Thursday, March 19, 2009

Natasha Richardson, Epidural Hemorrhage and Canadian Health Care

This CT scan (LEFT) shows 4 TYPES of intracerebral hemorrhage:

1. EPIDURAL short white arrow;
2. SUBDURAL short black arrow
3. SUBARACHNOID long black arrow
4.INTRAPARECNCHYMAL ( = in the brain matter itself)
long white arrow

Yesterday it was my conclusion that Natasha Richardson suffered from a subarachnoid hemorrhage (from a ruptured aneurysm)rather than an epidural or subdural hemorrhage because, as I said:

"Both epidural and subdural hematomas should have / would have been rapidly diagnosed and she would have had an emergency procedure to release the pressure."

In other words, it was my assumption that if she had an epidural or subdural hematoma it would have been rapidly treated when she was taken to a local hospital --Centre Hospitalier Laurentien--after falling ill with a recent history of head trauma.

So if Natasha Richardson had an epidural hemorrhage, the question becomes: did she get a STAT CT scan and was there a neurosurgeon at the hospital, or nearby on call who would be able to do the emergency procedure needed to save Natasha Richardson's life?

Canadian Health Care

It's important to ask this question, because this is precisely the situation where the Canadian-type health care system -- much touted by reform advocates -- tends to fail Canadians.

In the United States, we pay a lot for health care, but that care is widely dispersed, into communities, with high-level diagnostic and therapeutic options available in fairly wide-flung areas.

In Canada, there are only 10.3 CT scanners per million people whereas the U.S. has 29.5 per it is reasonable to ask if Centre Hospitalier Laurentien has a CT scanner, and did Richardson get a CT of the brain STAT?

In the United States if someone falls and hits her head and then an hour later is rushed to the emergency room you can bet she will get a STAT CT scan and immediate neurosurgical attention.

Can you bet that Natasha Richardson got that care? I hope so. I do have some doubts because shortly after being admitted to Centre Hospitalier Laurentien, she was shipped out to a larger hospital in Montreal; and, of course, later that day she was pronounced brain dead.

I hope Natasha Richardson got the appropriate health care and that this was all a tragic and improbable occurrence. But if not, it would be an important thing to know.


dr_dredd said...

There are many areas in this country where someone won't be able to get immediate neurosurgical attention. Due to the malpractice crisis and increasing numbers of uninsured, many neurosurgeons don't take emergency call at all.

Evan said...

As far as I can tell, Natasha Richardson's death does not represent a failure of diagnostic ability of Canadian physicians, but rather a failure of EMS and medical transport. Why are more qualified medics being called off by ski patrol without making patient contact? In the US, that would be considered NEGLECT. Any trained medic would NOT have signed her out AMA and would have insisted on transport and observation.

I am convinced this would not have happened in the US even if the medics got to her at the same point. She would have been IMMIDIATLY transported to the local hospital. The local hospital, knowing it did not have neurosurgical support, would have called in an medical evac helicopter, which would have been waiting "hot" on the helipad. After basic stabilization (maybe with a head CT taken), she would have been flown to a trauma center and would have been in surgery in about an hour. However, if the local hospital were too far, she would have been flown to a trauma center instead perhaps saving any more time. Depending on injury, she would have had a strong shot at surviving and regaining most function.

Instead, Quebec EMS DROVE her to the local hospital and then onto Montreal, which killed any window of possible survival. Transport time was OVER TWO HOURS. She arrived in Montreal at 7 pm, hours after her accident. Honestly, Quebec EMS should be embarrassed. This tragedy did not have to happen, and I only hope the province reforms its EMS so this never happens again.

otyikondo said...

Whilst I'm not a medic, and so probably should not even be commenting here, I think Evan's post ignores one salient "human" point, connected with the patient in question. I suspect that the refusal of an ordinary Joe or Josephine to have treatment would be easier to overturn than that of a high-profile celebrity who said she was "perfectly OK, not to worry". Again, I'm on a limb here, but is it not possible that excessive deference to the patient's wishes (coupled perhaps with the apparently innocuous nature of the fall) conspired to allow that first contact to go wrong, and so vital time was lost? Would American EMS have acted differently, under the same circumstances?

Rositta said...

I'd bet my life that this woman got better treatment than any Canadian got. I would be surprised if there were Neurosurgeons available in a small community in fact there is a shortage of them everywhere in Canada. They all moved stateside for better money.We now know that Quebec doesn't have a medical helicopter. Not every province has one, that's just life up here. Our small community hospital in Ontario's cottage country doesn't have any specialists at all. There is only one doctor available for trauma and it is a good three hour drive to the nearest big city hospital. I guess helmets need to be the newest fashion accessory...ciao

Evan said...

To respond to otyikondo,

When I was a medic, I worked in Los Angeles where I had several "celebrity" patients. I have had this same situation before, and I honestly treat them like any other person. After all, I was the medical authority on scene and most capable of making decisions. Their entourage usually recognized this and let me do my work.

I can never force anyone to go to the ER (there are some exceptions); however, I can be very persuasive. If I did not feel comfortable signing her out AMA, she would know it, and I would have put much effort into convincing her to go. At least in the US, if there is an actual patient, you have to make contact with him, accept the refusal in person, and move on (it is neglect otherwise). Who called off the medics without patient contact? Was she already examined by someone of higher medical training? If not, that is a problem. Also, the whole point of EMS is to get the patient to the right person who can treat her. If the province EMS is not set up that way, than it will happen again. I would have the exact same opinion if it were Joe Skiier.

Starbuc said...

Battle of the medical community rages on it seems in this case. As a 5th year surgical resident I've learned trauma is about time. The time from injury to treatment often makes the difference between life and death. Of course she should have went with the 1st ambulance but that mistake alone should not have been a death sentence.

It was the 7-8 hours it took for her to reach a qualified hospital. My big question is this, why were "burr holes" NOT done at the first hospital with or without a CT Scan? It is the quickest and easiest way to decrease ICP. Put her in a medical coma, drill and go. I've done "burr holes' in a patients room, no operating room required. The knew they would have to transport by ground and how long that would take. Why assist and maintain the heart and lungs when the brain is dying minute by minute. No medication can reduce ICP as effectively as burr holes, yet that was left out of the equation.

I agree with Evan, why did ski patrol call off the ambulance. No matter what the patient said they should have at least seen her. If this had occured I believe she would have been tansported immediately. Medic's are front line and know all the horror stories and they are not afraid to tell them, especially when it's in a patients best interest.

The system failed on every level in this case and it cost a life. I can only wonder how many others have there been? The Canadian system needs a complete overhaul.

I'll get blasted for this ,but I do believe if she had here in the US, she would be at home recovering with her family, not dead and buried.

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James said...

I can never force anyone to go to the ER (there are some exceptions); however, I can be very persuasive side effects. If I did not feel comfortable signing her out AMA, she would know it, and I would have put much effort into convincing her to go.

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