New York's Health Department has released its findings on the events leading up to Joan Rivers' death at Yorkville Endoscopy last August. It gives a fascinating reading on how celebrity and unprofessional behavior of physicians can interfere with the best laid plans to protect patient safety.
Basically the report states that Yorkville Endoscopy failed in its responsibilities in these four areas:
1. Have a process in place to assure that only authorized personnel are permitted in the procedure room.
2. Have an effective process in place to assure that only credentialed physicians can perform procedures.
3. Ensure that informed consent is obtained for all procedures that will be performed and
4. Ensure a "Time-Out" (a preprocedure protocol for verification of the correct person, procedure, and site) was called to confirm each procedure to be performed.
Essentially, all these deficiencies point back directly at the ENT surgeon, Dr. Gwen Korovin. The report states that Dr. Lawrence Cohen, the gastroenterologist, wrote that Ms. Rivers needed an EGD to evaluate for gastric reflux and hoarseness in her voice. However, two nasolaryngoscopies were performed by Dr. Korovin, as confirmed by the anesthesiologist. The first one was performed before the endoscopy while the second one was done immediately afterwards. The Interim Medical Director and the Vice President of Clinical Operations both confirmed that Dr. Korovin had no privileges to perform procedures at Yorkville. Ouch.
The endoscopy technician said she had never seen Dr. Korovin before. During the Time Out, there was no mention of a nasolaryngoscopy to be performed on the patient. Dr. Korovin's role in the procedure room was not brought up during the Time Out. There was also no consent for Dr. Korovin to do a procedure or Ms. Rivers to have a laryngoscopy.
The report clearly documents the downward spiral that took place in the room. Ms. Rivers' baseline vital signs were: BP 118/80, HR 62, RR 16 O2 sat 100%. During the course of the procedure, the vitals steadily deteriorated:
9:12 AM: BP 117/60, HR 71, O2 sat 92%
9:16 AM: BP 92/54, HR 56, O2 sat 94%
9:21 AM: BP 89/44, HR 54, O2 sat 97%
9:26 AM: BP 84/40, HR 47, O2 sat 92%
Two minutes later, a Code Blue was called. Even the type of cardiac arrest is in dispute. One note, called the Cardiac Arrest Record, indicated that the patient became pulseless at 9:30. Meanwhile, a different page called the Endoscopy Code Blue Record said that the patient went into ventricular tachycardia with a pulse. In either case, there is no indication that she received the proper resuscitation protocol per ACLS.
Much of the events mentioned came from the GI tech and administration staff, as the physicians in the room have all essentially lawyered up and refused to give any incriminating statements. However the anesthesiologist was cited for two major violations. As part of her routine preop exam, she failed to mention the height and weight of Ms. Rivers. This could easily have led to an overdose of propofol if the correct weight is not used in calculating the rate the drug was given.
A second misstep was in the documentation of the drugs given during the procedure. In the computerized anesthesia record, the anesthesiologist said she gave a total of 300 mg of propofol. Yet in an addendum she said only 120 mg was given. When asked about this discrepancy, she said that she only administered a 100 mg bolus of propofol followed by a 20 mg bolus later. The computerized record showed she gave boluses of 100 mg, 100 mg, 50 mg, 50 mg all within five seconds of each other. Those other boluses, she said, were accidental double clicks on the computer for 100 mg. She couldn't explain how she double clicked 50 mg boluses when she claimed she only gave 20.
There are no statements made to the Health Department from the GI physician, Dr. Cohen, himself. I'm sure the anesthesiologist's statement that Dr. Cohen took a cell phone picture of the patient while she was asleep will not help his case. He probably has some very expensive lawyers right now telling him to just shut the f*** up for now.
What a tragic end to a brilliant comedic career.
We as anesthesiologists have spent the last few months preaching that this would never have happened to Ms Rivers if there had been an anesthesiologist present to monitor and resuscitate her. So now that it's become evident that there WAS an anesthesiologist there, what's our excuse?ReplyDelete
If they had not been performing an unauthorized and illegal surgical procedure, then a simple EGD wouldn't have turned into this catastrophe.Delete
Fiberoptic nasopharyngoscopy is a common procedure in ENT offices, however under these circumstances it sounds like a cluster. Still hard to imagine the inability to rescue.ReplyDelete