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.


Rositta said...

How can you get a Neurosurgeon to work in a remote community when there aren't even enough in the cities? Most of these small communities (our own cottage town included) can't even get a GP to work there. Young doctors simply don't want to live away from big cities. Mt. Tremblant is beautiful but to live there year round wouldn't be an option for a top doctor. What they need and can't afford is a medical helicopter. Would it have helped, maybe and then again maybe not. There have been a number of deaths this winter from both skiing and boarding notably 19 in British Columbia alone from avalanches. Bottom line is she refused help and you can't force someone to accept help against their will...ciao
sorry for rambling

Bananna in Chgo said...

Let's be real. Canadian health care sucks. It isn't reported because their media is filled with extreme socialists.
There aren't enough specialists to go around because there's no monetary incentive for physicians to seek advanced training. Thousands of Canadians die each year because of poor health care and being stuck on waiting lists for MRIs, CTs, etc. Or they do not receive the medication they need because it is considered too costly. So who really is the uninsured?
That's why many Canadians come to the US if they have cancer or other illness. If they have any assets, they liquidate them to pay for health care in the US.
Natasha Richardson died because the Canadian health care system. Shame on Canada for not having trained physicians to help her.
I would not go skiing in Canada. In fact, I may not travel there at all even though it is a beautiful country. I would rather travel to a 3rd world country. At least there is someone to treat you if you have cash! This is from a personal experience as a tourist in Canada. I had visited Canada 4-5 times a year for the past 10 yrs. Stupid me for putting myself at risk.

Bananna in Chgo said...

I forgot to mention in rural areas they may not have neurosurgeons on hand.. but they do have physicians who are comfortable performing common life saving operations for head trauma. This was not the case in Mt. Tremblant. It shows they don't give a crap about the tourists. It's all a money grab for them. If you ski, stick to Vail.

northernjim said...

Natasha's death was tragic. She died because of a tragic accident. To suggest that she died because of Canadian health care is disingenous. Her CT scan was delayed for hours because she made a mistake and initially refused help. Would it have made a difference? No one will ever know. But please 'Bananna' continue your rant, don't let facts interfere with whatever your agenda is.

John said...

"Let's be real. Canadian health care sucks. It isn't reported because their media is filled with extreme socialists."

Actually the report on problems all the time. Like any system, it has it's flaws.

That said, we live longer than you guys. And we have a considerably lower infant mortality rate.

But whatever you do, don't let the facts get in the way of exploiting an accidental death to promote your deeply flawed ideology.

Bananna in Chgo said...
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Diggadave said...

You may be a doctor, Dr. T, but you are no mathematician.

If Canada (population 32m) has 174 neurosurgeons and the USA (pop. 300m) has 3,500, then according to my math, for Canada to equal the USA's 1 neurosurgeon per 55,000 people, then Canada's 174 neurosurgeons should be sufficient for a total population of 96m people, to THREE TIMES THE SIZE of the EXISTING POPULATION!!!!

Perhaps you are referencing some future Canada? Or MAYBE you took a study that applies to the US, ignoring the metrics used to compile the statistics and simply can't divide and multiply???

I'm not sure which it is, but it sure doesn't add up to a robust critique of the Canadian medical system.

Dr.T said...


Ummm...I don't want to embarrass anyone here but you need to divide 32 milion by 55 thousand.

Even if you couldn't do that computation and you just looked at the population figures you could see that we have more than 10x the Canadian population and they have a far less disportionate number of neurosurgeons.

franco said...

Tremblant is beautiful but to live there year round wouldn't be an option for a top doctor. What they need and can't afford is a medical helicopter
i saw your website when I was in generic viagra class and I am very interested

James said...

I would not go skiing in Canada. In fact, I may not travel there at all even though it is a beautiful online xanaxcountry.

MIPS said...

Your math doesn't suck but you didn't show the calculation that shows the USA is short of neurosurgeons to meet the 1 / 55,000 density. ;)

MIPS said...
This comment has been removed by the author.