The unexpected death of Joan Rivers at 81 years of age occurred during a routine outpatient procedure at an accredited doctor-owned surgery center. Although there are few confirmed reports of what actually occurred, what we do know is that media-fed information can resonate amongst the general public — and our patients. Concerns have been raised about the outpatient setting, patient selection, and types of surgeries that are performed.
As a result, the responsibility falls on us to take a seat at the table in order to address these concerns and to avoid being on the menu. If we take a backseat, the rules will be made for us by those — regulators, lawyers, elected officials — that may lack the expertise or who are not stakeholders. Let’s take a look at some tough issues and start an open and honest dialogue about them.
Routine and minor. Virtually every newspaper article, television segment, and social media post are touting that Joan Rivers was undergoing a routine procedure or minor elective surgery. The words “routine” and “minor” are often misconstrued as being simple or without risk. Thanks to advances in science and research, the dangers of surgery and anesthesia have decreased substantially. But that doesn’t mean these procedures are without risks. Any number of things can go wrong in the operating room. We must weigh the risks of performing the procedure against the diagnostic or therapeutic benefits.
Chronological age versus physiological age. Chronological age should not serve as a cutoff for performing a procedure in an ambulatory surgery center. Elderly patients may benefit from the access, focus, specialization, and quality that are delivered. However, we must be diligent about assessing the patient’s physiological age and carefully evaluating their suitability for the procedure at our centers.
In some cases, the term “age is nothing but a number” bears some truth. We have all seen very healthy 80-year-olds that can literally run circles around some of our 18-year-olds. However, we must keep in mind that age-related disadvantages do exist. In other words, our bodies experience routine wear and tear and there can be a decreased tolerance to physiological stress (e.g. decreases in oxygen levels or blood pressure).
Types of surgery. There is no question that ambulatory surgery centers increase access and convenience for patients while decreasing healthcare costs. However, as we explore new frontiers regarding the types of surgeries that can be performed at our centers, we must remain being staunch vanguards for safety. In addition to having appropriate staff training and an emergency plan (even for rare events), we need to create a review system to see how we are doing and if our results are acceptable.
We must also ask the question: If a complication occurs, would the patient have been better suited to have had the procedure done at the hospital? My first — and hopefully last — tracheotomy that I performed was on a patient being held in the recovery room after an anterior cervical disc fusion (ACDF) because his inpatient room was not ready. The combination of being an inpatient and the delay saved his life. Seven hours after his surgery, the surgical site started bleeding and compressed his airway. He had a respiratory arrest that soon caused a cardiac arrest.
Because he received immediate and heroic care, he lived. Although this is a rare complication, it is a possibility — it was a reality to me, our patient and everyone concerned.
Anesthesia and sedation. They’re not always a necessity. Some procedures that come to mind include cataract surgery, epidural injections, and skin biopsies. I have had patients demand that they be “knocked out”; to which I have responded that I am not Mike Tyson. And, recently, I had a gentleman leave without having his cataract extracted because I told him that his risk for general anesthesia was unacceptable but that we had other options for providing comfort. I slept well that night and the patient lived to tell (or complain) about it.
Pushing the envelope. While doing so has served Madonna’s bank account well, it is unacceptable when patient safety is involved. Let’s say that today we perform an umbilical hernia operation on a patient with a body mass index (BMI) of 35, hypertension, and diabetes. Then tomorrow, we do so on a patient with a BMI of 36, hypertension, and diabetes. And then next week, the patient has a BMI of 37, hypertension, and diabetes. The argument for performing surgery on the heavier patients could be that it has already been done on someone almost the same weight and with the same comorbidities … but nothing bad happened, then. Cutoff lines must remain clear, defined and accountable for review.
As we reflect on the loss of Joan Rivers — an icon, mother, and patient — the media will continue to fuel consumers concerns with information unconfirmed and confirmed. We can do our part in helping to reduce barriers of concern in our communications and actions as we continue to stay vigilant and accountable to proactively review, address and revisit patient safety within our surgery centers.
We are vanguards, hawks, and advocates for our profession on every level. Together, we can ensure that people get the care they need and deserve in the safest and most honorable possible setting.
Nina Singh-Radcliff is an anesthesiologist.
