Tech entrepreneur Josh Linkner gave the keynote speech at this year’s ASA annual meeting in San Francisco, delivering a rousing talk designed to leave the audience inspired with a can-do attitude and new hope for the survival of anesthesiology as a profession.

It should be a good talk; Mr. Linkner clearly has given it plenty of times. According to national speakers’ bureaus, the 48-year-old “innovation and creativity speaker” and “New York Times bestselling author” charges from $30,000 to $50,000 a pop for his keynote addresses, and guarantees a “fast-moving and entertaining” experience for listeners with “real takeaway value.”

So what did we get for our money?

We learned from Mr. Linkner about five “big ideas” that he believes are the keys to driving innovation in any field:

Every barrier can be penetrated

Video killed the radio star

Change the rules to get the jewels

Seek the unexpected

Fall seven times. Stand eight.

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New York Post reporter Susan Edelman revealed on January 4 the name of the unfortunate anesthesiologist allegedly present on August 28 at Yorkville Endoscopy, during the throat procedure that led to the death of comedian Joan Rivers. She is reported to be Renuka Reddy Bankulla, MD, 47, a board-certified anesthesiologist from New Rochelle, NY.

Having her name made public will be a nightmare for Dr. Bankulla, as investigators will certainly target her role in Ms. Rivers’ sedation and the management — or mismanagement — of her resuscitation.

When the news of Ms. Rivers’ cardiac arrest and transfer to Mt. Sinai Hospital became public, many of us guessed that there might have been no qualified anesthesia practitioner — either anesthesiologist or nurse anesthetist — present during the case. The gastroenterologist and then medical director of the clinic, Dr. Lawrence Cohen, argued famously that the sedative propofol, which Ms. Rivers received, could be safely given by a registered nurse under his supervision, and that no anesthesiologist is necessary.

However, with the publication of the Centers for Medicare & Medicaid Services (CMS) report of September 5, it became clear that an anesthesiologist was definitely present. The anesthesiologist was identified only as “Staff #2” in the report. She was interviewed by the CMS surveyors four days after the event, but said she was “advised by her legal representative not to discuss the case.”

Key pieces of information about what happened still haven’t been made public. Nonetheless, the surveyors gathered enough information to reach this conclusion:  “The physicians in charge of the care of the patient failed to identify deteriorating vital signs and provide timely intervention during the procedure.”

By any standard of care, the anesthesiologist clearly would be one of the physicians in charge.

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“I’m here to say ‘Yes, they can,’ which is different from ‘Yes, they always do,’” says James Moore, MD, President-Elect of the California Society of Anesthesiologists (CSA).

To the contrary, enthusiasm for electronic medical records (EHRs) is part of a “syndrome of inappropriate overconfidence in computing,” argues Christine Doyle, MD, the CSA’s Speaker of the House.

The two physician anesthesiologists (and self-identified “computer geeks”) squared off in a point-counterpoint debate in New Orleans as part of the American Society of Anesthesiologists (ASA) annual meeting, with Dr. Moore defending the benefits of EHRs and Dr. Doyle arguing against them. Dr. Doyle chairs the ASA’s Committee on Electronic Media and Information Technology, while Dr. Moore leads the implementation of the anesthesia information management system (AIMS) at UCLA.

Legibility, accuracy, quality

Dr. Moore defined safety in anesthesia care as “minimizing patient injury resulting from or occurring during anesthesia, and keeping surgeons from harming patients any more than they have to.” He said that computerization contributes to safe anesthesia care by improving legibility, offering clinical decision support with readily available reference information, and providing alerts and reminders.

Computer tracking of the anesthetized patient’s vital signs is more accurate, Dr. Moore said. It prevents the “normalization” of blood pressure that tends to appear on the paper record. Quality reports are easier to generate and outcomes are easier to measure with EHRs in place, he noted. “Postop troponin levels and acute kidney injury are easy to track.”

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The ear, nose and throat specialist who treated comedian Joan Rivers on August 28 has been identified as Dr. Gwen Korovin, a prominent New York physician who is known as a voice doctor to many entertainers and Broadway stars including Hugh Jackman and Julie Andrews.

With a physician who is an expert in airway anatomy at her side, and all the technologic advantages of a modern clinic in Manhattan’s upper east side, the 81-year-old Ms. Rivers must have anticipated an uneventful procedure. Instead, she stopped breathing and suffered cardiac arrest. The question remains:  What went wrong?

Credentials questioned

Several sources have reported that Dr. Korovin had not completed usual credentialing procedures at Yorkville Endoscopy, and did not have privileges to do anything but observe on the day Ms. Rivers was treated.

In fairness, the credentialing process at a hospital or ambulatory surgery center (ASC) simply reviews documentation that the physician is qualified to perform procedures, and grants the physician privileges to practice there. Physicians choose where they want to work, and don’t necessarily maintain privileges at more than one hospital or ASC.  A lack of privileges doesn’t imply a lack of experience or training; it simply means that the physician hasn’t gone through credentialing steps at that facility.

In Dr. Korovin’s case, her attorney’s statement notes that she “maintains privileges at one of the city’s most prestigious hospitals.” Her prominence in Manhattan may have led to an assumption that her credentials at Yorkville Endoscopy were in order, although it is the responsibility of each facility and its medical director to make sure.  Dr. Lawrence Cohen, Ms. Rivers’ gastroenterologist, was the medical director of Yorkville Endoscopy at the time of Ms. Rivers’ treatment, and has since resigned.

Critical lack of oxygen?

Ms. Rivers suffered cardiac and respiratory arrest while at Yorkville Endoscopy for evaluation of why her voice was getting raspier. She was resuscitated and transferred to a nearby hospital, but died a week later after discontinuation of life support.

Initial autopsy results were inconclusive, according to CNN’s report of a statement from the medical examiner’s office, meaning that no obvious cause of death was clear, and more tests will be done.  This information appears to rule out some causes of sudden cardiac arrest such as pulmonary embolism, the formation of a large clot that stops blood flow through the lungs.

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Since the death of comedian and talk-show host Joan Rivers, more information has surfaced about the events on the morning of August 28 at Yorkville Endoscopy. But key questions remain unanswered.

News accounts agree that Ms. Rivers sought medical advice because her famous voice was becoming increasingly raspy. This could be caused by a polyp or tumor on the vocal cords, or by acid reflux irritating the throat, among other possible causes.

So Ms. Rivers underwent an endoscopy by Dr. Lawrence B. Cohen, a prominent gastroenterologist, to evaluate her esophagus and stomach for signs of acid reflux. At the same time, a specialist in diseases of the ear, nose, and throat (ENT) reportedly examined her vocal cords (also known as vocal folds).

We don’t know exactly how much or what type of sedation Ms. Rivers’ may have received, though several news sources have reported that she was given propofol, the sedative associated with the death of Michael Jackson. No physician who specializes in anesthesiology has been identified on the team taking care of Ms. Rivers, and we don’t know who was in charge of giving her propofol.

It seems clear that at some point during Ms. Rivers’ endoscopy and vocal cord examination, there was a critical lack of oxygen in her bloodstream.

Was laryngospasm the cause?

Giving sedation for upper endoscopy is tricky, as any anesthesia practitioner will tell you. A large black endoscope takes up space in the mouth and may obstruct breathing. Any sedative will tend to blunt the patient’s normal drive to breathe. But most patients breathe well enough during the procedure, and go home with no complaints other than a mild sore throat.

News reports have speculated that the root cause of Ms. Rivers’ rapid deterioration during the procedure could have been laryngospasm. This term means literally that the larynx, or voice box, goes into spasm, and the vocal cords snap completely shut. No air can enter, and of course the oxygen in the bloodstream is rapidly used up.

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