Pure Pedantry

I have been reading more on the Natasha Richardson story overnight, and it appears the story has moved into blame-placing mode. (For the original discussion of the story, read this.)

Possible places to lay the blame (that I have read thus far):

More on these under the fold.

I said before about mandatory helmet laws (and many others said in the comments of the previous post) that while I don’t have a problem with mandatory helmet laws for children, I don’t think they should be enacted for adults. I think adults should be allowed to make risk assessments on their own. Furthermore, as many people have pointed out, a helmet might have saved this woman, but then again it might not have. Helmets can be effective for some things, but it would still be possible to get a deceleration injury with one. Further, there are lots of ways to get hurt on the ski slopes, and it would be unfortunate if helmets gave people the illusion of safety in what is a still dangerous sport.

With respect to the Canadian medicine/CT thing, I agree with MDOD a lot, but not in this case. If Richardson had been taken to the ER and languished there waiting for a CT, I would say that there was a medical system problem, but it doesn’t look like that was the case here. Rather, it looks like she felt fine and didn’t want to go to the hospital during what would have been a critical period for treatment:

Yves Coderre, director of operations at the emergency services company that sent paramedics to the Mont Tremblant resort, told The Globe and Mail newspaper that he reviewed the dispatch records and the first 911 call came at 12:43 p.m. Monday.

Coderre said medics arrived at the hill 17 minutes later. But the actress refused medical attention, he said, so ambulance staffers turned and left after spotting a sled taking the still-conscious actress away to the resort’s on-site clinic.

At 3 p.m., a second 911 call was made — this time from Richardson’s luxury hotel room — as her condition deteriorated. An ambulance arrived nine minutes later.

“She was conscious and they could talk to her,” Coderre said. “But she showed instability.”

The medics tended to her for a half-hour before transporting her to a hospital a 40-minute drive away.

Further, in trying to compare American and Canadian medicine, I have written before that American medicine exceeds other countries on some benchmarks, fails on others, and is equivocal based on differences in patient populations on still others. As a result, I certainly wouldn’t make a judgment based on this single incident, and in general I think that such comparisons are a waste of time.

Whether a helicopter would have saved her? I doubt it. Not unless she wanted to go to the hospital.

Which brings us to the issue of patient education. I am certainly not blaming this poor woman for what happened to her. Do I think she should have gone to the hospital? Yes. Is there any reason that she would have known that? No. And I understand the point of view of the paramedics in this case. You can’t force her to go in the ambulance, even if you very much think her life is at stake. She may have even thought that the ski resort was being excessively risk averse and trying to avoid a lawsuit. The real world isn’t like House: we don’t get to bully patients into doing what we want. We have to persuade them.

The sad fact of this situation is that majority of the public has no idea how head injuries work, how we treat them, and when a good time it is to go to the hospital. And it isn’t just head injuries. Otherwise healthy people — i.e. not elderly, not immunocompromised — come to the ER with the flu all the time, when there is not a damn thing anyone can do about them.

If there is one thing that should come out of this, it should be a greater awareness that even innocuous head injuries can be serious. Be safe, not sorry. If you have a head injury, have it checked out.

But that is just my two cents, what do you all think?

Comments

  1. #1 Tony P
    March 24, 2009

    I had a car accident in 1986 and I wasn’t wearing a seatbelt.

    It was obvious that I hit the windshield. When I got to the hospital the first thing they did before they even stitched me up was x-rays.

    No concussion, no major problems just 11 stitches. Not bad. My left knee got a little messed up but nothing major.

    Like I said, I didn’t refuse treatment. Head wounds bleed like crazy so I knew I at least needed stitches.

  2. #2 Texas REader
    March 24, 2009

    The paramedics didn’t transport for 30 minutes after they arrived at her hotel? I remember a discussion after Princess Diana’s death about “scoop and run” versus “attempt to stabilize before transport” and that scoop and run is the norm in the U.S. and might have saved Diana.

    Though this maybe wasn’t clearly life threatening at the time, perhaps that 30 minutes should be re-evaluated.

  3. #3 John S
    March 24, 2009

    Jake,
    I greatly appreciate your assessment. It would be an even greater tragedy if a resort area and even an entire province suffered economic loss (especially during these times) because of unsubstantiated rumor and innuendo. A family friend recently died under similar circumstances. A seemingly innocuous fall in the home and a “bumped” head resulted in a tragic death less than a week later. This was a very bright and talented man of 49 that thought nothing of the fall and didn’t see a doctor until the following day. Like Natasha Richardson, he paid with his life. Hopefully Ms. Richardson’s legacy is awareness. It may have been her celebrity that cost her her life and it may be her celebrity that saves others.

  4. #4 yirmin snipe
    March 24, 2009

    The other question that no one is talking about, is how much does it cost to do a CT on someone that bumps their head. The fact is it isn’t cheap… if you educate people about the dangers you will end up with hundreds if not thousands or even tens of thousands of people getting CT’s to show they are fine for every one person that is found to have a problem… assume you only waste $250 on a CT scan that could easily be 2.5 million dollars spent to catch that one true hard hit, and no guarantee that the one hard hit person will even be saved…. Does spending that much money make sense? I honestly don’t think so.

  5. #5 D. C. Sessions
    March 24, 2009

    The consent issue is worse than you think.

    If you ask around among ski patrollers and EMTs, you’ll find that (hardly surprising) we’re not immune to closed-head trauma. Despite the fact that we know better than almost anyone the importance of time in the “golden hour,” when a patroller gets bonked on the noggin we often have a very hard time persuading hir to do what we are constantly telling our “customers” to do — go get it looked at. This, despite the fact that on-the-job injuries don’t even have the cost or “waste a good day on the mountain” or “ruin it for the rest of the party” excuses.

    Patient education doesn’t look like a silver bullet either.

    IMHO, consent in the case of head injuries, especially those which impair judgment, is a problem with no good solutions. We live in an imperfect Universe and may as well get used to it.

  6. #6 D. C. Sessions
    March 24, 2009

    assume you only waste $250 on a CT scan that could easily be 2.5 million dollars spent to catch that one true hard hit, and no guarantee that the one hard hit person will even be saved…. Does spending that much money make sense? I honestly don’t think so.

    The cost is for the scanner. Using it is relatively inexpensive, so that assumed $250 is amortized across the thousand (and more.) If you only use it for the three cases where nothing else will do, you still have $250K, pieced out at $83,000 per case. Add in that without the scanner, you’re looking at keeping all of the 1000 under close observation (as was the practive prior to current radiology) and the cost is much more.

    You might as well use the thing and save the extra life.

  7. #7 Cindy Martin
    March 24, 2009

    I agree that people just need to be educated about head injuries and the signs to look for. I wasn’t, and I almost lost my daughter 3 years ago. On Dec. 22, 2005 my 8-year-old daughter fell and hit her head on our tile floor. She cried but seemed okay (clue #1 – no goose egg). During the night she vomited twice (clue #2). The next day my husband and I had the day off, so we went Christmas shopping. When we got home that night we were told she had slept almost all day (clue #3). I decided to wait until the next morning to take her to the doctor. The morning of Dec. 24th I called the pediatricians office and thankfully they were open (I probably wouldn’t have taken her to the ER because that is a $100 co-pay). I really hesitated about taking her to the doctors because it was a $20 co-pay and she seemed a lot better, but I was sure my 7-month-old son had an ear infection so I went ahead and paid the $40 co-pay to have them both seen. When I explained my daughter’s symptoms to the doctor, he stated that she seemed fine but everything I had described could be due to a head injury so he sent us to the hospital for a CT just to be on the safe side. It was a Saturday so we had to go through the ER. The ER physician agreed saying that she seemed fine and it was probably a concusion, but he also agreed to a CT just in case. As the CT began the tech immediately picked up the phone. Within minutes of returning to her room the ER physician gave me the news. My daughter had a large right frontal epidural hematoma (2-1/2 inch) including approximately 5mm midline shift of her brain. They immediately life flighted her to the nearest children’s hospital for emergency surgery. The neurosurgeon told us that if she would have started bleeding again we would have lost her. He said he had never seen a child in such a critical condition that was so alert and responsive. She was talking to the doctors and moving around like a normal kid. She seemed fine. My ignorance and lack of knowledge could have cost my daughter her life. I would never have forgiven myself. Everyone thought I was crazy for taking her to the ER on Christmas Eve. I heard “She just bumped her head – all kids do it – it’s no big deal.” Now they all feel differently. She has a scar from the center of her forehead at the hairline in an arch all the way to her right ear, which reminds us everyday how lucky and truly blessed we are. My daughter is a very happy and healthy 11-year-old. Thankfully she did not suffer any brain damage from her injury. She has been cleared by all of her doctors and is expected to live a long and normal life. Please, please, please don’t take any chances with a head injury. It is better to be safe than sorry.

  8. #8 D. C. Sessions
    March 24, 2009

    Cindy:

    Could I please use your story in a collection I’m putting together for “patient education” at the sharp end of the stick? If it’s all right with you, I’d like to carry this discussion off-board; you can PM me at my (disgustingly public) e-mail address:

    initials at lumbercartel.com

  9. #9 ms mo
    March 24, 2009

    There is no easy answer.

    Several years ago, I was hit on the head by a large sheet of ice falling from a 5 story building. When I continued to have headaches the next day, I called a nurse hotline, was advised to go to a clinic, was sent by the clinic to the ER at a prominent hospital. I waited and waited, and then near midnight was scolded by a resident for being there, and had to take an expensive cab home and go to work the next day. I later received a voicemail telling me I should not have been discharged.

    A year and a half ago, I was violently knocked flat on my back in a public subway. I struck the back of my head on a tile floor. I was dazed and may have been out for a moment or two. I declined the only offer of assistance I received – a call for an ambulance. I would have been taken to the same ER, and preferred to go home on the train to a big bill, a long ER wait only to have another snide doc tell me I shouldn’t be there, and a late taxi ride home.

    I had speech problems for several months, and think I still have damage.

  10. #10 D. C. Sessions
    March 24, 2009

    Cindy:

    Could I please use your story in a collection I’m putting together for “patient education” at the sharp end of the stick? If it’s all right with you, I’d like to carry this discussion off-board; you can PM me at my (disgustingly public) e-mail address:

    initials at lumbercartel.com

  11. #11 Shines
    March 24, 2009

    Thanks for the info. This should be an eye opener to all young and old, just to look for signs.

  12. #12 Lisa Pender
    March 24, 2009

    It is very unfortunate that everyone wants to blame someone else today for accidents these days. My son had a bicycle accident. By the time I got to him (his helmet was on his head, but he hit the pavement face first so it did nothing for his head), his face looked like hamberger. The doctors did a CT scan and where afraid that the bones around his eye socket where broken and looked for probelms with this brain. To our luck and his amazing bone structure, there was nothing. Not even a concussion! The point is, you never know about how each humans body is going to react to any given trauma. Blame is so much easier then taking responsibilty or even recognizing that accidents happen. Are we to blame doctors because someone has cancer? I feel for the Liem/Richardson family. Let them deal with their lose without blame. They will go through that emotion during their healing process. Yes, this would be a good time for people to become aware of the signs of head trauma as Ms. Martin talked about.
    My respects to Mrs. Richardsons family.

  13. #13 Joannah
    March 25, 2009

    I recently came across your blog and have been reading along. I thought I would leave my first comment. I don’t know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

    Joannah

    http://2gbmemory.net

  14. #14 Health Fitness
    March 25, 2009

    I think it is human nature to look for something to blame when a tragedy like this happens. It’s hard for people to understand how someone didn’t receive proper medical care in time and because of it lost their life. What initially looked to be a simple fall, which occurs all the time at ski slopes, turned out to be a more fatal condition.

    There does seem to be failure on various levels that needs to be improved to prevent future tragedies like these from happening. Sure you can’t make someone go the hospital if they don’t want to, but maybe if they have a head injury they may not be thinking as clearly in the first place so it is the responsibility of others around them to persuade them to get medical treatment as quickly as possible.

    Since many ski resorts are in remote areas, it does start there where they need to have mandatory policies in place to help prevent serious injuries from occurring. Also by having an onsite medical technician readily available can help to assess the seriousness of injuries that do occur.

    http://www.s5b.com

  15. #15 remywill
    March 25, 2009

    What an excellent article/post……fact based and balanced without ridiculous unfounded comments and finger pointing. The whole thing is just really sad, hope her family gets through okay.

  16. #16 Jill
    March 25, 2009

    “Joannah” @ 1:11 AM on March 25 is a spam post. I get this one on my blog all the time. Just thought you’d want to know.

    What haunts me about this death, aside from the fact that Richardson was a wonderful actress, is that I think of how many times I’ve bonked my head and now I wonder when you need to seek attention and when you don’t. About a month ago I was getting into the car and hit my forehead HARD on the car — hard enough to see stars. Not only didn’t I seek medical attention, but I then drove 20 miles to work. A few days after Richardson’s death I hit my head on the freezer door, and instead of thinking nothing of it I immediately felt nauseous wondering if I needed to get checked out. It would be helpful if there was a way to know what needs attention and what doesn’t.

  17. #17 canadianrob
    March 26, 2009

    Well for one thing it was revealed that the local hospital to which she was taken actually does have a CT scanner. The hospital does not comment on specific treatments given to people, but it is accepted that she likely did have one.

    THe second point is that while it is probably a concern for the people who live in Quebec that there is no helicopter medevac (they have airplanes however) it is not necessarily true that the helicopter would have gotten there significantly sooner. For starters, we have to assume that the helicopter would have to be dispatched from its base to pick her up wheras the hospital has its own ground ambulance. That means the transport time is not 15 minutes as reported but at least 30 minutes, assuming the chopper is coming from Montreal. Add to that the time to plan the flight, prepare the aircraft and contact air traffic control and get clearance, the time is likely closer to 45 minues as compared to the 60 minutes it took for ground tranportation.

    And while I’m not sure if this policy varies from jurisdiction to jurisdiction, or if its relevant in this particular case, but from what I know (my father is a neurosurgeon who has practiced in both countries) many air ambulance polices requre that even a healthy patient be anesthetized and placed on a respirator since there is less room on a helicopter to work on the patient if they suddenly loose consciousness or stop breathing. This can sometimes make it more difficult to diagnose a patient upon arrival at the medical facility, especially for brain injuries, because the patient is “doped up” and this can delay treatment.

  18. #18 Julia
    March 29, 2009

    candianrob is right. The US press has done a shoddy job reporting what happened to Natasha. She received a CT scan immediately upon arriving at Sainte-Agathe, a trip that we now know took only 8 minutes. (911 transcripts have been released.) A helicopter would not have made much difference time-wise because the distance between Sainte-Agathe and Sacre-Coeur is not as far as American press is reporting. They got here there in 45 minutes, accompanied by a trauma nurse and respirologist. A helicopter ride would have taken only a few minutes less because of the necessary preparation for such a trip.

  19. #19 Dan Maggiora
    April 24, 2009

    No one really wants to see all the times when skiers fall down, go boom, bounce around or whatever and get up and carry on. Heck, how do you think I learned to ski? And that was in the pre-helmet days.
    As tragic as this condition was, I guess I’m living proof it’s just not a super, super common occurance.