Joan Rivers' Fatal Surgery: What Went Wrong

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A timeline of the alleged mistakes that led to the comedienne's tragic end

Joan Rivers entered Yorkville Endoscopy on Aug. 28 for a routine procedure. Then, complications that proved fatal arose. She died at Mount Sinai Hospital in Manhattan on Sept. 4 from a lack of oxygen to the brain, the medical examiner ruled.

On Monday, the Centers for Medicare and Medicaid Services (CMS) issued a scathing report that details for the first time what happened in the operating room at the outpatient clinic. Until then, few details were known, even to Rivers' daughter, Melissa, who hired a medical malpractice law firm to investigate her mother's death.

The 81-year-old comedienne, who had been complaining of hoarseness and had a history of acid reflux, had scheduled an esophagogastroduodenoscopy (EGD), a procedure in which a thin scope with a light and camera at its tip is used to look inside the area between the throat and upper intestines. However, the report shows that another procedure, a nasolaryngoscopy (an inspection of the voice box using a spaghetti-thin scope that's passed through the nose), was performed twice by an ENT doctor not privileged to perform procedures at Yorkville. The report says Rivers was never informed of, or consented to, that procedure.

See more Joan Rivers' Life and Career in Pictures

Just prior to the procedures, the endoscopy technician found out that Rivers was coming with her personal ENT (ears, nose and throat) doctor, identified in media reports as Dr. Gwen Korovin. Korovin was escorted into the procedure room by Yorkville Endoscopy's medical director, Dr. Lawrence Cohen. He's since been fired. Korovin was wearing scrubs and holding a suitcase. Cohen requested an extra table so Korovin could set up her suitcase.

CMS contracted the New York Department of Health to review medical records, documents and interviews to compile the report. It's findings provide enough information to establish an approximate timeline of what happened in Rivers' final moments of consciousness. The report says doctors "failed to identify deteriorating vital signs and provide timely intervention during the procedure."

See more  Hollywood's Notable Deaths of 2014

Thursday Aug. 28, 2014

8:44 p.m. Rivers vital signs are taken pre-procedure. Her blood pressure is 118/80, her pulse is 62 and the concentration of oxygen [SpO2] in her blood is 100 percent (the report says normal is between 95 to 100 percent).

9:00 a.m. Scheduled start time for the EGD. The anesthesiologist says she met the ENT doctor for the first time in the procedure room.

9: 04 a.m. A "time-out" (a pre-procedure protocol for verification of the correct person, procedure and site) is called for the EGD by the technician, not by the anesthesiologist, as per policy. The technician "stated that after the 'Time Out' was announced for the EGD and sedation was administered by [the anesthesiologist], [Korovin] announced, "I will go first." Korovin "performed a Laryngoscopy for [Rivers] that was aborted because [Korovin] stated she could not see very well what she was trying to view."  Korovin performed a laryngoscopy before the EGD was done." 

9:12 a.m. Rivers vital signs start deviating. Her blood pressures falls to 117/60, her pulse increases to 71 and her SpO2 is 92 percent.

9:16 a.m. Rivers blood pressure drops to 92/54, her pulse drops to 56 and the oxygen in her blood increases to an SpO2 of 94 percent.

9:21 a.m. Rivers blood pressure (89/44) and pulse (54) continue to drop, and the oxygen concentration in her blood increases to an SpO2 of 97 percent. 

9:26 a.m. Rivers blood pressure drops to 84/40, her pulse drops to 47 and the oxygen concentration in her blood is below normal at 92 percent. 

9:28 a.m. The EGD is done. "The ENT surgeon went in again with a laryngoscope and was there for a minute or two. [Technician] stated that [Cohen] and [anesthesiologist] did not object to [Korovin] performing the laryngoscopy."

"The review of the medical record shows that not all members of the procedure team were identified in the Procedure Note and the role of each team member was not clearly understood by all team members. The team, prior to the procedure, failed to verify procedures to be performed and the indication for each procedure. Not all parties involved in the patient's procedure signed off on the procedure record and record time in accordance with the policy," investigators note. 

The technician "confirmed there was no separate 'Time Out' announced for the initial Nasolaryngoscopy conducted prior to the EGD and the second Nasolaryngoscopy after the EGD," according to the report.

During this second procedure by Rivers' personal ENT, Cohen took a cell phone photograph of the procedure, saying, maybe Rivers "would like to see this in the recovery area," according to the technician.

9: 28 a.m. Cohen finishes the EGD. 

There are two conflicting accounts for what happened next:

9:28 a.m. Korovin attempts the nasolaryngoscopy again. Rivers enters cardiac arrest. CPR is administered. 

9:30 a.m. Korovin withdraws the laryngoscope. CPR initiated.

9:30 a.m. Korovin removes the scope. Rivers blood pressure is 85/49, no pulse recorded and oxygen saturation at 92 percent.

9:38 a.m. Epenephrine and atropine are administered. 

OR

9:28 a.m. Rivers has a pulse and is in ventricular tachycardia (dangerously rapid heart beat), according to another set of notes. She was given the epinephrine and atropine right away.

10:00 a.m. Rivers is successfully resuscitated.

10:04 a.m. Rivers is transferred to Mount Sinai Hospital.

Rivers died one week later on Sept. 4 at 1:15 p.m.

Email: Soo.Youn@THR.com
Twitter: @lalasoo

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