Spontaneous Biopsy Caused Joan Rivers to Stop Breathing Doc who performed it said to be part of her entourage.

Outpatient Surgery News and Trends > General Surgical News and Reports

An unplanned biopsy conducted at Manhattan's Yorkville Endoscopy caused comedienne Joan Rivers' vocal cords to seize, cutting off her air supply and leading to cardiac arrest and ultimately her death, according to a New York Daily News story, which cites an anonymous "medical source who was briefed on the case."

The clinic is disputing the report, however, says the paper, insisting that " 'a biopsy of the vocal cords' has never been done at their facility."

The initial report claims that an unnamed physician, a self-identified ENT specialist who was part of the entourage that arrived at the clinic with Ms. Rivers on Aug. 28, intervened after the clinic's physician noticed something on Ms. Rivers' vocal cords. "He asked (to do the biopsy) and they let him," says the source. "A huge no-no."

Yorkville also refuted the paper's assertion that Ms. Rivers was under general anesthesia during the procedure. "General anesthesia has never been administered at Yorkville Endoscopy," it said in a statement. "The type of sedation used at Yorkville Endoscopy is monitored anesthesia care. Our anesthesiologists utilize light to moderate sedation."

Ms. Rivers died on Sept. 4, a week after being put into a medically induced coma.

"If laryngospasm were the precipitating event," says Corona del Mar, Calif., anesthesiologist Barry Friedberg, MD, "IV lidocaine 1 mg per pound STAT could have broken the episode and spared her life. Lidocaine is more often found than the usual muscle relaxants like succinycholine or rocuronium."

Meanwhile, a New York Times story offers further details regarding what took place on the day of the procedure:

Rescue personnel arrived at the clinic in waves, starting 5 minutes and 38 seconds after a 911 call was made, including trained medical responders, paramedics from Mount Sinai Hospital and EMTs. Ultimately, 10 emergency medical workers were on the scene.

By the time the first rescue personnel arrived, a defibrillator had been hooked up to Ms. Rivers, a breathing tube had been placed in her windpipe and she was being given medications and CPR.

The circumstances surrounding Ms. Rivers' death are being investigated by the State Health Department and the New York City medical examiner. "We would love to set the record straight from all the misinformation that's out there," Daniel J. Adler, MD, PC, a colleague of Ms. Rivers' personal physician, Lawrence B. Cohen, MD, tells the Times. "Unfortunately, our lips are sealed."

It isn't known, says the Times, whether an anesthesia provider was present, but the story notes that Dr. Cohen was among 3 authors of a 2007 article that appeared in the American Journal of Gastroenterology, arguing that under the right circumstances, gastroenterologists should feel free to perform endoscopic procedures without having an anesthesiologist present. "Growing evidence suggests that with the appropriate patient selection, equipment, staffing, and training, gastroenterologists can safely and effectively administer propofol during endoscopy," the authors write.

The Times also notes that the tragedy has "drawn attention to" outpatient surgery centers. Yorkville, it says, "is run by an outside management company which is led by a former salesman, a former investment banker and a gynecologist. Its website lists 10 centers in the New York area, and says they take advantage of 'favorable reimbursement market trends.'"

"A biopsy like that should only be done in a hospital setting," adds the Daily News, quoting its source. "If she had been in a hospital when it happened, she might have been OK."

Jim Burger