23 March 2009

Follow-up on Natasha Richardson

Regarding actress Natasha Richarson, who died after an apparently trivial fall, the medical examiner issued his report showing that the incident lesion was an epidural hematoma after all. Not a huge surprise, in that the "lucid interval" was so classic.

It reminds me of a case I blogged last year, about a young skier who arrested on the hill. In that case, I heard the post-mortem showed that the minor fall which had preceded the arrest had caused a fractured clavicle. The bizarre element there was that the clavicular fracture fragment had lacerated the subclavian artery (a complication which I had never even dreamed of) and the patient had exsanguinated into her thorax. And every year a few skiers die of asphyxia after falling into tree wells. Just last Tuesday I helped dig out a snowboarder who had gotten himself stuck in one -- fortunately head-up.

There are so many stupid ways to die out there -- not stupid in the sense that the victim did somethign stupid, but stupid in the sense that some little trivial thing suddenly winds up much bigger and worse than you would ordinarily expect. Sad.

Back on the original point, the Director of Trauma Services for McGill University Health Center, Montreal's trauma center, recently said that the lack of helicopter transportation may have been critical in her injury progressing beyond survivability. I think that may be an overstatement in this case. Certainly the 2-1/2 hour ground transport to Montreal didn't help matters, but the 2 hours' delay in getting to the first hospital put them so far behind the eight-ball that it would have been very difficult to save her in any case.

Having said that, it does kind of boggle my mind that they don't have some sort of medevac capability in a province the size of Quebec. I trained in Maryland, and for that fairly small state there were no fewer than eleven Dauphin helicopters operated by the State Police for EMS transport. And Quebec doesn't even have one? Amazing. Before the "single-payer sucks" advocates jump on this, I would like to point out that in Maryland and many other localities, EMS is paid for primarily out of tax coffers, not by the insurers. This is not about single-payer.

Others commented that it was kind of funny that she wasn't taken to a trauma center straight away, and suggested that too, is a failure of Canadian health care. I would like to point out that would be common at many US ski resorts. I work at times at a level 4 trauma center that is the closest receiving facility to a major ski area, and we get all of the trauma from the resort. Most of it is simple orthopedics, and we are well equipped to handle that. Anything more dramatic gets stabilized, bundled up, and shipped to the local level 2 or 1 center, as appropriate. Except we have helicopters for when it is necessary.


  1. I wonder what the weather was like up in Quebec that day- could a chopper be cleared to fly?
    My family is in NH, and a good portion of the time you cannot get a helicopter evacuation due to nasty northern weather (and tree cover. lots and lots of trees)

  2. It's interesting that you commented on the great access that Marylanders (and anyone passing through) have to medevac helicopters. The system strategically places 8 helicopters around the state so everywhere is within 20 minutes. Unfortunately, that system along with the Maryland Institute for Emergency Medical Services Systems (MIEMSS, which I'm sure you are familiar with if you trained here) is under attack by politicians with financial ties to private medevacs. Can you say conflict of interest? The senators pushing to make the change are trying to capitalize on the crash of Trooper 2 last fall. Could the system use some tweaking? Sure. But what these senators want is to destroy it. It's disheartening.

  3. The Maryland system is an example of a bad state run system. This may be the most dangerous EMS in the US.

    Just about everywhere else, you have two people providing patient care. Not in Maryland.

    There have been many improvements in safety in HEMS (Helicopter EMS). Not in Maryland.

    There is usually a focus on patient care, with highly trained medics, nurses, and/or doctors specializing in critical care. Not in Maryland.

    In Maryland, you stop being a paramedic, so that you can become a State Trooper. You work as a Trooper until there is an opening on the helicopter. Then they train you to be a medic again. A 14 week course. After 14 weeks, you are alone in the back of the helicopter with unstable patients - that is when you aren't performing law enforcement duties. This is not the way to provide good patient care.

    You won't find them cross-training pilots as State Troopers. You won't find nurses and doctors cross-trained, when their job is critical care. This is bad for patients.

    There have been several investigations of the operation of the helicopter system. MSP Aviation has serious systemic problems that need to be fixed. MSP Aviation is badly broken.

    After the crash in September, people realized that, just because they keep saying that MSP Aviation is the model for everyone else, doesn't make it true. Nobody else operates to such low standards.

    MSP Aviation is dangerous and an example of how not to provide HEMS.

    MSP Aviation is a political money grab.

    MSP Aviation has had to cut flights by 2/3 since the September crash. MSP Aviation predicted dramatic increases in fatalities. These never occurred. MSP Aviation continues to lie to get people to support their political money grab.

    Their big argument in support of the system - it's free! It is paid for by a tax on vehicles. Any similar profligate use of tax dollars would be held accountable. Not MSP Aviation. When it comes to accountability they get their protesters out. MSP Aviation has a lot of political support, but they are not an example of good patient care.

  4. I'm surprised too that Montréal doesn't have some kind of air rescue society. Alberta does, and their population is far smaller than the population of southern Québec.

  5. I'm also amazed that Richardson wasn't put on a helicopter--as I've noted before, they have a helipad right there at the Circuit Mont-Tremblant (the race track) for exactly that purpose--getting the critically-injured to the city's formidably-equipped facilities as fast as possibly--and furthermore, there are various commercial helicopter services that offer aerial tours for visitors, though I have no idea if any of them co-ordinate with the hospitals.

  6. I'm currently training out in Ireland (and I'm in Dublin)... You're lucky if an ambulance has a 20 minute response time here. You're actually quite lucky if the ambulance can find your house. And as for choppers, there's one. One. For the whole country. And it isn't a medevac chopper. It's an Irish coastguard sea rescue chopper that every once in a blue moon is lent to the medics for extenuating circumstances.

  7. Anonymous,

    Does the British Army(?) no longer have helicopters in Northern Ireland?

    If they do, are they available for mutual aid? Their posts tended to be near the border, so they should have pretty good access into a large part of Ireland. Or is the border crossing too much of a political problem?

  8. This is one of the trauma team's major bones of contention, the helicopter issue.

    I never understood why we didn't have one, other than the fact that there just wasn't the $$$. Alberta has traditionally been awash in cash and the infrastructure is incredible there. QC simply doesn't tend to invest in infrastructure.


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