Showing posts with label Joan Rivers. Show all posts
Showing posts with label Joan Rivers. Show all posts

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.

Wednesday, January 28, 2015

The Finger Pointing Begins. The Joan Rivers Malpractice Lawsuit

You knew it would come to this. For all the talk about medical staff teamwork in the operating room, when the sh** hits the fan, each person is on his own, trying to save his own butt from the wrathful vengeance of the malpractice attorney. In the medical malpractice lawsuit filed by the late Joan Rivers's daughter, each doctor is now essentially blaming each other for the comedienne's untimely death last September 4th during a simple endoscopy.

During the official investigation following her demise, a note was found in the chart that was handwritten by the anesthesiologist, Dr. Renuka Bankulla, that said she tried to find the ENT surgeon who had performed the laryngoscopy and possible vocal cord biopsy, Dr. Gwen Korovin, when Ms. Rivers went into cardiac and respiratory arrest. However Dr. Bakulla couldn't find Dr. Korovin in the room to perform a cricothyrotomy to open up the patient's airway even though she was there only minutes prior to the arrest. The suit speculates the Dr. Korovin fled the room at the first sign of trouble because she was not credentialed to perform procedures at the Yorkville Endoscopy center.

The attorney for Dr. Korovin counters that she was in the room all along. In fact, the faithful doctor was the last person to leave the room when the patient was taken away by ambulance. Just because the anesthesiologist didn't see her doesn't mean she had left the room. However, Ms. Rivers's lawyer wonders why, when Joan wasn't able to get any air into her lungs, the surgeon didn't take over the airway and performed the emergency operation. Said Jeffrey Bloom, the attorney, "She's an airway specialist. Why isn't she stepping forward and saying 'I'll do it' or 'You do it'. Instead she obviously did nothing."

Naturally much more will come out as the lawsuit proceeds. More witnesses will be testifying as to the whereabouts of Dr. Korovin, including the testimonials from the GI doctor and two other anesthesiologists and nurses that were in the room when disaster struck.

This is an important lesson for all anesthesiologists. You may think you are good buddies with your favorite surgeon, going out and playing golf or fishing together. Maybe you send each other Christmas cards or your children play soccer on the same junior high team. But when trouble hits, that friendship will quickly dissolve into acrimony.

A few years ago, one of our anesthesiologists was working with a highly likeable orthopedic surgeon. The surgeon was always friendly and loved to tell corny jokes in the operating room. Everybody wanted to work him. Then one day, after a simple joint procedure on an elderly female patient, the surgeon wrote a narcotics order after she had already been transferred out of recovery and to the floor. The patient consequently had an unwitnessed respiratory arrest and died. The inevitable malpractice suit was filed and now the surgeon was blaming the anesthesiologist for oversedating the patient while in recovery leading to the arrest from a routine narcotics order when she went to her room. That happy face mask quickly disappeared when facing a multimillion dollar lawsuit. A tough education no anesthesiologist should forget.

Tuesday, November 11, 2014

What Really Happened At Yorkville Endoscopy?

The release of the Health Department's inquiry into the death of Joan Rivers has certainly shed some light on the event last August at Yorkville Endoscopy clinic. While the following is merely speculative, and we may never know exactly what occurred in that procedure room, we can certainly use some analysis of published data to try to draw a clearer timeline of what led up to her demise.

For months, most anesthesiologists, including myself, thought for sure that Ms. Rivers went into laryngospasm during the case. This is because most of us have seen it happen during a routine endoscopy. Then word came out that there was an ENT surgeon involved who may have been examining her vocal cords without prior consent to look for a source of her hoarse voice. This really put the laryngospasm theory into overdrive. We all slapped our foreheads with our palms and went "Duh! What do you expect will happen when you touch the cords during a sedation case?"

The official report from the Health Department doesn't paint such a clear cut picture. First of all, as it turns out, an anesthesiologist was present during the procedure. I guess Dr. Cohen will use an anesthesiologist for his VIP patients after all. The report also throws the whole laryngospasm theory in doubt. In the document, it helpfully lists Ms. Rivers' vital signs from preop up to when she went into cardiac arrest at five minute intervals. After looking at the data closely, it seems more likely she did not go into respiratory arrest at all before the cardiac arrest.

We know that she had perfectly normal vital signs in preop at 8:44 AM: BP 118/80, HR 62, O2 sat 100%. The patient went into the operating room at 9:00 AM. Then we get to see the vitals as they occurred during the procedure. 

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%

The report does not indicate what time the procedure started. However it does say that Dr. Korovin started first with a nasolaryngoscopy before handing the patient over to Dr. Cohen for the EGD. The endoscope was removed from the patient at 9:28 at which time Dr. Korovin attempted to perform a second nasolaryngoscopy. At about 9:30 was when Code Blue was called.

So let's assume that the first VS was the baseline before the patient entered the room. Judging by the drop in blood pressure and oxygen saturation at 9:16, she had probably already started receiving some sedation with propofol. The electronic anesthesia record noted that propofol was given at the following times: 100 mg @ 9:21.45, 100 mg @ 9:21.46, 50 mg @ 9:21.48, and 50 mg @ 9:21.50. This is a total of 300 mg of propofol pushed in five seconds.

The anesthesiologist claims that those quantities are mistakes. The patient had only received 120 mg of propofol for the whole case, which she wrote in an addendum to the record later that day. She told the investigators that she accidentally double clicked the computer for the 100 mg boluses and really meant to click on 20 mg bolus instead of double clicking 50 mg boluses.

One thing about electronic medical records--just because you click on an event doesn't mean it actually happened at that time. You may have been too busy with your responsibilities before realizing you forgot to enter it on the computer. You then finally document it even though it happened a few minutes prior. Even though the anesthesiologist may appear to have first bolused the propofol at 9:21.45, it is conceivable that this was a slow bolus given over several minutes but not charted until that time. If we presume that the hypotension seen at 9:16 was already the beginning of the sedation, then the drug was not entered into the computer for five minutes. At that point the anesthesiologist documented 100 mg at 9:21 even though it may have been given over several prior minutes.

Why was her O2 sat only 92% at 9:12 even though the rest of her vitals were normal? This maybe an instance of bad oximetry data. There are many reasons for a sat monitor to pick up an erroneous reading. Perhaps her fingers were cold. Maybe she was shivering. Or maybe somebody was moving her arm. The computer will record whatever number it sees at a particular time without regard to its accuracy. It is up to the user to write a note explaining the false data in the record.

As the oxygen saturation started to drop during the procedure, the anesthesiologist says she turned up the oxygen flow and applied jaw thrust to open up the airways. The anesthesiologist's statement that she kept the O2 sat greater than 90% is true based on the recorded data. But unfortunately that was not Ms. Rivers' problem.

I've seen many laryngospasms during an endoscopy. On nearly all of them, the O2 saturation drops first because the patient can't pass any air. Then the body starts fighting like mad to open up the airways. This results in a severe tachycardia that doesn't slow down until the cords open up or the O2 sat drops so low that the heart becomes ischemic, leading to bradycardia, a most ominous sign.

But Ms. Rivers' problem doesn't seem to be hypoxia. Her sat never goes below 90. Instead we see hypotension and bradycardia first. This is most likely due to a depressed cardiac output. If the CO drops, the O2 saturation eventually falls too as the heart can't pump enough blood for adequate oxygen exchange in the lungs.

What could have caused her heart to fail? Right at the top of the list is propofol. That is why propofol is such a dangerous drug. If not used judiciously, it can cause severe cardiac depression and hypotension, sometimes fatally. In an elderly patient, the impaired heart function can be quite profound. While I want to give the anesthesiologist the benefit of the doubt and agree that she didn't give 300 mg of propofol to an 81 year old in a span of five seconds, which would no doubt lead to a catastrophic bottoming out of her blood pressure, even 100 mg of propofol if pushed too quickly can cause a severe decreased cardiac output.

Another possibility is a strong vasovagal reaction. This is especially true with something as stimulating as a laryngoscopy. If the patient is not sedated adequately, the stimulation from the procedure can cause the BP and HR to drop in some people. This usually goes away once the stimulant is removed by withdrawing the scope. Respiration again is not impaired but the sat may fall because of the decreased blood flow to the lungs and tissue.

Could she have suffered a pulmonary embolus? A PE can cause acute hypotension and bradycardia as the right heart workload suddenly increases. But a PE also usually causes severe hypoxemia, especially for one that leads to death like a saddle embolus. The medical examiner's report also failed to mention a PE as the cause of her death.

An acute myocardial infarction? Maybe. But it would be awfully coincidental for her to suffer an MI right at the time she was getting a procedure done, though it wouldn't be outside the realm of possibility.

If laryngospasm is no longer the likely cause of Ms. Rivers' death, it also explains why she had a hypoxic brain injury. It is easy enough to treat laryngospasm, especially with an anesthesiologist and an ENT surgeon at the bedside already. If it can't be broken with positive pressure ventilation, then give a muscle relaxant to open up the cords and intubate the patient. None of that should take so long as to cause brain ischemia. However if she had heart failure, the low cardiac output would starve the brain of oxygen leading to its death. She sent into cardiac arrest at 9:30 and was not fully resuscitated until 10:00. That is a full thirty minutes of suboptimal blood flow and oxygen exchange to the delicate brain tissue. Thus the brain dies.

Therefore the most likely reason that Ms. Rivers died that day was her heart failed. Either she went into such a severe vasovagal reaction during the laryngoscopy that they couldn't revive her heart or the anesthesiologist felt she needed to give so much sedation to perform the laryngoscopy (Anesthesia! The patient is moving!) that it irreversibly impaired her heart function.

That's just my two cents.

Joan Rivers. The Health Department Report Shows Major Violations.

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.

Thursday, November 6, 2014

Celebrity Doctors And Their Celebrity Patients

The New York Times has a lengthy puff piece on the ENT surgeon who was present during Joan Rivers' final and fatal procedure, Gwen Korovin, M.D. Dr. Korovin graduated from Cornell then went to SUNY Syracuse for medical school. Upon graduation she did her residency in Manhattan's Lenox Hill Hospital. There, she was mentored by Dr. William Gould, an ENT physician with many celebrity patients. When Dr. Gould retired, Dr. Korovin assumed his practice, retaining many of his famous clients.

Dr. Korovin was highly recommended among the rich and famous. She appeared to have treated everyone on Broadway for throat and sinus ailments. They all loved her. And she loved them back. She was glamorous in her own right, dressing in chic outfits that rivaled her patients and attending their red carpet premiers. Like a good concierge physician, she apparently could be reached at all times day or night by her patients. She received their loyalty when she confronted show producers and demanded they let the stars rest their voices instead going on. So much for the old show business ethos, "The show must go on."

The writer, who admits he has been Dr. Korovin's patient, name drops the doctor's patients throughout the article. Stars like Cher, Bruce Springsteen, Elvis Costello, Ariana Grande, and many others are mentioned. I wonder if all these people that are named gave the author permission to mention them as being patients of Dr. Korovin. If not, this is a huge HIPAA violation.

Perhaps it was these ongoing relationships with VIP patients that ultimately led to her downfall. She may have been just a bit too cocky as she breezed into Yorkville Endoscopy that fateful day last August to treat her good friend Ms. Rivers. She was so sure of her status that she couldn't even bother identifying herself to the staff at the surgery center, some of whom assumed she was the patient's makeup artist.

The coroner's report ultimately stated that Ms. Rivers died from an anoxic brain injury from a propofol sedation that was "a predictable complication of medical therapy." A doctor who has no credentials for working at a surgery center can just waltz in without any identification is a complication of medical therapy? When a doctor can perform a procedure that the patient may not have consented to is a complication of medical therapy? When a surgeon is so confident of her relationship with her patient that she can commit the atrocious act of taking a selfie with her phone while the patient is asleep under anesthesia is a complication of medical therapy? An ENT surgeon who is actually present in the operating room when a patient suffers laryngospasm but incredibly is unable to establish an emergency airway is a complication of medical therapy? Wow. Who paid off the coroner's office in New York?

Whether the doctor will be sued by Ms. Rivers' daughter for medical malpractice is still to be determined. But that is the life of a VIP doctor. Your mistakes are just as outsized as your patients.

Tuesday, October 14, 2014

What The Deaths Of Michael Jackson And Joan Rivers Have In Common

Following the unexpected death of Joan Rivers, I am once again inundated daily with questions from concerned patients about the safety of anesthesia. Everybody comes in with wide eyed fears while family members produce a list of questions about how likely their loved one will die during a routine outpatient procedure.

This hysteria is similar to the events five years ago when Michael Jackson was found dead in his rented mansion after being sedated by an inattentive cardiologist. At that time patient anxiety was actually far more intense because of Mr. Jackson's notoriety and the widespread news of propofol's involvement.

However, my answer to questions about both Mr. Jackson's and Ms. Rivers's deaths are quite similar--in both cases an anesthesiologist was not present to give the sedation. We know for a fact that MJ was overseen by Dr. Murray in a private bedroom with absolutely no evidence of any anesthesia resuscitation equipment available, not even oxygen. Ms. Rivers's case is still under investigation so we only have gossip and heresay to tell her story. However all evidence point to Dr. Cohen, her gastroenterologist, as the primary procedurist in the room. He has strongly voiced his opinion that the use of propofol by a non-anesthesiologist is just as safe as when an anesthesiologist is giving the sedation. With such a strong advocate of DIY anesthesia as Dr. Cohen, it is unlikely that he let any anesthesiologist sedate his patients, especially for a procedure as "benign" as an EGD.

As you can see, in both tragic cases there was no anesthesiologist in the room when a crucial airway emergency occurred. When patients ask about these sensational events, they must be firmly told that an anesthesiologist would most likely have prevented the untimely deaths of these two celebrities. No amount of PR material from the ASA about physician anesthesiologists (how I hate that term) can compare to a face to face bedside education that an anesthesiologist can give to his patient about the safety of our craft. This is another golden opportunity to inform our patients about the frequently misunderstood practice of anesthesiology. Out of tragedy anesthesiologists can really shine and demonstrate to the public the indispensable skills we possess to safely guide a patient through his most vulnerable period.

Sunday, September 14, 2014

The Murky Death Of Joan Rivers

I have tried not to comment on the untimely death of comedienne Joan Rivers last week due to the fact that the investigation into her demise at the Yorkville Endoscopy center in Manhattan is still ongoing. However, more details are starting to leak out about that fateful day and the story is starting to get more disturbing.

Ms. Rivers was scheduled to have a procedure performed at the center that day by her personal gastroenterologist, Dr. Lawrence B. Cohen, to evaluate a worsening hoarseness in her famously raspy voice. Ms. Rivers appeared to be in good health and spirits at the time, even performing the night before at a club.

Now it's not uncommon for GI docs to evaluate hoarseness. What does the GI tract have to do with poor phonation? Severe gastric reflux can produce acid that comes up the esophagus and potentially damage the cords. Therefore it's not unheard of for a GI physician to perform an endoscopy to look for evidence of reflux that might lead to vocal cord damage.

Up to this point I have no problems with the story. Then the whole episode starts to go awry. At first the news was that Ms. Rivers went into respiratory and cardiac arrest during the procedure. The first thing I thought of was laryngospasm, which is not uncommon during upper endoscopies performed with only conscious sedation or monitored anesthesia. An anesthesiologist present would have known precisely how to reverse the laryngospasm as that has been drilled into us since day one of residency training. However, it would have been unusual for Dr. Cohen to have used an anesthesiologist to give sedation to Ms. Rivers since he is well known in academic circles for looking with disdain at using anesthesiologists at all for endoscopies. He's one of those GI docs who feels he can simultaneously perform his duties of a gastroenterologist and an anesthesiologist without jeopardizing patient safety. So it's highly likely that Dr. Cohen was the one directing the nurses in the room to give IV sedation for the procedure, despite the claims of Yorkville spokeswoman Marcia Horowitz, who states that an anesthesiologist is always at a patient's bedside throughout the procedure and "immediately assumes control of the airway and assists with a patient's ventilation" if the patient is in jeopardy.

Ms. Horowitz says the center has three or four anesthesiologists working any given time to help with airway management. Yet they also say that succinylcholine is not available at the facility. Whaaa? I don't know of ANY anesthesiologist who will work anywhere without having access to at least one vial of succinylcholine at a moment's notice. It is precisely for emergencies like a laryngospasm that a rapidly acting muscle relaxant is most essential. So to claim that they have multiple anesthesiologists standing by with all the latest resuscitation equipment ready yet have no sux around doesn't make any sense at all.

Now comes the bombshell that Ms. Rivers had her vocal cords biopsied by an ENT surgeon who isn't even authorized to do procedures at Yorkville Endoscopy. In fact the surgeon was assumed by the center's staff to be a makeup artist for Ms. Rivers. Curiously, without knowing the identity of this person, they let her into the procedure room with her little black bag of equipment. If that's not the worst Joint Commission violation in the first degree, I don't know what is. First of all, did Ms. Rivers even know this surgeon or that she would be coming in during her EGD to possibly perform a vocal cord biopsy? Was the surgeon's name on the consent? Was there even a consent for vocal cord biopsy since the staff didn't even know the surgeon? Are the staff at Yorkville Endoscopy so intimidated by the GI doctors that they are afraid to raise questions about irregularities in the procedures?

The identity of this ENT hasn't been revealed, yet she could possibly be the worst ENT surgeon in the world. An ENT surgeon has looked at thousands of vocal cords during a lifetime of practice, including many airways horribly deformed by cancer. Therefore if Ms. Rivers went into laryngospasm, presumably the ENT would have just as much or more experience than the anesthesiologists in intubating her to reverse her hypoxia. One may assume that anesthesiologists have more experience with intubating the trachea, but many anesthesiologists who work at these outpatient ambulatory centers probably haven't intubated a patient in years. Even if the ENT had difficulty intubating Ms. Rivers, which they eventually did, the surgeon would have been the perfect person to perform an emergency tracheotomy to save her life.

So this raises the question of how Ms. Rivers was being monitored during her endoscopy. Did she have all the basic monitoring equipment in place according to ASA guidelines, including pulse oximetry? Even if she went into laryngospasm, there is usually at least a few seconds to get the endotracheal tube in place to prevent hypoxia leading to cardiac arrest and brain damage. The surgeon would have been in precisely the right location to quickly insert the tube. Yet it sounded like they didn't realize the patient was desaturating quickly until it was too late. 

So as you can see, a lot of this story doesn't make sense yet. The investigation into what happened in that procedure room will take months to complete and may never be completely revealed to the public. In the meantime, Dr. Cohen has lost his job as the medical director and procedurist at Yorkville Endoscopy. And I'm once again having to explain to my patients in preop why they won't suffer the same fate as poor Joan Rivers.