Don’t Let What Happened to Joan Rivers Happen to You

Ever since Joan Rivers died after a routine surgical procedure at an outpatient center in Manhattan, people have been wondering if they’re better off having surgery in a hospital.

The reality is that the vast majority of outpatient procedures go off without a hitch. But you can reduce your risk by getting involved before the procedure. Important steps…


Check Your Physical Status

Ask your doctor about your “physical status classification.” The American Society of Anesthesiologists uses a numerical scale to assess a patient’s surgical risks. Patients with higher physical status (PS) scores (four or five) because of health problems should have procedures done in hospitals because their risk for complications is higher.

Example: A patient who needs a knee replacement also might have poorly controlled diabetes, kidney insufficiency and nerve damage. His/her PS might be rated as four—too high to safely have a major procedure at an outpatient center.

In general, patients with PS scores of one through three—with one being generally healthy and three indicating that they have serious diseases that aren’t life-threatening—are good candidates for outpatient procedures.

Pick Your Surgeon Carefully

Don’t assume that every surgeon in an outpatient center has the same experience—or the same credentials.

Suppose that you’re planning to get Botox or Restylane injections. These are not as simple as most people think. For the best results—and the lowest risk for complications—you should have the procedure done by a physician who is board-certified in plastic and reconstructive surgery.

Caution: In many states, many procedures can be done by any physician who has undergone minimal training in these procedures, such as a weekend course or three-day seminar. These doctors might be board-certified in something but not necessarily in the field that concerns you.

Also important: The amount of experience. Studies have clearly shown that doctors who do a lot of procedures have better results, with fewer complications, than those who do them less often.

Example: If I were planning to have LASIK eye surgery, I wouldn’t feel comfortable seeing a surgeon who had done the procedure 50 times. I would want someone whose total cases numbered in the hundreds or even thousands.

Insist on Pain Control

Most people assume that their surgeons will do everything possible to ­minimize postoperative pain. Not true. Some doctors are reluctant to order strong painkillers on an ongoing basis because they worry that the patient will become addicted. Or they mainly use narcotics (opioids, such as codeine and morphine) that dull pain but can cause unpleasant and sometimes dangerous side effects, including impaired breathing, constipation, itching, nausea and vomiting.

Poorly controlled pain is among the most serious postoperative complications. It impairs immunity and increases the risk for infection…slows healing times…and can increase the risk for blood clots when patients hurt too much to move normally.

My advice: Tell your surgeon that you’re terrified of pain. Ask what he/she plans to use to relieve your pain—and emphasize that you would like to avoid narcotics if at all possible.

Also, ask about bupivacaine (Exparel), a nonnarcotic anesthetic that was recently approved by the FDA. The active ingredient is encapsulated in ­liposomal (fat-based) particles and slowly released over 72 hours. When injected into the surgical area, it relieves pain as effectively as narcotics with fewer side effects.

Beware of Supplements

Tell your doctor about everything that you’re taking. Surgeons and anesthesiologists routinely ask patients about medications that they’re using. They don’t always think to ask about supplements.

This is a dangerous oversight because many supplements—along with garden-­variety over-the-counter medications such as aspirin—can interact with the drugs that are used during and after surgery.

Examples: Garlic supplements increase the risk for excessive bleeding, particularly when they’re combined with aspirin. The herbs ephedra and kava can interfere with anesthetics.

Patients who are taking natural remedies—including vitamin E, echinacea, ginseng, valerian and St. John’s wort—should ask their doctors if they need to quit taking them. You may need to stop two weeks or more before the procedure. Aspirin should be discontinued two to three days before.

Plan for the Worst

Even routine procedures sometimes go south. Most outpatient surgical centers are equipped with crash carts (used for cardiac emergencies) and other equipment and drugs for handling serious complications—but some don’t have these on hand.

Ask the surgeon if a crash cart will be available. Also ask…

• Is there dantrolene (Dantrium)? It can reverse a rare but deadly complication from anesthesia known as malignant hyperthermia. The drug is always stocked in hospitals, but an outpatient center might not have it.

• Is there succinylcholine (Anectine, Quelicin)? It’s a fast-acting paralytic agent that assists doctors in quickly intubating patients who can’t breathe—one of the most dangerous complications of anesthesia. It has been reported that Joan Rivers might have lived if this drug had been available.

Don’t Put Up with Nausea

It is estimated that 30% of all postsurgical patients will experience nausea, retching or vomiting. These are among the most common surgical ­complications.

My advice: Tell your anesthesiologist/surgeon if you’ve suffered from surgery-related nausea in the past. He/she can administer granisetron (Kytril) or ondansetron (Zofran), which helps prevent nausea in most patients.

Get Moving

Try to get moving as soon as you can. Surgeons used to recommend lengthy bed rest for postsurgical patients. They now know that it’s better to move around as soon as possible to prevent constipation, urinary retention and muscle weakness, among other common complications.

As soon as you’re able, get up and walk (with your doctor’s permission, of course). If you can’t stand right away, at least move in bed. Stretch your legs. Move your arms. Roll over, sit up, etc. Any kind of physical movement increases blood flow and improves recovery times. It also improves the movement of your lungs, which can help prevent postsurgical pneumonia.