Hey Doc, Can We Talk? Examining the Death of Joan Rivers Featured

By Seema Iyer, Esq.

September 16, 2014

Joan Rivers’ death at 81 seemed sad yet predictable due to her age.  The story surrounding her death was oddly secreted, but now piece by piece is being slowly revealed.  And it appears the doctors involved may have made some serious mistakes.

By now we all know Ms. Rivers went to the Yorkville Endoscopy Clinic complaining of a sore throat and hoarse voice.  The renowned gastroenterologist, Dr. Leonard Cohen, was tasked with performing an endoscopy to explore her digestive system suspecting acid reflux.  During the procedure where Ms. Rivers was under full sedation (by propofol which ultimately killed Michael Jackson) Dr. Cohen called in Ms. Rivers’ Ear, Nose and Throat doctor to examine Ms. Rivers’ vocal cords.  This ENT doctor accompanied Ms. Rivers to the clinic appearing as a member of her ‘entourage’ – mistaken for her makeup artist.

Original claims that a vocal cord biopsy caused Ms. Rivers’ death have since been denied by the clinic, which makes the cause of her death even more confounding.  Privacy laws are shielding questions from the public however, both the New York City Medical Examiner and the NY State Health Department are investigating the clinic, the ENT’s name has still not been released and Dr. Cohen, also the clinic’s medical director, has…….‘left the building’ – or, more likely, asked to leave the building.

In 2009 a Scientific American investigation found that over 200,000 people die each year from preventable medical mistakes and infections – more than twice the amount from just a decade ago.  According to Diederich Healthcare in 2012, 31% of all medical malpractice claims were death-related. 

What went wrong first in Ms. Rivers’ case?  With her advanced age, history of heart arrhythmia and bulimia, having an endoscopy in an outpatient clinic rather than a hospital seems like a poor choice.  But she consented, essentially waiving that portion of any claim.

Dr. Cohen was indeed qualified to perform the endoscopy.  During the procedure Ms. Rivers was sedated with propofol.  The clinic has stated Ms. Rivers was not under general anesthesia but rather light to moderate sedation.  Considering propofol is more commonly used for deep sedation and general anesthesia, the use of it as the clinic purports heightens suspicion.  If Ms. Rivers stopped breathing because of complications from the anesthesia it could be because there is such a slim margin of error in the administration of propofol – a thin line between sedation and respiratory arrest.

Still the risks of anesthesia are quite low.  The American Society of Anesthesiologists have found that over the past 25 years anesthesia-related deaths have decreased from two deaths per 10,000 to one death per 200,000-300,000 anesthetics administered.

A specific possibility related to both reflux and anesthesia, Ms. Rivers may have experienced laryngospasm, shutting of the vocal cords, which could have been managed with the drug succinylcholine.   That drug was not on hand.  Still, the clinic maintains it has the lifesaving equipment tantamount to a hospital emergency room.

It is still unclear why the ENT came into the room to examine Ms. Rivers - the ENT who did not have authorization to practice medicine at the clinic.  Even if Ms. Rivers was in moderate sedation she wouldn’t have had the volition or authority to request her doctor, the ENT, to enter the room.  And by examining Ms. Rivers did the ENT also administer treatment?  Leading to the ultimate question – did the ENT contribute to Ms. Rivers’ death?

Doctors, hospitals, all medical providers in fact, have a legal obligation known as a duty of care – to provide a standard of reasonable care while performing any action that has potential to cause injury.  Medical providers must adhere to the accepted standard of the medical community in their field. 

There is no doubt that every doctor in Ms. Rivers’ case – from Dr. Cohen to the ENT, the anesthesiologists purportedly present at the clinic all the way to the doctors at Mt. Sinai hospital where she died – owed Ms. Rivers that duty of care.  The next inquiry is whether that duty of care was breached.

From the limited information we have now, Dr. Cohen and the clinic appear to have been deficient in the endoscopy procedure.  That could specifically include the anesthesiologist who administered the propofol.  By allowing the ENT to examine Ms. Rivers without clearance, the ENT, Dr. Cohen and the clinic, as an entity, breached their respective duties.

Still breach means nothing without causation.  The ultimate inquiry is whether the breach was the cause of the injury. 

If the cause of death was not from propofol – the anesthesiologist did not breach any duty.  And even if the ENT’s examination did not cause Ms. Rivers’ death, there was still a breach.  However, breach without causation equals no recourse. 

So maybe fault lies in the intubation, an emergency procedure to restore breathing.  Extremely difficult to perform but for those few with expertise, perhaps that is what caused Ms. Rivers’ death.  Might Ms. Rivers have had a natural adverse reaction?  Or was an error during the endoscopy compounded with further mistakes during the attempt at saving her life.  Bottom line – did medical negligence harm Joan Rivers?

That is what will surely be (or should be) litigated in the months to come.  At eight-one years old, Ms. Rivers still juggled a demanding work schedule.  In a wrongful death lawsuit, family members can recover both economic and non-economic damages.  Ms. Rivers passed in New York where the medical malpractice payout is the largest in the land; in 2012 it was $763,088,250 compared with Pennsylvania far behind at second with $316,167,500.

Yes, it’s morbid to talk dollars right now when the country’s still mourning the loss of a comedic legend.  Yet it’s never too early to investigate, analyze and question avoidable injury.  Our doctors are held to impossible standards at times but ones they took an oath to uphold.  Simply put, something went wrong in that room while treating Joan Rivers, something that made death come too early – even at 81.

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Seema Iyer is a criminal defense & civil rights attorney with her own lawfirm in NYC.  Seema appears frequently on MSNBC, HLN and CNN as a legal analyst. Follow her on Twitter @seemaiyeresq

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