18 March 2009

Talk and Die

Kevin has a bit of speculation about actress Natasha Richardson, who reportedly, suffered a head injury during a ski lesson in Canada.   She is universally described as seriously ill, with some reporting that she is brain dead.  Hopefully that will turn out to be an exaggeration.

It has been noted numerous times that while she was not wearing a helmet, she was on a beginner's hill having a private lesson when she fell, with the implication that she was not engaging an a particularly risky activity.  True enough -- the serious injuries only rarely occur in these settings. 

But the really key thing to recognize in these injuries, is that although snow is soft, ice is hard, as hard as concrete, and even a low-risk mechanism of injury such as a fall from a standing position is more than sufficient to crack the skull.   A fall on skis, or ice skates (especially ice skates) needs to be recognized as a high-energy mechanism of injury.    This is why I'm such an aggressive advocate of wearing a helmet while skiing or snowboarding -- one of the hospitals where I work is the closest to a regional ski resort and we see lots of head injuries there.   Fortunately, helmets are fashionable wear for the teens these days -- they like it because it makes them look "extreme."

As for the mechanics of the "talk and die" syndrome, the blogger at Kennedy's Tumor has a differential:

1. Epidural Hematoma
2. Subdural Hematoma
3. Subarachnoid hemorrhage

To which I would add:
4. Cerebral contusion
5. Diffuse axonal injury

I recently wrote about a young man with nonsurgical head injuries who surprised us by dying.   He differed from Ms. Richardson in that he was clearly concussed, while media reports describe her as asymptomatic for the first hour or so.   But who really knows?

I'd favor an epidural hematoma, myself, as the most likely cause of the problem, but it would be anything.   I'd differ from Dr. T in that I think a non-traumatic SAH is possible but pretty unlikely -- we know she fell and it seems needlessly complicated to presume a pre-existent lesion.  Ultimately, though, it's a huge tragedy for all involved, and very sad even if she does pull through.  The take home message is for everybody who straps on skis to get yourself a goddamn brain bucket and wear it religiously.  I do -- and it's saved me from a few concussions (or worse).   Better yet, it keeps your head warm and keeps your ipod ear buds in place.  It's a win-win!

UPDATED:
Ms Richardson is now confirmed to have died.  My condolences to her family.

16 comments:

  1. All good points, and the first thing duly noted is that she wasn't wearing a helmet.

    Its hard to believe she could fall and hit her head hard enough to fracture the temporal bone (the usual case for epidural) yet be "laughing" and refuse treatment then saunter home. But as you say, there really isn't enough info and...who knows, for sure. These cases are always disturbing...

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  2. I had a pretty bad concussion after getting knocked over in a hockey game (wearing a helmet) around Valentine's day the year before last. It was my second concussion in a month (the first one was tiny, I didn't even recognize it for what it was). I felt fine at first -- I even played out the game (dumb!) -- but over the next couple of days it got worse and I ended up pretty miserable and impaired for a couple of months. Anyway, the point of this story is that I was surprised how cavalier my doctors were about the whole thing. Obviously I'm here today so I guess they were right, but every time I read a story like this where the patient initially felt fine I think "eesh, it could've been me".

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  3. Even on a motorcycle, what the helmet protects against is a fall from sitting height to the ground. The lateral forces are less significant. If you ride a motorcycle straight into something, no helmet will matter. Other injuries will also be fatal.

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  4. Maybe she had a TIA kind of thing which caused her to fall and then developed into a massive stroke later.

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  5. This sort of stuff is scary. We had three patients all in a row who either had a TBI or a spinal cord injury from falling on ice.

    They all recovered well (which is why working in acute rehab is SO INSPIRING!)

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  6. Doubt diffuse axonal injury. They are gorked out from the beginning.

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  7. In cycling, there's much debate about whether helmets are actually effective at protecting against injuries. Surprisingly, research is pretty inconclusive. (And I say this as a religious helmet wearer.)

    Is there good evidence that ski helmets actually reduce injuries?

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  8. Anon,

    I tend to view it in the vein of -- there's no good evidence that helmets reduce skiing (or cycling) injuries in the same way that there's no good evidence that parachutes reduce skydiving injuries.

    Just common sense, I guess. If you wanted to do a study it'd be damn difficult to do, what with the relative rarity of such injuries, on the order of 1 per 100,000 hours the activity is engaged in. What sort of numbers would you need for statistical significance? It'd be huge. And what about the control group? Would that even be ethical?

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  9. Do you think they did a STAT CT on Richardson at Centre Hospitalier Laurentien, where she was initially taken for care? Seems that she was shipped out shortly thereafter to a larger hospital in Montreal, and thereafter declared brain dead.

    It might be a relevant inquiry given that in Canada,there are only 10.3 CT scanners per million people (whereas the U.S. has 29.5 per million) and that in the Canadian system they brag that the average STAT CT is done in "less than 24 hours."

    I talked about it today at http://tedstumor.blogspot.com/2009/03/natasha-richardson-epidural-hemorrhage.html

    I think it's an important question.

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  10. Dr T,

    Good question, though I'm not sure how to find out the answer. Let me know if you find anything definitive on the point.

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  11. The parachute example is just silly. There's LOADS of research on parachutes, and was before they started using them to jump out of planes. They tested shapes, sizes, materials, and continue to test those things, which is why parachute technology has advanced so significantly.

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  12. Sheesh. Talk about missing the point. You see, they never tested parachutes vs no parachutes!

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  13. The NYT is reporting that the autopsy results show the cause of death was indeed blunt trauma to the head. This gave me chills, as I am out in New Mexico skiing with my own sons, and no, we don't have helmets. We leave tomorrow, and when we ski again, it will be with helmets.

    RE: the local hospital possibly not having a CAT scanner. My husband, who used to live in Montréal and ski at Mont Tremblant all the time, says that the ski area a relatively short drive to Montréal (about 1.5 to 2 hours), but more saliently, there is a big heliport right there to serve the race track--where serious head and spinal injuries can and do happen--and that Ms. Richardson could and should have been transported to the city. Rapidly.

    (That said, I hope this isn't going to turn into one of those openings for people to start slamming Canadian health care.)

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  14. Anonymous,

    The parachute argument is used by those who do not understand science. There is no comparison between riding a motorcycle without a helmet and jumping out of a plane without a parachute. This is just a science denialist argument. If somebody wants to argue for something, without any evidence, this is one of the justifications.

    There has been a lot of research on helmet use by motorcyclists. As you state, the research is not conclusive. The ethical argument is on a par with the parachute research claim. This argument jumps to the conclusion that is desired, then claims it would be unethical to provide evidence, because the claim is so obvious. Many anti-science groups use this kind of bad logic. alternative medicine depends on this kind of rationalization.

    It is important to oppose these anti-science claims. Just because something is rare, does not mean that it cannot be studied. Just because something appears to be common sense, does not mean that it is true. Motorcycle helmets is an area of research that people have very strong biases about, so there is not a lot of good research.

    If you are going to hit your head, a helmet will probably decrease the injury. That is true regardless of whether you are on a motorcycle or walking down the street minding your own business.

    I also choose to wear a helmet when I ride. Forcing a helmet on someone else, because seeing someone ride without a helmet makes me uncomfortable? That is unethical.

    Unlike testing parachutes vs no parachutes, there has been research that has looked at helmets vs no helmets. Does a mandatory helmet law decrease head injuries and fatalities? Nobody knows.

    Anyone telling you otherwise is letting their bias show, which is not very good science.

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  15. Rogue,

    You're veering way off topic here, on helmet laws. I'm not bothering to go there.

    But you're just wrong when you say it's "science denialism." You look two comments above and you can see that I point out the challenges in performing the science, which are damn near prohibitive for unstructured activities like skiing and cycling. It's not denialism to say that there's no good evidence, nor to say that there's no point in proving the obvious. There's a whole subset of EM literature dedicated to demonstrating the obvious. I recall one which "proved" that being on a backboard is uncomfortable. What a waste of time and effort! (For that matter, there's no good evidence that backboards make any difference, either!)

    Helmets and motorcycles are a different animal, as was pointed out, due to the much higher energies involved. But it seems to me that the virtues of helmets in activities like skiing, skating, cycling, skateboarding are truly self-evident and not in need of "proof".

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  16. But you're just wrong when you say it's "science denialism." You look two comments above and you can see that I point out the challenges in performing the science, which are damn near prohibitive for unstructured activities like skiing and cycling. It's not denialism to say that there's no good evidence,

    To claim that only large scale randomized placebo controlled trials are good science is wrong. This is something looked at, in part, here:

    Fiction and Fantasy in Medical Research: The Large Scale Randomised Trial
    By James Penston
    Published by London Press, 2003
    ISBN 0954463617, 9780954463618
    144 pages

    Observational studies are also important.

    nor to say that there's no point in proving the obvious.

    Depends on who is claiming that something is obvious. Medicine is full of treatments that have been discarded, because researchers actually investigating the obvious benefit proved there was no benefit.

    There's a whole subset of EM literature dedicated to demonstrating the obvious. I recall one which "proved" that being on a backboard is uncomfortable. What a waste of time and effort!

    And yet there are plenty of people who ignore the pain they cause by immobilizing their patients. If it is so obvious, why is it ignored?

    (For that matter, there's no good evidence that backboards make any difference, either!)

    Not only is there no good evidence that backboards provide a benefit, the only large study showed that immobilized patients did worse than those who were not immobilized. Of those with unstable fractures, the patients not immobilized had better outcomes than those who were immobilized.

    Out-of-hospital spinal immobilization: its effect on neurologic injury.
    Hauswald M, Ong G, Tandberg D, Omar Z.
    Acad Emerg Med. 1998 Mar;5(3):214-9.
    PMID: 9523928 [PubMed - indexed for MEDLINE]

    And the commentary in the same issue:
    Out-of-hospital spinal immobilization: is it really necessary?
    Orledge JD, Pepe PE.
    Acad Emerg Med. 1998 Mar;5(3):203-4. No abstract available.
    PMID: 9523925 [PubMed - indexed for MEDLINE]

    An example of obvious knowledge that was wrong is that we have to give prophylactic antiarrhythmics to post-MI patients with PVCs. Even though it was clearly unethical to put patients into a placebo arm of this study, somebody did and they died at about 1/3 the rate of the patients taking flecainide (Tambocor)and encainide (Enkaid) - the obvious life saving drugs.

    Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators.
    [No authors listed]
    N Engl J Med. 1989 Aug 10;321(6):406-12.
    PMID: 2473403 [PubMed - indexed for MEDLINE]

    Another is that everybody knew that ulcers could not possibly be caused by bacteria. That was obvious. Helicobacter pylori could never do that.

    Helmets and motorcycles are a different animal, as was pointed out, due to the much higher energies involved.

    A helmet really does not do much in a high speed impact. The trauma to the rest of the body is likely to be fatal anyway. The indirect impacts are what the helmet is useful for.

    But it seems to me that the virtues of helmets in activities like skiing, skating, cycling, skateboarding are truly self-evident and not in need of "proof".

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