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Prevetable death? from a Qc MD... our mini Lady Di

Charles Brault c_brault at yahoo.com
Sun Mar 29 18:29:05 BST 2009

There is still very little clinical information filtering out
And many stakeholders emitting there own comments oozing ever so slightly of there own agenda
The Paramedic lobby is pushing to have SOME (advanced care) Paramedics
According to newspaper and radio transcripts it appears that the second ambulance spent 50 min at the hotel
And did not transport to a Trauma center... and no ALS was done or could be done (Basic EMTs)
The Trauma system Lobby must be embarrassed by the shortcoming of their existing system
The patient spent 1:50in the small hospital before being land transferred to the level 1 Trauma center (Sacre-Coeur)
The story does not say what her Neuro Status was at this point, if Dx correctly done, (most probably), if trepanation was considered on site.
It does not say if the Pt was intubated at this point and who accompanied the patient (improvised MD & RN team) (No dedicated ICU ambulances)
Were there delays in mobilizing medical staff for transport ?
The Helicopter is the least human intensive and most techno reliable answer to improve care (by rapid transport to THE qualified care)
Much easier trusting technology than trusting in any degree and organising better training, QA/QC and (re)certification of EMTs and ER staff
The (US) private health system Lobby is pointing the finger to the socialised medicine model
How it can go so wrong
But they fail to recognize that the best EMSand Trauma system in North Americaare Canadian
Ontarioand British-Columbia have outstanding system
And are parts of our socialised medicine system
Well Quebecis our EMS AIG (What can I say ... SIGH!!!)
And as for Lady Di
There was no blatant mistake that was made in relation to the pre-existing system and it's local standards and level of medicine
It merely bring to the attention of other jurisdiction
An ongoing level of practice (Past, Present... and future)
PS What does the ATLS say about field hospital treatment of epidural bleeds ?
COULD actress Natasha Richardson's tragic death have been prevented if her skiing accident had occurred in America rather than Canada? 
Canadian health care de-emphasizes widespread dissemination of technology like CT scanners and quick access to specialists like neurosurgeons. While all the facts of Richardson's medical care haven't been released, enough is known to pose questions with profound implications. 
Richardson died of an epidural hematoma -- a bleeding artery between the skull and brain that compresses and ultimately causes fatal brain damage via pressure buildup. With prompt diagnosis by CT scan, and surgery to drain the blood, most patients survive. 
Could Richardson have received this care? 
Where it happened in Canada, no. 
In many US resorts, yes. 
Between noon and 1 p.m., Richardson sustained what appeared to be a trivial head injury while skiing at Mt. Tremblant in Quebec. Within minutes, she was offered medical assistance but declined to be seen by paramedics. 
But this delay is common in the early stages of epidural hematoma when patients have few symptoms -- and there is reason to believe her case wasn't beyond hope at that point. 
About three hours after the accident, the actress was taken to Centre Hospitalier Laurentien, in Sainte-Agathe-des-Monts, 25 miles from the resort. Hospital spokesman Alain Paquette said she was conscious upon reaching the hospital about 4 p.m. 
The initial paramedic assessment, travel time to the hospital and time she spent there was nearly two hours -- the crucial interval in this case. Survival rates for patients with epidural hematomas, conscious on arrival to a hospital, are good. 
Richardson's evaluation required an immediate CT scan for diagnosis -- followed by either a complete removal of accumulated blood by a neurosurgeon or a procedure by a trauma surgeon or emergency physician to relieve the pressure and allow her to be transported. 
But Sainte-Agathe-des-Monts is a town of 9,000 people. Its hospital doesn't have specialized neurology or trauma services. It hasn't been reported whether the hospital has a CT scanner, but CT scanners are less common in Canada. 
Compounding the problem, Quebec has no helicopter services to trauma centers in Montreal. Richardson was transferred by ambulance to Hospital du Sacre-Coeur, a trauma center 50 miles away in Montreal -- a further delay of over an hour. 
Because she didn't arrive at a facility capable of treatment (with the diagnosis perhaps still unknown) until six hours after the injury, in all likelihood by that time the pressure buildup was fatal. The Montreal hospital could not have saved her life. 
Her initial refusal of medical care accounted for only part of the delay. She was still conscious when seen at a hospital and her death might have been prevented if the hospital either had the resources to diagnose and institute temporizing therapy, or air transport had taken her quickly to Montreal. 
What would have happened at a US ski resort? It obviously depends on the location and facts, but according to a colleague who has worked at two major Coloradoski resorts, the same distance from Denver as Mt. Tremblant is from Montreal, things would likely have proceeded differently. 
Assuming Richardson initially declined medical care here as well, once she did present to caregivers that she was suffering from a possible head trauma, she would've been immediately transported by air, weather permitting, and arrived in Denver in less than an hour. 
If this weren't possible, in both resorts she would've been seen within 15 minutes at a local facility with CT scanning and someone who could perform temporary drainage until transfer to a neurosurgeon was possible. 
If she were conscious at 4 p.m., she'd most likely have been diagnosed and treated about that time, receiving care unavailable in the local Canadian hospital. She might've still died or suffered brain damage but her chances of surviving would have been much greater in the United States. 
American medicine is often criticized for being too specialty-oriented, with hospitals "duplicating" too many services like CT scanners. This argument has merit, but those criticisms ignore cases where it is better to have resources and not need them than to need resources and not have them. 
Cory Franklin is a physician who lives outside of Chicago. 2009 ChicagoTribune; distributed by Tribune Media Services.
The five-hour scramble to save Natasha Richardson
Recordings of exchanges between medics and 911 dispatch reveal how actress's treatable condition steadily worsened 
From Saturday's Globe and Mail
March 27, 2009at 9:33 PM EDT
MONTTREMBLANT, QUE. — The crackling message over the 911 scanner is delivered with cold precision: The female patient in the ambulance is dazed and concussed, clinging to consciousness.
Natasha Richardson lay on a stretcher inside the speeding vehicle, her mind confused, her breathing aided by oxygen. A fall taken on a ski hill earlier was already, silently, killing her.
"I'm arriving with a female in her 40s … [she's] disoriented …" the medic radioed to hospital staff. "It's following … a ski fall that happened at noon. Soon afterward she presents signs of confusion, a concussion."
Radio exchanges between ambulance medics and a 911 dispatch centre obtained by The Globe and Mail reveal that as she was being rushed to a Laurentians hospital in the afternoon, Ms. Richardson's health had deteriorated but her condition was still eminently treatable. By the time she reached a Montrealtrauma centre at the approach of sunset, her state was dire, the damage to her brain probably irreversible.
Audio timeline: Tragic choices and lost time
Radio recordings between medics and 911 dispatch reveal how Natasha Richardson's condition steadily declined after falling while skiing at Quebec's Mont Tremblant resort.
Play Video
Natasha Richardson laid to rest
Actress Natasha Richardson has been laid to rest near the home in New York's HudsonValleywhere she wed Liam Neeson. The 45-year-old died Wednesday at a Manhattanhospital after sustaining a head injury in a skiing fall.
Play Video
Related Articles
	* 911 transcript: Tragic choices and lost time  
	* Tom Campbell: Insurers should refuse coverage to ski resorts unless they insist on helmets  
	* News: Giving organs was 'very Natasha'  
	* The funeral: Friends, family remember Natasha Richardson  
	* Helmet testing: It may become mandatory  
	* Globe editorial: Celebrity death, overdue action  
The medic read her vital signs on the way to hospital in the afternoon, all reassuring: Blood pressure 124 over 86. Pulse 70 beats per minute. Breathing "100 per cent" with the help of oxygen.
"We'll be there in about eight minutes," he said.
Ms. Richardson, 45-year-old scion of a theatrical dynasty, was suffering from a blunt head trauma, blood forming a clot inside her skull that ended up fatally pressing on her brain.
Two days later, the award-winning actress was removed from life support.
Ms. Richardson struck her head during a beginner's ski lesson at Quebec's Mont Tremblant in a banal spill, the kind seen any day on Canadian slopes.
Yet this fall set off a sequence of events that, in a conflation of tragic choices and lost time, doomed her.
The Nansen run at Mont Tremblant is a bunny hill, a gently sloping run favoured by ski instructors coaching novices and parents with young children.
Ms. Richardson had signed up for a lesson on Monday, March 16, a day that promised a skiers' paradise of abundant sunshine and near-windless conditions. The temperature reached several degrees above zero, but before lunchtime, the snow was still firm enough to give someone a good knock on the head if they fell, according to a resort veteran who'd skied it that morning.
Ms. Richardson was on an area known as the flats when she tumbled within sight of her instructor. No one knows exactly what caused the spill, but the blow and after-effects were worrisome enough for the resort's ski patrol to call an ambulance.
The call was routed to the 911 dispatch centre near Mirabel, Que.
"Priority 3, Tremblant resort … female, 42 years old, 17-Bravo-1," the dispatcher says.
Despite the mix-up about Ms. Richardson's age, the message underscores the severity of what had just occurred: 17-B-1 is paramedic jargon for a fall, possibly dangerous.
Priority 3 meant medics have to get to the hill immediately and use their siren if necessary. They are told to go to the NansenBridge, a narrow overpass spanning the ski run.
They arrive 17 minutes later.
But no one is there.
"10-17," the medic says at 1 p.m., meaning he has arrived. "Uhh, we're still waiting for the patient."
Ms. Richardson makes a fateful decision. In a response not uncommon among head-trauma victims, she feels fine and refuses medical help. Her minders tell the waiting medics.
"There's a [ski] patroller who just went by, who tells me it's a 10-3," the medic reports to dispatch at 1:11 p.m.
10-3: In ambulance code, it means the job is cancelled.
Rising on the shoreof LakeTremblant, the Hotel Quintessence is a refined getaway with fireplaces in each room and a celebrity clientele. Ms. Richardson had booked in with one of her young sons while her husband, actor Liam Neeson, was shooting a film in Toronto.
Ms. Richardson decided to retreat to her suite after her fall, accompanied by the ski instructor. The actress, sloughing off concerns over her condition, is said to have walked there under her own steam.
Under ski patrol rules, she would have been asked to sign a waiver saying she declined medical help.
A private medical clinic with a physician is steps from the hotel. But the owner said Ms. Richardson didn't seek treatment.
As mid-afternoon approached, she began to experience severe headaches. The hotel decided to call 911.
Ambulances have different levels of priorities when they're answering calls, and this one got the most serious: Priority 1, requiring the ambulance to race to the scene with sirens on.
"Priority 1, Mont Tremblant," the dispatcher says at 2:59 p.m."This will be at the Hotel Quintessence, Suite No. 11. For a female, 41 years old. 17-Delta-1."
This designation means that the injury is now classified as "dangerous."
Within 45 minutes, the medics load Ms. Richardson into the ambulance and head to the Centre Hospitalier Laurentien in Sainte-Agathe, a local hospital serving 60,000 people in the Laurentians and injured or ill skiers.
Racing toward the hospital just before 4 p.m., the medic gives a crucial index of the actress's state: She has a Glasgowscore of 12 out of 15. The Glasgowcoma scale measures degrees of consciousness. A rating of 12 is worrisome, but a doctor would consider the patient very much treatable. (A fully alert person would receive a score of 15.) The medic says the patient is "verbal," meaning she responds when spoken to, but otherwise drifts off.
She is losing touch, however. Her orientation rating is 0, meaning that she doesn't know where she is, what day it is, or what happened to her.
The hospital whisks Ms. Richardson into one of its two emergency rooms, Crash Room 2. Staff work to stabilize the actress and prepare her for transfer to Hôpital du Sacré-Coeur, the closest of two Montrealtrauma centres.
A dispatcher summons an ambulance.
"Priority 2 Sainte-Agathe … Crash room 2, destination Sacré-Coeur," says the call at 5:15 p.m."With oxygen, 10-48 [an escort] and a [heart] monitor."
The ambulance arrives in five minutes. Ms. Richardson is loaded in with a nurse and respiratory technologist.
They set off at 5:55 p.m.
The trip from Sainte-Agathe to Montreal's Sacré-Coeur hospital is 88 kilometres.
On a typical weekday evening, commuters are heading home out of Montreal. And the ambulance ferrying Ms. Richardson was flying down Hwy. 15, commonly known as the Laurentian Autoroute, at up to 138 km/hour.
It reached Sacré-Coeur in less than 45 minutes, at 6:38 p.m.
According to a medical insider, a neurologist there was overheard saying that Ms. Richardson's pupils were unresponsive, a sign of advanced brain damage.
From the time the ambulance was dispatched to her hotel room and her arrival at the specialized hospital, nearly four hours elapsed. Some have said a medical helicopter, which can make the trip from Mont Tremblant to Sacré-Coeur in less than 30 minutes, might have saved Ms. Richardson.
By lunchtime the next day, she was airlifted to New Yorkand taken to LenoxHillHospital, a community medical centre on East 77th Street.
The brevity of her stay at Sacré-Coeur suggests she was already brain dead and beyond help.
Among those who notice such things, the fact that Ms. Richardson was taken to Lenox Hill was a quiet admission that she was likely beyond hope. The respected institution has handled head trauma, but does not specialize in complicated neurosurgery. She was placed on life support.
"If you're brain dead already, the rest of your body isn't far behind," explained Marc S. Arginteanu, an attending neurosurgeon at Lenox Hill who was not involved in Ms. Richardson's care. "You have to support their lung functions, their respiratory rate, but you'll also have to support their cardiovascular function, so a lot of times there'll be drips of medication to keep their blood pressure high enough to allow their heart to beat. The other thing that happens is the hormones that control fluid balance stop being produced, so you have to artificially allow that to be dripped into the patient's veins too.
"Despite everything you could possibly want to do, once somebody is brain dead, it's really just a matter of time before the body goes."
Ms. Richardson wasn't the first celebrity to use Lenox Hill as death's waiting room. Others who have died there include the novelist Olivia Goldsmith (The First Wives Club), Katie Couric's husband, Jay Monahan, Ed Sullivan, and the alleged spy Alger Hiss.
After years on the public stage, the final moments of Ms. Richardson's life unfolded in a forum that was not entirely private. On the seventh and eighth floors, the cream-coloured walls of Lenox Hill's intensive care units are brightened up by posters from the MetropolitanMuseumand the BrooklynMuseums. As in most hospitals, the units are open, the beds enclosed on three sides by glass walls with a curtain.
Family members, including Ms. Richardson's two sons, and her mother, actress Vanessa Redgrave, gathered at her bedside to say goodbye.
Removing someone from life support, said Dr. Arginteanu, is "usually very emotional for the family. The patient themselves, you have to understand they really are dead before you're doing anything else. If they're brain dead, it's the same as being dead in general, it's just that there are machines are keeping the heart beating. So you have to have people say their last goodbyes, they don't necessarily want to be there at the last moment when everything is totally stopped."
At about 8 p.m.on Wednesday, Mr. Neeson's publicist delivered the news. Family members had decided to remove the actress from life support. Natasha Richardson, who had gone skiing on a sunny day, had died.
With a report from Simon Houpt in New York
From Saturday's Globe and Mail
March 27, 2009at 10:13 PM EDT
Related Articles
	* The five-hour scramble to save Natasha Richardson  
Natasha Richardson, 45, signed up for a lesson at Mont Tremblant on a day that promised a skier's paradise. She struck her head in a fall around noon. The radio exchanges obtained by The Globe and Mail show that by sunset the damage to her brain was probably irreversible.
12:43 p.m.: On the hill 
"Priority 3, Tremblant resort … (inaudible) … female, 42 years old, 17 Bravo 1 … 12:43, assigned 12:44." 
Code 17 means a fall. Bravo 1, or B-1, means possibly dangerous. Priority 3 is the second most urgent emergency call from the public. It requires medics to get to the scene immediately and place their sirens on if they're held up at an intersection. 

1 p.m.
"10-17. Uhh, we're still waiting for the patient." 
10-17 is code for arrival at the site. 

1:11 p.m.
"There's a (ski) patroller who just went by, who tells me it's a 10-3. Did you get a call about that?" 
10-3 means cancelled job. 

2:59 p.m.: At the hotel 
"Priority 1, MontTremblant. We're talking about the side, facing the south side of The Shack. It will be at the Hotel Quintessence, Suite No. 11. For a female, 41 years old. 17 Delta 1." 
17-Delta-1, or 17-D-1, refers to a fall, now upgraded to "dangerous." 

3:55 p.m.: In the ambulance 
"This is vehicle 112 do you hear me well?"
"I hear you 5 out of 5."
"I'm arriving with a female in her 40s, presently at verbal (responds to verbal stimulus but otherwise fades out), disoriented 0 out of 4. It's following a story, a ski fall that happened at noon. Soon afterward she presents signs of confusion, a concussion. Glasgow at 12 … vital signs: 124 on 86, breathing 100 per cent with O2, cardiac sequence at 70. We'll be there in about eight minutes." 
The Glasgowcoma scale measures degrees of consciousness after a traumatic brain injury. A rating of 12 is consistent with a moderate brain injury. Vital signs of 124 over 86 refers to her blood pressure. The cardiac sequence is her pulse. She is being given oxygen so her oxygen level is 100 per cent. 
5:55 p.m.: On the way to Montreal
"Priority 2, Sainte Agathe … Crash room 2, destination Sacré Coeur. With oxygen, 10-48 and monitor." 
A priority 2 call is the most urgent call from a hospital (as opposed to from the general public, which is Priority 1). 10-48 means an escort. The monitor refers to a heart monitor. 

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