A Bedtime Story
A bedtime story:
Once upon a time there was a doctor who specialized in looking into peoples intestines. He made a lot of money doing this, but he wanted to make more. He thought and thought about what he could do to make more money. I could charge more for my procedures, he thought, but Medicare won’t pay. I could do more procedures, he thought, but there’s not enough time in the day. And then the doctor had an idea. A terrible, awful, glorious idea. He would do the anesthesia for his procedures himself! That way he could get paid for the procedure AND the anesthesia! The doctor was so excited about his new idea that he published a whole paper about it in 2003 in his favorite magazine (Gastrointest Endosc. 2003 Nov;58(5):725-32.) He continued on doing both his procedures and his anesthesia for many years, and came to think of himself as quite a smart and famous doctor. He would have lived happily ever after except that one day another famous person came to have her intestines looked at by the smart and famous doctor. He did his procedure and his anesthesia as he always did, but something happened, and the famous person died. Now the doctor is famous, but for a different reason. The end.
I know, it’s kind of brothers Grimm don’t you think? Unfortunately this is a true story, as my dear readers have no doubt figured out. The famous person was Joan Rivers, the doctor one Dr. Lawrence Cohen. Now, Dr. Cohen has for some years been a vocal proponent of nurse-administered anesthesia for his endoscopy procedures, generally colonoscopies and endoscopies (scope of the stomach and upper intestines). At my institution nurses do plenty of sedation without the oversight of an anesthesiologist, in selected patients, in graduated doses of a sedative (midazolam) and a narcotic (fentanyl), with upper limits. For colonoscopies, in particular, this usually works fine. They never, ever use propofol. In his 2003 paper Dr. Cohen opined that “…propofol, potentiated by small doses of midazolam and meperidine, can be safely and effectively administered under the direction of a gastroenterologist.”
What’s the problem? Well, I’ll tell you what the problem is. Propofol is a powerful sedative that is also used to induce general anesthesia. General anesthesia generally involves making someone stop breathing so that the anesthesiologist can do it for them. Some people will stop breathing with 30mg. Some people are still snoring at 350mg. If a person wants to use propofol for sedation, there’s a very fine line between asleep and not breathing, a line which is different for everyone. So propofol can make you stop breathing. Then Dr. Cohen, in his infinite wisdom, decides it’s ok to add meperidine (demerol, a narcotic) ON TOP of the propofol. Narcotics can make you stop breathing too. Then Dr. Lawrence decides that Midazolam is ok to add too, because, really, why not? It’s super irritating when he’s trying to do his procedure and the patient is moving around.
Nine times out of ten Dr. Cohen would get away with this, as long as everyone is familiar with how to mask ventilate with an ambu bag, like on ER. Theoretically a nurse could stop the sedation and “bag” someone for the 5 minutes it takes for the propofol to wear off. As long as the patient is maskable, which isn’t always the case and takes experience to predict ahead of time. It’s dangerous and stupid, but he could probably squeak by.
And even THAT would have been OK for Ms. Rivers, since she was probably maskable, except for one small problem. If the vocal cords are shut tight, you can mask ventilate until Saturday Night Live comes on and no air will get into the lungs. Why would the cords be shut tight? Because the endoscopist (i.e, Dr. Cohen), is mucking about in the patient’s mouth and throat, pushing large scopes into the esophagus which is, lo and behold, right behind the vocal cords. Now usually if you get something on your cords you just cough. BUT, if you are too sedated to cough because you have three sedatives on board you don’t cough. Your vocal cords just spasm and you suffocate.
And even THAT would not have killed Joan Rivers if she had had an anesthesiologist in the room who knew what to do in such situations. But she didn’t. She had Dr. Lawrence Cohen, amateur anesthesiologist to the stars.