House Calls / Dr. Michael Schwartz

Recently, the world was shocked by the sudden and untimely death of comedian Joan Rivers. Rivers died from complications that arose during a "routine medical procedure." Now, many are questioning how such a tragedy could have happened to such a strong and vibrant woman. Many are speculating that utilizing a physician's office or out-patient facility for a procedure on an 81-year-old woman must have contributed to her death, while others are questioning what procedure she had and whether it was necessary. Regardless of this speculation, the common concern is if her death could have been prevented.

While the public may never know what actually caused Rivers' death, there are some very important lessons that can be learned from this tragic event. Did Rivers undergo a preoperative (pre-op) examination prior to her surgery? If her procedure had been performed in a specialized medical center (which are generally better equipped should an emergency occur), would she have survived? Finally, what can patients do to minimize their risks during surgery?

When a patient is scheduled for an operation or invasive procedure or test, the doctor performing the procedure will often request a "pre-op" clearance. A pre-op clearance is a specialized medical exam to determine a patient's health status and surgical risk. It does not necessarily mean there is anything wrong with the patient; it is merely protocol to ensure that the patient is in the best possible condition to have a surgical procedure while minimizing the risk for complications. There are established criteria for a patient's surgical risk based on many factors including age, medical history, type of surgery being performed and if anesthesia is going to be used during the procedure.

The pre-op exam will help to determine if it is safe for the patient to undergo the planned procedure. The pre-op exam is generally performed by the patient's own primary- care physician and involves the assessment by the physician, after a thorough examination, of the patient's risk of undergoing a surgical procedure including the anesthesia involved. Based on this exam, additional recommendations may be suggested in order to ensure that the risk is minimized and the patient is in the best condition to successfully undergo the scheduled procedure.

The exam begins with a thorough history. This includes a past medical history, surgical history, a list of medications being taken, an evaluation of social history (such as tobacco use, alcohol consumption or drug abuse), a discussion of family history and any allergies the patient may have. Next, the physician will obtain vital signs (i.e., blood pressure, heart rate and temperature). Depending on the age and risk factors of the patient, an electrocardiogram may also be performed to assess cardiovascular status. Blood tests are very common and help determine a patient's overall health status including the patient's ability to clot should bleeding occur during the procedure. Sometimes, a urine test may be performed to exclude underlying infections or kidney issues. Depending on age and risk factors, the doctor may also order additional screening tests. These may include a cardiovascular stress test to determine the health of the heart and a chest X-ray, especially if a patient is a smoker or has a history of lung disease.

Additionally, some patients with pre-existing conditions may require a consultation with a specialist. It is not unusual for a primary-care physician to recommend a visit to a cardiologist or a pulmonologist if concerns are identified during the initial pre-op exam. Also, depending on the type of surgery being performed, your physician may withhold some of your medications. For example, you may be asked to avoid taking aspirin within a week of surgery and even discontinue vitamins and supplements as they may also increase the risk of bleeding. Most of the time, however, you will be instructed to take your usual medications (with sips of water) before the procedure, especially if they are critical to maintaining regularity, such as normal blood pressure. Your doctor may also prescribe an antibiotic prior to the procedure based on your medical history. Lastly, some medications may actually interfere with anesthesia or the specific surgical procedure you are scheduled to have. Taking certain medications can, in rare instances, cause life-threatening reactions if taken with certain anesthesia agents.

Ultimately, your primary-care physician will prepare a report for your surgeon's review and consideration. It will include any additional recommendations or suggestions before, during and after the procedure to minimize risk and complications. Ultimately, it may also help your surgeon determine the best facility for your procedure.

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Unfortunately, despite all the tests, exams and evaluations, things can go wrong. Risks of surgery include bleeding, infection and sometimes even death. These and other risks should be discussed with you in detail by the doctor performing the procedure. Fortunately, complications can be further minimized when the patient undergoes a comprehensive pre-operative clearance examination.

Joan Rivers' death is a great loss to many. She made us laugh for decades; she was an inspiration of strength and determination; she was/is an immortal comedian. We may never know why Rivers passed so untimely; perhaps her death can serve to help others stay healthy. If you have an upcoming procedure, discuss a pre-op exam with your doctor and the best facility to have the procedure performed. Make certain to ask all the important questions. Yes, we certainly can talk about how to have a safe surgical procedure.

Dr. Michael Schwartz is board certified in internal medicine with a private practice in Darien. For comments or questions, visit his website at