if she aspirated, had a spasm in her larynx or stopped breathing simply from an excess amount of sedation.

What we do know is that she was 81-years- old, putting her at much greater risk of a side effect of anesthesia.   

Joan Rivers’ millions of fans wish her family the best and are saddened by a significant loss of laughter from the world.

I am certainly in no position to comment on whether the procedure she had was necessary or not and whether it was performed in an appropriate manner. Retrospective medical analysis is the worst kind. And endoscopic procedures are almost always life preserving rather than life ending.

But I can use this unfortunate outcome as a motivation to issue a warning to my patients and patients everywhere:  The older you are the more reluctant you should be to undergo an elective procedure or surgery. And if you do need to have a medical procedure, make sure you have it in the best place possible with the best doctors doing it.

Don’t rush into it; make sure you are carefully screened beforehand by your internist or your cardiologist.