David F. Dies

It was reported that Joan Rivers underwent endoscopy by Dr. Lawrence Cohen, one of the most prominent GI doctors in the country. During the procedure he allowed another physician not licensed in that facility to biopsy her vocal cords.

Ms. Rivers had consented for endoscopy of the GI tract, not a biopsy of her vocal cords. While under deep sedation she then developed vocal cord spasm and could not breathe. Whoever was in charge of her sedation was unsuccessful at reversing it quickly and maintaining her airway. She “coded” and later died.

In 2009, Dr. Cohen became controversial in the GI world when he published a liberal editorial arguing that sedation with a popular sedative called propofol was so safe that no anesthesia personnel were needed. He furthered his agenda by chairing a task force that published four more papers in all the major GI journals calling for less regulation on procedural sedation with that drug. I was personally aghast by what I felt would be a very risky medical practice. In frustration I wrote a letter to the editor of the most prestigious medical journal in my field. I argued that only trained anesthesia personnel should administer propofol sedation. I felt this “little ole” Shreveport doctor’s letter would never get noticed or published, but writing it made me feel better.

Funny thing ... my letter got both noticed and published. Other doctors around the country shared my concerns and a grass roots effort evolved to oppose this “de-regulation.”

CMS (the governing body for Medicare) apparently shared my views and ultimately ruled that propofol sedation could only be administered by trained anesthesia personnel (such as a CRNA or a doctor). The FDA concurred and similar language is plainly contained in the official product package insert. I have since heard Dr. Cohen speak and he continues to disagree with these governing bodies.

I was not present that day. I wonder when Ms. Rivers developed respiratory trouble if anesthesia personnel were available because Dr. Cohen was so outspoken against it and felt it unnecessary. During a sedation emergency, trained anesthesia personnel can be invaluable.

Louisiana (fortunately) has stricter regulation than the state of New York. Here, propofol sedation cannot be given during a procedure by a nurse or assistant. It can only legally be given by an MD or a CRNA. If your surgeon intends to sedate you with propofol then ask a few questions. “Who will be giving the sedation?” The answer needs to a doctor or CRNA, not a nurse or an “assistant.”

Once you identify who will be giving the sedation, then ask “who will be monitoring me while I am asleep?” The standard of care is that the person monitoring you cannot be actively involved in the surgical procedure. Their only job must be to monitor you. Even if the person monitoring will not be giving the sedation, minimal qualifications of training still exist. In Louisiana the monitor has to be a physician, CRNA or a nurse. Other “assistants” are not legally allowed to monitor medical sedation. Finally, the operating surgeon should not also be administering and simultaneously monitoring sedation.

Sadly, the “queen of comedy” will no longer make us laugh. I hope that her story and an abundance of respect for safety during procedural sedation will save someone’s life, which in my humble opinion is no laughing matter.

Dr. David F. Dies lives in Shreveport.