Joan Rivers 'stopped breathing' in surgery

[Isabelle]

B

Per the released report, the notes say that she was given a large amount of propofol, but the person administering this propofol claims that this was an error and she was actually give a much smaller amount. Somehow I don't find this believable. But if it's true, that suggests poor record keeping on the part of this clinic.

That clearly sounds like CYA, after the fact.

 

[Isabelle]

With every report that published, I am more and more incredulous. The reported behavior of the OR staff is reprehensible. In the years I spent working PACU and coding patients in the OR, I don't think I have ever seen or heard of such inappropriate and unprofessional behavior.

Our crash carts were stocked and sealed by pharmacy and had a plastic lock on them so one could tell immuediately if the crash cart was accessed. I don't remember if Succ (pronounced sucks for short) was routinely stocked on the crash cart. The anesthesia ppl had it at the ready for when they had to intubate someone. I can't imagine the anesthetist or anesthesiologist not having those drugs in their intubation kits.

Agree and when I worked in PACU, the crash cart was checked every shift and this included testing the defibrillator. A document was completed every shift and signed by the RN doing the check. If I recall correctly, the crash cart had to be opened once a week for a full inventory, including a check of expiration dates on medications. This is serious business!

 

[Isabelle]

Something in the information released is not right. Where in the record does it show vitals or some change that would have alerted staff that there was a problem. At some point her oxygen saturation would have precipitously dropped, but all we see are 90's. Where is information that shows the moment the crisis was discovered? What a freaking mess. I wouldn't work for that facility if it was the last place to work. I like my freedom too much.

Now to wait and see if the good old boy (medical board) network takes any action.

 

[nrdsb4]

Weight would have been a part of how much propofol she was supposed to get. The notes say she got a very large amount, although the person administering it claims that was an error and she got a smaller amount. But how did they know how much to even give her since they didn't take her weight?

I think K_Z mentioned this, as have other anesthesia providers I have read comments from, but certainly weight is a factor, but not required so rigidly to the pound as you might expect with pediatric patients or other drugs. They could eyeball it pretty well and still be giving proper doses.

I personally don't think the discrepancy noted in the record has anything to do with the fact that they didn't get a weight on her. Also, it's possible someone weighed her and verballed it to the anesthesia provider. We do that in the OR I work in, though of course I always document it on my notes.

 

[nrdsb4]

Something in the information released is not right. Where in the record does it show vitals or some change that would have alerted staff that there was a problem. At some point her oxygen saturation would have precipitously dropped, but all we see are 90's. Where is information that shows the moment the crisis was discovered? What a freaking mess.

Agree. I didn't see in the record where the "event" happened vis a vis the vital signs. I think one of the sats was 92%, which is certainly a downward trend, but not arrest. It does sound like a big mess.

 

[Zuri]

Weight is supposed to be documented and is actually required by insurance companies for reimbursement to providers. As far as the anesthesiologist goes, it is my understanding that an anesthesiologist has to be present in the facility and review patient's history etc. Anesthetists actually administer the anesthesia and are present in the OR the entire time.

Somebody was not paying attention. Vital signs are documented typically at least every 5 minutes. KZ can speak to this much better. There seems to be such gross negligence in this case it is mind boggling. IMO

 

[SStarr33]

Didn't the report linked make reference to "Staff member #2, patient's anesthesiologist on 8/28/14"? (page 7 of 22)

I personally have never witnessed propofol administered by anyone other than an anesthesiologist or CRNA; in other words, people specifically trained in the administration of general anesthesia. I have seen endoscopies or colonoscopies performed where RNs used IV sedation, NOT propofol. I've never seen a procedure like this where the GI doctor performing the procedure is also handling the anesthesia or sedation. I don't see how that would actually be physically possible.

K_Z will be the authority on this most likely.

The guy who did River's endoscopy wrote papers about it--I posted it above. If you google propofol administered by nurses endoscopy you will see lots of results. Not saying that is what happened here, but it looks like it has happened in the past and that River's physician, Cohen, is a proponent.

 

[nrdsb4]

My endoscopy clinic does not allow RNs to administer propofol under any circumstances. CRNA or MD only, and this is my experience as well in other facilities where I have worked. I can't speak to what other facilities do and did not intend to imply any different. It's simply my experience.

Regardless of who was supervising the anesthesia/sedation in Joan Rivers' case, clearly there was a major fail in administration and monitoring of the patient. These drugs are wonderful when used correctly in the proper setting by the proper HCW with the appropriate patient, but they can kill if not administered correctly.

There apparently were failures on numerous levels in this case, and I don't blame Melissa a bit for being outraged and for going after the people involved in this tragedy.

 

[nrdsb4]

Weight is supposed to be documented and is actually required by insurance companies for reimbursement to providers. As far as the anesthesiologist goes, it is my understanding that an anesthesiologist has to be present in the facility and review patient's history etc. Anesthetists actually administer the anesthesia and are present in the OR the entire time.

It may depend on state law, not sure, but there are no anesthesiologists present in the endoscopy clinic where I work, where propofol is the agent of choice. CRNAs are present at all times during the case and do a pre-op assessment before the case after reviewing the RN admitting assessment.

Somebody was not paying attention. Vital signs are documented typically at least every 5 minutes. KZ can speak to this much better. There seems to be such gross negligence in this case it is mind boggling. IMO

Yes, the clinic will probably attempt to settle out of court because I doubt any jury would rule in their favor.

 

[K_Z]

Weight is supposed to be documented and is actually required by insurance companies for reimbursement to providers. As far as the anesthesiologist goes, it is my understanding that an anesthesiologist has to be present in the facility and review patient's history etc. Anesthetists actually administer the anesthesia and are present in the OR the entire time.

Somebody was not paying attention. Vital signs are documented typically at least every 5 minutes. KZ can speak to this much better. There seems to be such gross negligence in this case it is mind boggling. IMO

BBM. I've been a CRNA for nearly 20 years, and have worked "independently" (no MDA) in free standing surgery centers, hospitals, office based practice, etc. I haven't worked with an anesthesiologist since I was in graduate school. Any requirement in any facility for an "on site" anesthesiologist is a local, facility specific requirement. Medicare (CMS), the VA, insurance companies, JCAH, and state inspectors do not require this. CRNA practice is outlined in the Nurse Practice Act (by law) in each of the 50 states. In my state, I am required to be licensed as an RN, also state licensed separately as an APRN (Advanced Practice Registered Nurse), as well as certified nationally.

Each facility determines what their ratio of CRNAs to MDAs will be, and what roles each have. Some facilities choose to have both CRNAs and MDAs in an "anesthesia care team", others have only CRNAs, and others have only MDAs. (There is another category of provider called Anesthesiologist Assistant, but they are confined to working with MDA's in the room constantly, and only in a few states.) Staffing patterns vary widely across the U.S. depending on the size of the facility, urban vs rural, and the staffing patterns predominant in that state.

That said, it appears there was just one female physician anesthesiologist present providing (not just "supervising") the anesthetic during JR's procedures at the outpatient endo center. That individual will have to answer a lot of very direct, potentially difficult questions, once this case is filed and moving thru the civil system, IMO.

IMHO, this is a disaster that didn't have to happen. Very sad.

 

[K_Z]

When does something cross from malpractice to criminal? Because if you ask me, we need to see some manslaughter charges.

No way, IMO.

As examples, the egregious conduct of Dr. Conrad Murray (Michael Jackson's doc), and equally egregious conduct of Dr. Roberto Bonilla, "only" generated involuntary manslaughter convictions, and brief sentences, after a lengthy and controversial prosecution. Doctors engaged in a "therapeutic relationship" have a golden parachute against criminal prosecution, IMO-- they have to be proven to have engaged knowingly in conduct that would kill a patient. When a patient dies in the course of medical treatment, it's just a bad outcome, and relegated to the civil system. To cross over into criminal negligence is such an enormously high bar, that almost never is a doc prosecuted criminally for a death, as long as they engaged in what they "thought" was reasonable practice.

No way will any of these docs face criminal charges, IMO. Seldom, if ever are criminal charges brought in the death of a patient. Any litigation will be in civil court.

Example where criminal charges were brought, and the doc convicted of involuntary manslaughter:

Dr. Roberto Bonilla/ Osvaldo Hernandez case in California:

http://latimesblogs.latimes.com/lan...ts-death-during-surgery-at-a-home-clinic.html

http://latimesblogs.latimes.com/lan...doctor-license-surrendered-patient-death.html

 

[Blondie in Spokane]

CPR delayed as She Lay Dying

http://pagesix.com/2014/11/30/joan-...sources/?_ga=1.53807208.1126446268.1335160290

 

[Isabelle]

CPR delayed as She Lay Dying

http://pagesix.com/2014/11/30/joan-...sources/?_ga=1.53807208.1126446268.1335160290

What are a bunch of clowns doing caring for a patient under the effects of anesthesia! If these doctors are not disciplined I won't know what to think.

 

[SStarr33]

What are a bunch of clowns doing caring for a patient under the effects of anesthesia! If these doctors are not disciplined I won't know what to think.

IMO, the discipline they need is jail.

 

[nrdsb4]

What are a bunch of clowns doing caring for a patient under the effects of anesthesia! If these doctors are not disciplined I won't know what to think.

It sounds like an episode of the Keystone Cops, only it is the real story of a life ended after what sure sounds like total incompetence.

 

[BetteDavisEyes]

Joan Rivers' Will: Melissa Rivers Named Executor of Estimated $150 Million Estate

Natalie Finn, eonline
13 hours ago

Joan Rivers knew that laughter was essential to the healing process—but time and money never hurt either.

Details of the iconic comedian's will were revealed today after it was filed in Manhattan Surrogate's Court and, not surprisingly, Rivers earmarked a portion of her fortune—estimated by some to be as much as $150 million—to a number of charitable causes, including the New York-based God's Love We Deliver.

Rivers competed (and won) The Celebrity Apprentice for the nonprofit, which prepares and delivers meals to people in need who are too ill and infirm to leave the house or buy the necessary ingredients for a nutritious meal.

According to a coyp of the will obtained by Page Six, Joan's will also included money for California's Guide Dogs for the Blind, the Jewish Guild for the Blind in Manhattan, the Simon Wiesenthal Center, the Jewish Home and Hospital Federation of Manhattan and The Cystic Fibrosis Foundation...

http://xfinity.comcast.net/articles/entertainment/20141210/joan.rivers.will/?cid=hero_media

 

[Blondie in Spokane]

The anesthesiologist involved in Joan Rivers’ botched throat procedure — who, experts say, could have prevented the comedian’s death — was Renuka Reddy Bankulla, The Post has learned.

Bankulla, 47, was the third doctor responsible for Rivers’ treatment besides then-Yorkville Endoscopy medical director Lawrence Cohen and celebrity ear, nose and throat specialist Gwen Korovin, but she has never been identified publicly.

http://pagesix.com/2015/01/04/anest...ntified/?_ga=1.87868248.1126446268.1335160290

 

[Blondie in Spokane]

EXCLUSIVE: FDNY launches probe of EMS workers that accessed 911 emergency records tied to Joan Rivers' death

The hunt has been going on for about two weeks — and FDNY investigators want to know if EMS workers sneaked a peek out of curiosity or to leak details of the case to the media, sources said. Those leaking information to reporters are who are particularly being sought out.

http://www.nydailynews.com/new-york...oan-rivers-911-info-leakers-article-1.2071272

 

[Blondie in Spokane]

Yorkville Endoscopy — where Joan Rivers went into cardiac arrest — gets temporary reprieve from closing
The Centers for Medicare and Medicaid Services notified the Upper East Side earlier this week it would not suspend its federal accreditation on Wednesday, as originally announced.

http://www.nydailynews.com/new-york/clinic-joan-rivers-treated-temporary-reprieve-article-1.2071291

 

[SStarr33]

Yorkville Endoscopy — where Joan Rivers went into cardiac arrest — gets temporary reprieve from closing
The Centers for Medicare and Medicaid Services notified the Upper East Side earlier this week it would not suspend its federal accreditation on Wednesday, as originally announced.

http://www.nydailynews.com/new-york/clinic-joan-rivers-treated-temporary-reprieve-article-1.2071291

Shocker.

Govt sucks.