Blogfinger

Bloomberg News (9/12, Langreth, Gilblom) reports that the death of Joan Rivers during an undisclosed procedure has centered attention on aging population seeking care at ambulatory care facilities. Anesthesiology experts say such “centers generally need to go out of their way to identify pre-existing conditions in patients because some facilities may not have all of the emergency equipment a hospital would.” Beverly Philip, professor at Harvard Medical School said that since older people are generally more frail and there is a need to re-evaluate “the suitability” of these individuals “for minor outpatient procedures at centers” that lack full array of equipment for responding to medical emergencies

BLOGFINGER MEDICAL COMMENTARY:  Paul Goldfinger, MD, FACC

There is not enough information out there about the Joan Rivers case to draw any specific conclusions now, but a death during an outpatient”minor” procedure is very rare.  The Rivers case is being investigated—not because it is she, but because any such incident would be investigated.

We don’t know if there were any unusual  specific problems in this one case.  We do know that this particular outpatient center had anesthesiologists present. The Bloomberg News article  (link above)  is quite good, but it emphasizes the importance of having certain “equipment” on hand for emergencies. Surely any facility that would give anesthesia to a person over 80, especially with a history of medical issues, must have had appropriate emergency equipment.

So the investigation would have to look at the check list results for this patient during the pre-op assessment. Were there any warning signs in her history or physical exam and/or were any corners cut or mistakes made during  her assessment and during the procedure?

If she had laryngospasm, (larynx spasm)  then an anesthesiologist should be able to solve that problem.

I think that anyone with a cardiac history should be carefully considered for having their procedure done at the hospital, even if it is a more annoying preop. assessment.  To say that the equipment is the same at both kinds of facilities  does not mean that the safety is the same.  If someone has a cardiac arrest in the hospital, the cavalry  arrives in less than one minute including cardiologists.  That won’t happen at an outpatient center where only the EMT unit arrives.

Also, the article says that there is a 4 minute window without oxygen before brain damage occurs, but that window is actually much smaller in an elderly person.