NEW YORK, NY--The call came in to 911 one second before 9:40 a.m. on Thursday, Aug. 28, from the staff at a clinic on East 93rd Street in Manhattan — a patient in cardiac arrest. The call was coded as “Segment 1,” the highest-level priority handled by 911, according to two New York City officials.
Five minutes and 38 seconds later, at 9:45 a.m., a Fire Department engine company with trained medical responders arrived on the scene. Firefighters entered the clinic, officials said, where staff members were already engaged in trying to save Joan Rivers, the comic known for her raspy voice, rapier wit and surgically enhanced eternal youth. While no specifics have been released by the family, Ms. Rivers was believed to be at the office for a procedure on her throat.
A defibrillator had been hooked up to her and a breathing tube had been placed in her windpipe by the clinic staff, the officials said. She was receiving medications and CPR in an attempt to revive her. Firefighters took over from the clinic staff and started to provide CPR.
Paramedics in an ambulance from Mount Sinai Hospital arrived at 9:47 a.m. and began working on Ms. Rivers as well, along with, a minute later, emergency medical technicians from the Fire Department who arrived in a separate ambulance, said the officials, who spoke on the condition of anonymity in order to discuss the medical response in detail. By 9:50 a.m., there were 10 emergency medical workers on the scene, including a Fire Department supervisor, which is standard practice on serious calls.
“The resuscitation efforts appear to be as good as one could hope for,” one of the officials said.
But seven days later, Ms. Rivers died, after being kept alive on life support.
Since the comedian’s death on Thursday, much has been said about her outspoken, madcap life, but there has been very little discussion of what exactly happened in the medical office where she lost consciousness, or the drama of the all-hands-on-deck attempt to save her life.
The death is being investigated by the State Health Department and the city’s medical examiner.
Her treatment at the clinic, Yorkville Endoscopy, a for-profit center, has drawn attention to a flourishing model of medical treatment, outpatient surgery centers, which have been licensed by the state to replace hospital operating rooms for minor procedures.
Their management structure is often explicitly designed to maximize profits for doctors, who are typically the majority owners. They are common in other states, but only now gaining traction in New York, where by law, the traditional hospital model is nonprofit.
Yorkville is run by an outside management company, Frontier Healthcare, 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.”
While there have been no allegations of wrongdoing, Ms. Rivers’s death has raised a host of questions: Was an anesthesiologist, who would be trained in sedation and intubation, in the room? Was there enough lifesaving equipment in the outpatient setting? Was there adequate prescreening of Ms. Rivers? Despite her appearance enhanced by plastic surgery, she was 81 years old and had admitted to a history of bulimia and heart arrhythmia.
“We would love to set the record straight from all the misinformation that’s out there,” Dr. Daniel J. Adler, a colleague of her personal physician, Dr. Lawrence B. Cohen, at Yorkville Endoscopy, said this week. “Unfortunately, our lips are sealed.”
Marcia Horowitz, a spokeswoman for the clinic, also declined to comment on Ms. Rivers’s case, saying federal privacy laws prevented her or the doctors from speaking about it without the permission of her family, who have released little information.
It is unclear why Ms. Rivers stopped breathing and how long it took to restore her breathing.
“Underlying heart disease, reactions to drugs, the anesthesia, blood pressure changes, all make procedures potentially risky or lethal,” said Dr. Eric Manheimer, who is the former medical director at Bellevue Hospital Center. “The key is prescreening and equipment to manage a potential catastrophe.”
One of the techniques used to revive Ms. Rivers, endotracheal intubation, in which a breathing tube is pushed past the teeth and tongue, between the vocal cords and into the windpipe, is a standard lifesaving procedure. But insertion of the tube can be difficult, and with every passing minute without oxygen, the risk of brain damage grows.
Experts said most doctors lacked the skill to intubate a person in distress. Those who can are most likely anesthesiologists, emergency room doctors, intensive care doctors and emergency medical technicians in the field. “It is something you need to practice and do or you lose it,” Dr. Manheimer said.
Some patients are difficult to intubate because of their neck size, the configuration of their throat, prior surgeries and other factors, he added.
Without commenting on Ms. Rivers specifically, Ms. Horowitz said it was Yorkville’s policy to make sure a patient’s airway had been intubated, if necessary, and to make sure vital signs were stabilized before discharging that patient into the care of the Emergency Medical Service. “The center is not aware of any instance in which this policy was not followed,” she said.
She said patients were prescreened by Yorkville staff, and usually by their personal physicians as well.
The procedure that Ms. Rivers was scheduled to receive has never been fully explained. A spokesman for her said she died after a procedure involving her vocal cords. Friends said she had been complaining of a hoarse voice, a sore throat and strained vocal cords.
Dr. Cohen, her doctor, is a prominent gastroenterologist, with many publications and panels to his name. Based on his specialty, other doctors have surmised that she might have been treated for acid reflux, which could have affected her voice.
That could entail putting an endoscope, a tube with a light and camera, down the esophagus and into the stomach.
Dr. Cohen argued in a 2007 paper in the journal Gastroenterology that gastroenterologists should be able to perform endoscopic procedures on basically healthy people without an anesthesiologist present, a position that has provoked debate in the medical world.
Ms. Horowitz said that the clinic had performed 18,000 procedures since it opened in February 2013, and that its hospital transfer rate was a quarter of the national average. The state has no record of complaints against the facility.
Before Yorkville was formed, Dr. Cohen and a colleague, Dr. Kenneth M. Miller, were sued for malpractice by David Lehr, himself a medical doctor, who had an endoscopic procedure in 2003. Dr. Lehr, who was 93 at the time, said in court papers that he had not knowingly consented to the procedure, which had led to complications.
Ms. Horowitz said that Dr. Lehr was different from Ms. Rivers because he was a hospital patient, and because his treatment was an emergency, not an elective, as Ms. Rivers’s was. A trial led to a verdict in favor of the doctors.
The night before she went into cardiac arrest, Ms. Rivers performed at a cabaret in Manhattan’s theater district. Then she joined an old friend and collaborator, Jay Redack, for a few bites of salmon and her usual glass of white wine with ice at an Upper East Side bistro.
“We had a lovely, festive dinner,” Mr. Redack said.
She told him she was “going in for a little procedure” the next morning.
She did not explain any more, and he did not press her. “She laughed it off,” he said. “It was a thing like she’d go in for plastic surgery, not something that had been of any concern to her.”
SOURCE: The New York Tmes