ROGUE OR ROUTINE? Ms. Rivers died on Sept. 4, several days after going into cardiac arrest following a routine endoscopy at a surgery center.

She arrived in a limousine and left in an ambulance. Joan Rivers was supposed to undergo a routine endoscopy to diagnose why she was suffering a sore throat, a hoarse voice and strained vocal cords. Like dry cleaning, she'd be in by 9 and out by noon. Nobody foresaw a need for defibrillators, breathing tubes or sirens wailing on the ride to Mount Sinai Hospital, a mile away, where Ms. Rivers was kept on life support until she died a week later, on Sept. 4. But things went wrong inside Yorkville Endoscopy. Horribly wrong.

Callous and cavalier?
Routine endoscopy? Hardly. From privileges and propofol to selfies and safety standards, the 81-year-old comedienne's death leaves a trail of unanswered questions about what took place at the freestanding surgery center in midtown Manhattan and puts the safety of outpatient surgery once again under scrutiny.

"When death occurs to someone who is well-known, it seems like the roof's falling in," says anesthesiologist David Shapiro, MD, the former president of the Ambulatory Surgery Center Association. "That's not the case. Outpatient surgery in accredited facilities is safe. Not perfect, but safe. It's sad to me that the whole model of delivery of care has been questioned."

At press time, the New York City medical examiner hadn't yet reached a conclusion on what caused the death of Ms. Rivers, but he might want to list a callous disregard for safety and a cavalier attitude as contributing factors.

If we are to believe widespread reports and speculation about what happened on the morning of Aug. 28, Ms. Rivers, after sailing through many age-defying cosmetic surgeries without incident — "I've had so much plastic surgery, when I die, they will donate my body to Tupperware," she once joked — didn't die from the scheduled endoscopy. Gastro-enterologist Lawrence Cohen, MD, who was the medical director of the clinic until resigning after Ms. Rivers's death, reportedly found a polyp when he performed the endoscopy. Reports say he then let Ms. Rivers's personal otolaryngologist, who was neither credentialed nor privileged at the ASC, perform a biopsy on her vocal cords. The throat doctor, identified as Gwen Korvin, MD, was only authorized to observe Dr. Cohen. It's unclear whether Ms. Rivers had given Dr. Korvin consent to perform a biopsy.

The airway manipulation during Dr. Korvin's attempted biopsy likely triggered a laryngospasm, which led to cardiac arrest. Attempts to rescue Ms. Rivers failed, which has fueled speculation that there wasn't an anesthesiologist in the room.

"Sedation for upper GI procedures is extremely tricky," says Louis G. Stanfield, CRNA, PhD, pain management specialist at the Skiff Medical Center in Newton, Iowa. "The instrument goes right by the airway and all it takes is a little blob of mucus or some other irritation and the vocal cords can snap shut. The longer a laryngospasm persists, the more deleterious it is and the harder it is to break."

While a laryngospasm is not an uncommon response to a vocal cord biopsy, experts say it shouldn't have proven fatal. "Anesthesiologists are trained to treat airway issues," says Dr. Shapiro, adding that reversing or "breaking" a laryngospasm requires practiced airway rescue skills.

"Laryngospasm. That is the stuff of nightmares," says Dr. Shapiro. "The patient is dropping off a cliff and you've got one opportunity to reach your hand out and connect with their hand and secure the airway. Otherwise, they're going down."

It's unclear if an anesthesiologist, who would be trained in sedation and intubation, was in the room with Ms. Rivers. Yorkville released a statement saying that "only licensed medical doctors who are board-certified anesthesiologists administer anesthesia at the clinic. Our anesthesiologists monitor the patient continuously utilizing state-of-the-art monitoring equipment, and remain at the bedside throughout the procedure and into recovery."

Then there was the embarrassing selfie. A staff member at Yorkville reportedly told investigators that Dr. Korvin took a selfie photo in the procedure room of herself and the sedated Ms. Rivers. "She will think this is funny," Dr. Korvin reportedly said as she snapped the picture. "A selfie in the procedure room when the patient is asleep? Not very smart," says Ashish Sinha, MD, PhD, an associate professor of anesthesiology at Philadelphia's Drexel University College of Medicine.

In a statement, Dr. Korvin denies "performing an unauthorized procedure" and also "categorically denies" taking the selfie. Yorkville Endoscopy is denying reports that a vocal cord biopsy has ever been done at the clinic. The New York State Health Department is investigating the case. Efforts to reach Dr. Cohen and Dr. Korvin were unsuccessful. Neither has been accused of wrongdoing or of contributing to the death of Ms. Rivers.

VIP SYNDROME
Was Joan Rivers a Victim of Her Own Success?

Is fame to blame for the death of Joan Rivers? That's what New York plastic surgeon Elan Singer, MD, says. He writes in Forbes that Ms. Rivers "died because of VIP Syndrome. She died because her VIP status caused the people taking care of her to alter their routine."

Did Yorkville Endoscopy veer from its normal procedures in a misguided effort to accommodate Ms. Rivers's celebrity and guard her privacy? It's likely true, says Kenneth Rothfield, MD, MBA, chairman of the department of anesthesiology at Saint Agnes Hospital in Baltimore, Md. "Providers are no less immune than everyone else to being starstruck, and it can cloud your judgment."

In trying to provide star-worthy care, says Dr. Rothfield, physicians often end up losing perspective. "I think providers are thrown for a loop when dealing with VIPs. The natural urge is to provide extra-special care. You wind up doing stuff you wouldn't normally do, and sometimes the results aren't good. The best care typically is the care that's administered to strangers — to the average patient who shows up. My word of caution to celebrities would be to make it clear you want the same care the average Joe gets."

"Family, friends, VIPs and people who have surgery on Mondays," says Gary Lawson, MD, ticking off the list of patients who tend to have the worst surgical experiences. Dr. Lawson, an anesthesiologist at the Adult & Children's Surgery Center of SW Florida in Fort Myers, says the key is consistency. "Don't let it cloud your judgment, and remain ever vigilant. I've serviced the Prime Minister of Japan and 2 Presidents of the United States, and everything turned out fine."

— Jim Burger

An anesthesiologist in the room?
It's also believed that propofol played a contributing factor in the death of Ms. Rivers, thus reigniting the debate about the dangers of the sedative-hypnotic.

"Propofol is very safe — until it isn't," says Dr. Sinha. "Propofol doesn't kill people, but its inappropriate administration does. Anybody can administer propofol, even little machines. But not everybody can recover a patient from an overdose of propofol. That includes cardiologists, endoscopists and ENT surgeons."

Many GI centers today don't employ anesthesia providers, in large part because most insurers won't pay for an anesthetist to be present during endoscopy. What's more, GI docs are skilled at giving propofol to provide perioperative sedation and pain control. Dr. Cohen is a leading proponent of endoscopist-directed sedation over monitored anesthesia care, having authored the landmark paper, Endoscopist-directed Administration of Propofol: A Worldwide Safety Experience.

"It is very common to have an incredibly busy 15-suite GI center going all day and there's no anesthesia professional in the facility," says Dr. Shapiro. "Many millions of these procedures in all settings are done without an anesthesiologist present. It's just the way medicine is practiced in this country."

It's also a violation of the standards of the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), Yorkville's accrediting body, which requires that either a nurse anesthetist or an anesthesiologist administer propofol at its facilities. "Those are the rules of our accreditation standards," says Geoffrey R. Keyes, MD, FACS, president of the AAAASF. "Propofol is special. Depending on the patient's age and medical condition, with very low-dose increments you can change from a moderate sedation to a deep sedation where the cough and swallowing reflexes are no longer present. Propofol has that property about it to tip the balance very quickly. You need a skilled airway person in there delivering it."

In a statement, Yorkville says they do not administer general anesthesia, saying they use light to moderate sedation.

"General anesthesia has never been administered at Yorkville Endoscopy," the statement says. "The type of sedation used at Yorkville Endoscopy is monitored anesthesia care. Our anesthesiologists utilize light to moderate sedation."

Dr. Stanfield finds it hard to believe that a competent anesthesiologist was present during Ms. Rivers's case. "If there was a trained provider there, I don't see how this could have happened — how the situation could have progressed to a hypoxic brain injury."

Kenneth Rothfield, MD, MBA, chairman of the department of anesthesiology at Saint Agnes Hospital in Baltimore, Md., is wary of the assertion that gastroenterologists or other non-anesthesia providers can learn to confidently administer propofol. "Propofol is a very unforgiving drug," he says. "When patients stop breathing, their life is hanging by a thread and they're depending on the provider to do the right things. I don't believe other providers have the same skills that trained anesthesia providers have. For me to feel comfortable, they'd have to prove to me that they have all the required skills, know-how and experience to rescue a patient from severe respiratory depression."

Reputation of surgery clinics
Many bristle at the knee-jerk reaction that surgery centers are not as safe as hospitals. The statistics show that deaths at ASCs are exceedingly rare — 1 in 50,000, according to AAAASF data. But when that 1 is Joan Rivers, well, that'll skew the stats in the favor of those who argue Ms. Rivers would have been better off at a hospital rather than at a surgery "clinic," a word that makes an ASC sound like some back-alley operation.

"Criticism has to be made in the face of knowledge through data," says Dr. Keyes. "Scrutiny is always good, but jumping to conclusions without information is not good."

"I see a lot of dark hands at work trying to get people to shy away from surgery centers," says Gary Lawson, MD, anesthesiologist at the Adult & Children's Surgery Center of SW Florida in Fort Myers. "They will do anything, including spreading half-lies and half-truths."

"What is undeniable," says Dr. Shapiro, "is that millions of these procedures have been performed in outpatient settings just like this one with excellent results. Still, we have to be constantly vigilant. We have to be on top of our game every single day, every single patient."