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Monday, March 30, 2009

Did Natasha Richardson's Life End Prematurely Because of Canada's Healthcare?


March 26, 2009 --
COULD actress Natasha Richardson's tragic death have been prevented if her skiing accident had occurred in America rather than Canada?

Canadian health care de-emphasizes widespread dissemination of technology like CT scanners and quick access to specialists like neurosurgeons. While all the facts of Richardson's medical care haven't been released, enough is known to pose questions with profound implications.

Richardson died of an epidural hematoma -- a bleeding artery between the skull and brain that compresses and ultimately causes fatal brain damage via pressure buildup. With prompt diagnosis by CT scan, and surgery to drain the blood, most patients survive.

Could Richardson have received this care? Where it happened in Canada, no. In many US resorts, yes.

Between noon and 1 p.m., Richardson sustained what appeared to be a trivial head injury while skiing at Mt. Tremblant in Quebec. Within minutes, she was offered medical assistance but declined to be seen by paramedics.

But this delay is common in the early stages of epidural hematoma when patients have few symptoms -- and there is reason to believe her case wasn't beyond hope at that point.

About three hours after the accident, the actress was taken to Centre Hospitalier Laurentien, in Sainte-Agathe-des-Monts, 25 miles from the resort. Hospital spokesman Alain Paquette said she was conscious upon reaching the hospital about 4 p.m.

The initial paramedic assessment, travel time to the hospital and time she spent there was nearly two hours -- the crucial interval in this case. Survival rates for patients with epidural hematomas, conscious on arrival to a hospital, are good.

Richardson's evaluation required an immediate CT scan for diagnosis -- followed by either a complete removal of accumulated blood by a neurosurgeon or a procedure by a trauma surgeon or emergency physician to relieve the pressure and allow her to be transported.

But Sainte-Agathe-des-Monts is a town of 9,000 people. Its hospital doesn't have specialized neurology or trauma services. It hasn't been reported whether the hospital has a CT scanner, but CT scanners are less common in Canada.

Compounding the problem, Quebec has no helicopter services to trauma centers in Montreal. Richardson was transferred by ambulance to Hospital du Sacre-Coeur, a trauma center 50 miles away in Montreal -- a further delay of over an hour.

Because she didn't arrive at a facility capable of treatment (with the diagnosis perhaps still unknown) until six hours after the injury, in all likelihood by that time the pressure buildup was fatal. The Montreal hospital could not have saved her life.

Her initial refusal of medical care accounted for only part of the delay. She was still conscious when seen at a hospital and her death might have been prevented if the hospital either had the resources to diagnose and institute temporizing therapy, or air transport had taken her quickly to Montreal.

What would have happened at a US ski resort? It obviously depends on the location and facts, but according to a colleague who has worked at two major Colorado ski resorts, the same distance from Denver as Mt. Tremblant is from Montreal, things would likely have proceeded differently.

Assuming Richardson initially declined medical care here as well, once she did present to caregivers that she was suffering from a possible head trauma, she would've been immediately transported by air, weather permitting, and arrived in Denver in less than an hour.

If this weren't possible, in both resorts she would've been seen within 15 minutes at a local facility with CT scanning and someone who could perform temporary drainage until transfer to a neurosurgeon was possible.

If she were conscious at 4 p.m., she'd most likely have been diagnosed and treated about that time, receiving care unavailable in the local Canadian hospital. She might've still died or suffered brain damage but her chances of surviving would have been much greater in the United States.

American medicine is often criticized for being too specialty-oriented, with hospitals "duplicating" too many services like CT scanners. This argument has merit, but those criticisms ignore cases where it is better to have resources and not need them than to need resources and not have them.

Cory Franklin is a physician who lives outside of Chicago. 2009 Chicago Tribune; distributed by Tribune Media Services.


Friday, March 20, 2009
Natasha Richardson, Epidural Hemorrhage and No Help in Canada

The Death of Natasha Richardson

Kevin, M.D. today adduces that Natasha Richardson indeed had a CT of the brain at Centre Hospitalier Laurentien--after falling ill with a recent history of head trauma, but there was no neurosurgeon available to do a STAT craniotomy which would have saved her life; however, this is not a fault of the Canadian system:

in remote resort areas in the United States, small community hospitals would likely lack neurosurgical coverage. In fact, because of the huge malpractice risk associated with the field, even if there was a neurosurgeon available, whether he or she would take emergency call at a community hospital would be in question.

How Remote?

Mont Tremblant is one of the most recognized and popular ski resorts in the world. It is famous for celebrity sitings, and the rich and famous frequently take up seasonal residence there.

As of 2005, Mont Tremblant had been recognized by Ski Magazine as the #1 ski resort in Eastern North America for 8 consecutive years.

Given the popularity of the area and the nature of skiing and snowboarding, Natasha Richardson may be the most famous person that’s ever come down from Tremblant’s slopes needing emergency neurosurgery, but I doubt that she is the first.

According to JAMA :

...head injuries are common in alpine skiers and snowboarders. Head injury is the most frequent reason for hospital admission and the most common cause of death among skiers and snowboarders with an 8% fatality rate among those admitted to hospital with head injuries. Of the 3277 patients with injuries recorded, 578 patients (17.6%) had head injuries. Head injuries accounted for 288 (17.9%) of 1607 alpine skiing injuries, 248 (17.8%) of 1391 snowboard injuries, and 32 (17.9%) of 179 of Telemark skiing injuries.

Head injuries constitute only 5% to 15% of all injuries from ski and snowboard accidents, yet are the primary cause of serious disabling injuries and death. There are approximately 10 fatalities per year in Colorado from accidents on the ski slopes, and among the fatally injured in one study, head injury was the cause of death in 87.5%;

Another report lists the incidence of ski head injury incidence at 0.77 per 100 000 ski visits

And a mega-study estimated rate of one death per 1.5 million skier-days.

Comparable ski areas in the U.S. – say Vail and Park City – both list neurosurgeons in their cities. Vail, Colorado has a population of 4,589 and is home to 1 practicing neurosurgeon. Park City, Utah population 7,371 also lists 1 practising neurosurgeon.

So, ski resorts should probably think hard about neurosurgical availability, is my impression, but all of the above begs the real issue, which is the differences between the Canadian model for health care and ours -- and where ours is going.

Availability of Neurosurgeons

Kevin, M.D. rightly states that a neurosurgeon is probably just as unlikely to be available in a U.S. ski town, as in Canada, and that may be so but the reasons are diametrically the opposite.

Neurosurgeons are not so easy to find in Canada where subspecialization is not rewarded, and 50-60% of boarded neurosurgeons leave the country to practice somewhere else within 2 years of their certification.

The last good data I could find listed only 174 neurosurgeons in the entire country. In the U.S. we have 3,500. A study on the need of neurosurgeons listed the density of neurosurgeons in the U.S. to be about 1/55,000 people which means that an analogous number of neurosurgeons needed in Canada would be about 604.

It is true that neurosurgeons eschew emergency room coverage in the United States, but it is for completely different reasons than in Canada. Here, our ED’s don’t want to pay what it takes to hire a neurosurgeon for coverage; in Canada, no one wants to even be a neurosurgeon.

So, in a sense, the Candian model for health care failed Natasha Richardson because of an artificially created shortage of subspecialists, which is a purposeful design meant to keep costs low in a taxpayer-funded-system. The U.S. would very much like to go in this direction and the plan is to broaden non subspecialized care options while reducing higher-tech procedures, diagnostics and physicians.

But as we go towards a single-payer system, we can all expect that when we need it most, the system will not be there for us, as it was not there for Natasha Richardson.
Posted by Dr.T at 12:17 PM


My Thoughts

As tragic as Natasha's death is, it is even more tragic if it could have been avoided. Liberals always think that they're doing what they do for the people. However, it usually ends up hurting people more than it helps. To add something else to the story, I will also say that Democrats keep saying that they will make healthcare cheaper. People need to remember that you get what you pay for. If they are paying less for healthcare that will probably mean that it is not as good and could cost you your life.

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