Why I don’t take “You just go to sleep” lightly. Thoughts on anesthesia, my son and Joan Rivers

The implications of an anesthetic for Oliver, my 10-year-old son, didn’t fully sink in until he was wheeled into the operating room when I realized he had been assigned not one but two highly experienced anesthesiologists. I didn’t think I could feel any worse but then I heard the relief in one of the anesthesiologist’s voice when she learned that I had convinced my needle-phobic child to have the intravenous (IV) placed before he was sent off to sleep. Most healthy children get to go to sleep first to avoid the fear and pain of the needle stick, but for Oliver a devil’s litany of cardiorespiratory disasters lurked in the background waiting to be unleashed the second the inhaled anesthetic vapors reached his nervous system and heart. The minute or so it takes to get an intravenous into a tiny vein can seem like an eternity when all the alarms are firing. Having the intravenous in place before the anesthetic was one more safety step. Just like having two anesthesiologists. Just like coming to the operating room instead of the dentist’s office.

The dentist didn’t think getting nitrous oxide (laughing gas) to help him through the procedure in the office would be a big deal, but the pediatric cardiologist said absolutely no anesthetic outside of an operating room. For most healthy kids a whiff of nitrous wouldn’t be a concern. Oliver looks healthy so it’s easy to think I’m being over protective, but you only have to rest your hand on his chest and feel his murmur to know otherwise. I can feel it with every hug or when he falls asleep in my arms. They call a palpable murmur a thrill. It is anything but.

Getting to this point had been barely shy of a Herculean labor. Making arrangements for a child with heart and lung issues to have dental work done in the operating room was a challenge for me and I’m a doctor working at the hospital where the procedure was planned. It took interactions with three dentists, an anesthesiologist, a cardiologist, a pediatrician, a nurse practitioner, OR scheduling, the dentist’s scheduling staff as well as dealing with both the health and dental insurance just to get to the operating room. So many phone calls, visits, and e-mails all for such a minor procedure. I almost convinced myself that the effort was out of proportion. After all it’s just a cavity and thousands of kids every day get anesthesia in the dentist’s office. How bad could it really be? And then my partner at work asked how I would feel riding in the ambulance in the event that something catastrophic happened versus how I would feel if I were sitting in the waiting area of the operating room.

Hearing about Joan Rivers’ cardiac arrest during her minor surgical procedure and now her death has caused me to reflect more on our very recent experience. Given the great skill of two anesthesiologists and a dentist Oliver came through the surgery just fine although the way his heart behaved intraoperatively made me very glad that I had jumped over (or more correctly knocked down) every damn hurdle that we encountered. It was not smooth sailing, but it was as safe as it could be. I get a little sick thinking what might have happened without so many experienced hands.

As a physician and as someone who has enjoyed many laughs courtesy of Ms. Rivers I wonder what happened. I have yet to speak with a doctor who thought giving an 81-year-old a general anesthetic outside of an operating room was a good idea. While most patients have the resilience to tolerate many minor and even some major surgical and/or anesthetic misadventures or unexpected reactions there are factors that raise the risk of repercussions, age in the case of Ms. Rivers and cardiac conditions for Oliver. Did Ms. Rivers downplay her age or did her surgeon or anesthesiologist? Did she have an anesthesiologist or did the surgeon administer the sedation? Did she adamantly refuse to have the procedure in a hospital or was that option never offered? Did she have an undiagnosed medical issue that became life threatening once the anesthetic was on board, was there a mistake, or was this just a sad reminder of what can happen when an otherwise 81 year-old comes in contact with general anesthesia? And of course, did she even need a physician look at her vocal cords?

I know how much of a hassle it can be to have a minor procedure in a hospital, that it can seem like such a lot of work for what appears on the surface to be such a little thing. I understand how easy it can be for providers who might be less informed about anesthesia to unintentionally trivialize the experience. I also understand that as a patient (or parent) hearing what you want to hear is the default setting. And in reality out-patient surgical centers are generally very safe, so most people don’t have the experience of hearing about anesthetic related issues in these circumstances. A recent Canadian study found only 0.0004% of patients required transfer to a hospital on the day of surgery from a free-standing surgery center (like the one where Ms. Rivers received care) and another retrospective review from a plastic surgery practice found no hospital transfers for over 2,600 patients receiving moderate to deep sedation in the office.

A risk, even one as low as 0.0004% is still a risk. If you happen to have the bad outcome then in essence it was 100% for you. It is also important to keep in mind that most surgery centers deal with the very healthy. The risk will be the lowest for a very healthy 20-year-old, but higher for an otherwise healthy 81-year-old or a 10-year-old with heart problems. It’s not that being in the hospital necessarily reduces your risk of a catastrophe, but it gives you more options if things go catastrophically wrong. My son needed those options when he had his anesthetic and I wonder if Ms. Rivers did too.

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  1. I have wondered from the beginning if this negative outcome might be related to the variety of procedures Ms. Rivers had previously. I certainly don’t know her surgical history, but if her facelifts etc required anesthetics it is possible that she had more than her share. Just a thought.

  2. Anaesthesia in dental surgeries used to be quite common in the UK. After a few disasters—deaths—this has now ceased. There is no place for general anaesthesia outside of a fully equipped operating theatre in a fully equipped hospital nowadays.

  3. While I agree that many so-called minor procedures would best be done in a hospital, I am just curious – did Ms Rivers have general anesthesia? My endoscopy was not done under general anesthesia.

      1. It is possible to do an OGD (oesophago-gastro-duodenoscopy) without sedation, though it can be difficult if the patient isn’t very “cooperative”—some people get very anxious, understandably. The pharynx etc need a local anaesthetic. It would be possible to look at the larynx in the same way, but any procedure would need sedation. A bronchoscopy would certainly need sedation.

  4. An excellent article for anyone considering surgery. It hit close to home because of my own experience last year with a partial mastectomy. I’d had general anesthesia twice before for knee arthroscopy and a lap-cholecystectomy with no problems at all. But this time there was great difficulty getting me intubation. There was enough airway trauma that I needed a hefty dose of steroids intraoperatively and had considerable throat pain afterwards.

    The anesthesiologist spent a generous amount of time with me in recovery, explaining the type of equipment and airway size that was needed and gave me a written copy of this. Such information could be potentially life saving in the future.

    I had chosen to have my procedure done in a surgery center rather than the hospital. I had total confidence in both my surgeon and the high level of professionalism and care of the facility but the risks of anesthesia had hardly crossed my mind. Had it been a lesser facility with less skilled anesthesia staff, the outcome might have been tragic.

    No one should be terrified about general anesthesia but every consideration needs to be given to what procedures are appropriate outpatient and what options exist. Your article gives the reader considerable clarity.

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