Thursday, May 12, 2016

If Only They Had Listened To The Anesthesiologist

A settlement has been reached in the medical malpractice case involving the death of comedienne Joan Rivers. If you recall, Ms. Rivers died in 2014 while undergoing an endoscopy to evaluate her hoarse voice. The circumstances were pretty murky but somewhere along the line, Ms. Rivers' personal ENT doctor was allowed to evaluate her larynx during the procedure even though the surgeon had no privileges to operate at the Yorkville Endoscopy Center and there was no consent for it to be performed. Presumably during the laryngoscopy and possible cord biopsy, Ms. Rivers suffered laryngospasm, causing her to become hypoxic and go into cardiac arrest. Her heart was revived but she never regained consciousness. Life support was removed by her daughter one week later.

The terms of the settlement were not disclosed though supposedly the monetary compensation is quite substantial. However, more details about the events of that day have been released. Apparently, Dr. Renuka Bankulla, the anesthesiologist in the room, rightfully feared that she would face a malpractice suit after her patient's death so she wrote a lengthy five page note about what happened in the procedure. This proved to be invaluable for Ms. Rivers' lawyers during the case.

According to Dr. Bankulla, the doctors in the procedure room were so enamored of Ms. Rivers' celebrity status that they violated normal protocols of conduct, including taking pictures of the patient while she lay on the operating room table and allowing a surgeon to do a procedure who had no privileges at the facility.

The anesthesiologist documented that she told the surgeon the patient's vocal cords were swollen and they might close off. Dr. Lawrence Cohen, the gastroenterologist in the procedure, replied, "You're such a curious cat." and ignored her warning. He called his anesthesiologist "paranoid" and allowed the ENT surgeon, Dr. Gwen Korovin, to proceed with the laryngoscopy.

Sure enough, Ms. Rivers' cords snapped shut, closing off her airway. When Dr. Bankulla asked for help in performing an emergency cricothyrotomy, Dr. Korovin had already hustled herself out of the building, leaving the anesthesiologist and her colleagues by themselves to try to reestablish an airway. When they finally did, it was too late to save Ms. Rivers' life.

One has to wonder what might have been if Dr. Bankulla had been more forceful in her warning about Ms. Rivers' precarious airway status and stood up for her patient to prevent the laryngoscopy from proceeding. Was she intimidated by Drs. Cohen and Korovin? Was she in awe of Ms. Rivers and let her better judgement slip? We may never know.

The lesson here to all surgeons is that they need to listen to their anesthesiologist. If the anesthesiologist suspects trouble, it is time to back away from the procedure. Our only responsibility is the safety of the patient. Nothing else in the procedure room matters.


  1. Thanks for your coverage of this case. Very interesting to me as an MS1 considering anesthesiology as a specialty.

    Several questions if I may:

    1)Is it not expected that a board-certifed anesthesiologist (as Dr. Bankulla apparently was) be able to perform cricothyrotomy?

    2)Wouldn't the availability and proper use of succinylcholine have been a significant aid in stopping the laryngospasm and establishing an airway? According to the NYTimes, the anesthesiologist never called for a crash cart so this didn't seem to be considered (or maybe she knew the clinic didn't stock it?)

    3)The CMS report from 2014 says the anesthesiologist claimed she gave an initial 100mg bolus of propofol. Isn't this a somewhat large loading dose given Rivers' age and size? Although the clinic didn't weigh her, it seems unlikely she weighed more than 50 kilos.

    1. 1. I would bet that most anesthesiologists have never actually performed a cricothyrotomy. Yes we've read about it but most of us have never done one. The ENT who ran out of the room would have had much more experience with crics.
      2. Succinylcholine would have stopped the laryngospasm. But some outpatient centers don't even stock the drug if most of their cases are only MAC's. It's not clear if Yorkville Endoscopy Center had sux available.
      3. Yes 100 mg propofol sounds like a lot for a diminutive elderly lady.