Did the Canadian health system fail Natasha Richardson?

Would Natasha Richardson be alive today if she had gone skiing in the United States instead?

I don’t think it would have made a difference.

To recap the tragedy, Ms. Richardson died from an epidural bleed, after she fell while skiing. Her presentation was somewhat classic, with the well-described “lucid” period before she deteriorated.

According to Canada’s Globe and Mail, “ambulance workers were not called to Ms. Richardson’s luxury hotel room until more than two hours after she tumbled and hit her head at the Quebec ski resort.” It should be noted that an initial ambulance was refused and sent away, some 17 minutes after her fall.

After picking her up from the hotel, there was a 40-minute drive to the community hospital, the Centre Hospitalier Laurentien. She did have a CT scan there, and the decision was made within 2 hours to transport her to a tertiary care center, another hour away in Montreal.

She later died from her epidural bleed.

Epidural bleeds are treatable, by drilling a hole in the skull to relieve the pressure from the bleed, and often results in complete recovery. However, time is of the essence, and some are wondering if Ms. Richardson would have fared better Stateside.

Blogger Dr. T has been commenting on the case, and notes that, “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.”

But 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.

It is very likely that Ms. Richardson similarly would have been transported to a tertiary care center if her accident happened here. The difference, however, is that I think she would have been flown by helicopter, rather than taking hour-long drives by ambulance.

Would that have made a difference? Perhaps, but that can’t be a huge factor.

The biggest loss of time was when the initial EMS response was declined, the fact that several hours passed before a CT scan was performed, and the delay before making the decision to transport her to a tertiary care center in Montreal.

Those delays could conceivably happen in the United States as well.

Update 3/21:
As a speculated earlier this week, the fact that Quebec does not have some sort of med-flight system is coming into focus. Says Montreal’s top trauma doctor:

“It’s impossible for me to comment specifically about her case, but what I could say is … driving to Mont Tremblant from the city (Montreal) is a 2 1/2-hour trip, and the closest trauma center is in the city. Our system isn’t set up for traumas and doesn’t match what’s available in other Canadian cities, let alone in the States,”

And, over at Kennedy’s Tumor, the fact that Canada is tremendously short of neurosurgeons stands in start contrast to the United States. Did this “artificially created shortage of subspecialists” play a role?

Finally, Dr. Crippen from across the pond in the UK, blames the American wussification of today’s doctor, saying that the brave physician would have drilled the burr holes without the benefit of a CT scan:

It would be a career making or career breaking decision. Few American doctors are brave. Defensive medicine is the order of the day. You cannot have a migraine in the USA without someone ordering an MRI scan.

Indeed.

Comments are moderated before they are published. Please read the comment policy.

  • alexa-blue

    So what? Even if she would have lived in America (and I’m sure you could find someone who believes that to be the case) it’s not like you could draw any meaningful policy conclusions from that fact alone.

  • Anonymous

    I practice in a rural ski community that has a neurosurgeon that does take call. But, the two hours of delay at first would be hard to remedy. Even if she were whisked to the hospital (30 minutes from the ski slope), getting the CT, reading it, calling the neurosurgeon, and having her show up and get prepped, would have easily taken an additional hour. And there are several smaller hospitals within 100 miles of here, also with ski hills, that do not have a neurosurgeon. And it gets time to get in and out of a CT scanner, look at the films, and make a decision to ship someone immediately and get the ambulance there. And helicopters do not always fly, and even if they do, the time to summon them, land them, and transport the patient to and from them frequently makes up for any “time saved”. And that’s if they don’t crash.

  • Rositta

    I had the same thought initially having much experience with the Canadian health care system. But then I reconsidered when I read that an ambulance had been initially refused. The fact that she was a celebrity meant that she was being treated way better than a normal person anyway so I’m pretty certain everything possible was done. I recently waited in ER 6 hours for a brain scan and the delay for her wasn’t so great. I was shocked though that such a small fall caused a death. I skied that mountain many times in my youth and had many many falls. In those days helmets werent even on the horizon. It is sad and this will give the media something to speculate on for days to come…ciao

  • Reality Rounds

    Dr. Kevin,
    Have you been watching too much South Park? “Blame Canada, Blame Canada”! It was a tragic accident, end of story. There will always be time delays before treatment for any condition: heart attacks, strokes, bleeds etc. Treatment is not instantaneous. You must assess and test to know what your treating. Take some other “celebrity” deaths for example: John Ritter, Princess Diana, Jim Henson etc. Medical pundits were all over those cases also saying things could have been done better and faster. I would agree with this assessment only if we had the power to go back in time.

  • Kevin

    Perhaps you missed the line where I wrote, “I don’t think it would have made a difference.”

    In any case, this is a condition that is treatable with neurosurgery, but time was of the essence. Every second literally counted.

    Within that context, it’s fair to ask whether the Canadian health care system responded appropriately to the situation, or not.

    And, as I concluded above, I think they did.

    Kevin

  • Kipper

    I agree that the initial delay was the real problem.

    Here in the US I’ve been refused a CT after a concussion (in an ice hockey game, so it’s not like I wandered in after a fall from a sitting position to a soft padded surface). I’m sure that wouldn’t happen to a famous person, but it is for me a point of bitterness when reading those bloggers who were speculating the Canadian system was at fault.

  • Anonymous

    Wouldnt have made a difference? I disagree. Time is EVERYTHING when you are talking about treatment for a heart attack, stroke and TBI.

    It is my opinion that delay to treatment is what greatly contributed to Natasha’s demise.

    No medical helicopter? Was there even a neurosurgeon in Montreal?

  • Dr. Mary Johnson

    Thoughts: http://drjshousecalls.blogspot.com/2009/03/minute-in-dark.html

    Again, my sympathy to the family. This is just tragic and very sad.

  • Evan

    I posted this same comment in another blog, but I disagree with you. The Canadian EMS failed Ms. Richardson and failed her big time.

    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. 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 because of her deteriorating condition. 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. No helopcopter was waiting. The docs delayed ordering her transport even though she was clearly deterioiating. 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 takes a long hard look at its EMS so this never happens again.

  • Cockroach Catcher

    Quoted you on my post. Good post.

    The Cockroach Catcher

  • Anonymous

    Thanks Evan, you echoed precisely what I was thinking and what bothered me more than anything, about all the points that delayed her care.

  • Cockroach Catcher

    “After picking her up from the hotel, there was a 40-minute drive to the community hospital, the Centre Hospitalier Laurentien. She did have a CT scan there, and the decision was made within 2 hours to transport her to a tertiary care center, another hour away in Montreal.”
    Most Canadian papers I scanned seem to be saying the same thing.
    Why the delay? Why indeed!
    We are not looking at blame but in medicine we need to learn from mistakes of others. If such a famous and well off person cannot have the right treatment what chances do ordinary folks have.
    And you do not even need a CT scan or MRI, what is wrong with a simple but full neurological examination or do they no longer teach them that in the home of PBL.
    I remember the first ever lesson in Neurosurgery, given by a surgeon who looks like a movie star and drives a Ferrari was on burr hole. The burr hole was more impressive than his looks or Ferrari!
    Dr Cippen was right, if it is somewhere thousands of miles away from anywhere, a handyman’s drill would have saved her life.

    The Cockroach Catcher

  • Dr. Mary Johnson
  • ERP

    I found it shocking that Quebec does not have a helicopter evacuation/medical transport system in place,like most other Canadian Provinces.

  • Anonymous

    I’m Canadian, and would like to add that the Canadian healthcare system is not all that it’s cracked up to be. Did you know that Montreal for example does not help a medical helicopter? Had such a helicopter been available, it could have taken Natasha more expediently to Montreal. US hospitals tend to have much more high tech, and savvy medical equipment, and unfortunately, it is true that a bed shortage can delay care even in emergency situations. This routinely, happens in Canada and des result in deaths.

    I believe had the same accident happened in the US, that Ms. Richardson would have been more likely to survive, because her medical care would have been delivered expeditiously, in general all around better than what is available to Canadian residents. Doctor: Lack of medical helicopter cost Richardson
    http://news.yahoo.com/s/ap/20090321/ap_on_re_us/natasha_richardson

    Actually, the province next door to Quebec, Ontario, had too frequently had to send neurosurgery patients to the US. These were trauma patients brought into the ER at busy Toronto hospitals. Due to the bed shortages, ER nurses and doctors had to scramble to find care. In the meantime, these delays meant that the patients were not getting a crucial operation and moving them would perhaps presents lead to further deterioration, brain damage, and possibly death that might otherwise be prevented if more immediate care was available at the Toronto hospital. There are many problems that exist in all provinces and territories throughout Canada.

    Its important for Americans to keep in mind, when travelling to Canada, that healthcare may not be up to that received at home. If you get injured, rather than take a chance, go to the hospital, because it can take hours to get care in a Canadian emergency room. Often there are l-o-n-g delays. This even occurs when its necessary to send a person from a smaller hospital to a larger trauma centre. In some cases this happens when the tertiary hospital lacks critical care beds. In Canada this happens a lot, please be forewarned.

    You might find the following interesting:

    “More than 150 critically ill Canadians – many with life-threatening cerebral hemorrhages – have been rushed to the United States since the spring of 2006 because they could not obtain intensive-care beds here.”

    http://www.theglobeandmail.com/servlet/story/RTGAM.20080119.neuro191/BNStory/specialScienceandHealth/home

  • Katz

    I’m commenting from the US but I am familiar with Canada and the Laurentians having vacationed there a few times. The road up to Mont Tremblant is a long winding journey from Montreal. I can’t imagine having to go down that small road while you are having an emergency. When I first heard of the news, I thought the medics made a mistake taking her to the 40 minute away facility but then I realized that the first hospital is on the way to Montreal from Mont Tremblant.

    Since she had to be detetoriating fast after they picked her up from her hotel, maybe the medics thought based on her symptoms and history, a general surgeon could intervene. The tragedy was not having neurosurgeon at the location where they shot the CAT scan. Then there would be no need for Montreal or choppers.

    Vanessa Redgrave is an extraordinarily kind woman who has given so much to this world. I just hated to see her kind heart get broken this way.

  • JimN

    Ummmm – American doctors don’t have to be ‘brave’ – they’re INFORMED. We have sufficient medical technology for our needs – unlike most of the rest of the world – which is exactly why the rest of the world comes here for the most complicated and costly procedures…

  • Starbuc

    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.

    Maybe someday I’ll learn different but to put being sued for malpractice over what needs to be done, is sad at best. No air lift service is even worse. Come into the 21st century Canada, you are way behind and this case has shown your faults to the world.

    What my English countepart should have said was, you Canadian doc’s need to grow a set of bollocks.

  • Anonymous

    Was there even a neurosurgeon in Montreal? A city of two million serving up to five million, when you include the surrounding area? Give me a break. Of course there are many highly skilled neurosurgeons there.

    We now know that the ambulance took only about 45 minutes to make the trip. It is doubtful that the helicopter could have done much better.

    We also know that the local hospital had a ct scanner, and it is very likely the protocols would have required its use in this case (although they won’t confirm it was used, for privacy reasons).

    The rest, for now is speculation.

    But it may leave the question of whether the ambulance service, the private resort, the private hotel, and the private ski patrollers did enough to get Ms. Richardson help at the earliest possible stage.

    None of that has anything to do with weaknesses in the “socialized” Canadian healthcare system.

  • Anonymous

    The one thing I want to point out is that there are a LOT of places in the U.S. that don’t have access to helicopters – or hospitals or more than a countyr doctor. Those places tend to be remote/rural. To make this some big Canada v. US healthcare debate is stupid.

    As to the issue why the first ambulance went away…isn’t it a person’s right to refuse treatment if s/he doesn’t see anything wrong? My understanding is that you are absolutely within your rights to do so. It is a tragedy that there were no initial symptoms (as everyone says, this is common) and she did not seek immediate medical attention.

    It is easy to look back (knowing the diagnosis) and tell the doctors what they should have done. But the medical professionals on hand made their best diagnosis given the tools they had and the symptoms that had been presented.

    This is a terrible tragedy, but one that could have happened all over the US as well as in Canada. It is fair to question whether the health care system played a role, but let’s not over-romanticize the US here…the overall system covers rural areas and not just the big cities.