The editors of Insidesurgery.com are following the news reports of the apparent head injury from a skiing accident that has caused the death of actress Natasha Richardson. Although none of the editors at InsideSurgery.com are participating in her care we are baffled by the course of events as described in the news reports.<\/p>\n
As is being reported today by news organizations, Ms. Richardson was not seen by the paramedics who were dispatched to examine her from the local ambulance service. Rather she was accompanied by her instructor back to her hotel room. <\/p>\n
It is not clear who turned the paramedics away and why. Although trauma victims often refuse treatment, it is never a good idea to do so. <\/p>\n
Often patients say they “feel fine” but trained medical personnel can sometimes pick up subtle physical findings (signs or symptoms that the patient may be unaware of) or have a high index of suspicion for what is termed in the trauma field as “mechanism of injury.” A competent paramedic would be schooled in the mechanism, clinical course, and rquired urgency of care for an epidural bleed, which may be the injury that Ms. Richardson sustained.<\/p>\n
One question that arises is if there was no concern for injury, why did she just did not resume her ski lesson? She was reportedly accompanied back to her hotel room by her ski instructor, but it is unclear what level of concern was present. Paramedics were called a second time after she complained of a headache.<\/p>\n
Sudden onset of a headache after a trauma to the head is a siren call for action and is a bleed of some type in the brain until proven otherwise. This development calls for immediate and emergent care. When the paramedics arrived at her hotel room she was reportedly conscious but “not in too good a shape.” <\/p>\n
This probably means that her mental status (level of awakeness) was declining. Paramedics in this situation of a blow to the head, followed by a lucid period, followed by a headache and rapid decline in mental status must activate the highest level of care emergently to increase the odds of a successful outcome.<\/p>\n
Ms. Richardson was transferred to a local hospital and then subsequently transferred to Hopital de Sacre Coeur in Montreal and then to Lenox Hill Hospital in New York City. <\/p>\n
It is not clear from reports when or if Ms. Richardson received a computed tomography of the brain or was seen by a trauma or neurosurgeon. At this point, it is also not clear from the news reports what her exact injury was, although it is most consisent with an epidural or subdural hematoma from the trauma. <\/p>\n
There is also a posssibility that if she, in fact, had a bleed in the brain it was from a rupture of an undiagnosed brain aneurysm that might have been wholly unrelated to the fall or perhaps ruptured by the traumatic blow to the head.<\/p>\n
Although in the United States it would not be unusual for a local hospital to not have a neurosurgeon on staff, she almost universally would receive a head CT with a positive finding activating an emergency transfer to a tertiary care hospital and a ready and waiting operating room. <\/p>\n
In the US, patients with brain bleeds are typically transported by helicopter if they are traveling more than a few miles to get to the needed level of care most expeditiously.<\/p>\n
It is not clear what resources were available in the local Canadian Hospital, but there almost certainly would be a CT scanner and neurosurgeon available in the large hospital in Montreal that she was transferred to. <\/p>\n
It is also not clear how Ms. Richardson was transported from the ski resort town to Montreal and how much care and evaluation she received at the local Canadian Hospital.<\/p>\n
In the United States in a suspected head bleed being transported from the scene, it is not uncommon for the “life flight” nurses and paramedics in contact with base command to direct the patient directly to the tertiary care facility, bypassing the smaller hospitals that can not give definitive care.<\/p>\n
The goal in large epidural and subdural hematomas is to get to the operating room as quickly as possible and quite bafflingly current news reports do not mention attempted operative intervention to control the bleeding and drain the clot. There is very little chance of survival in these injuries if that does not occur.<\/p>\n
The transfer to Lenox Hill Hospital is very confusing. If Ms. Richardson had needed operative care to treat a possible brain bleed and had not received it in the first two days, there is little that can be done to improve the situation. It is unclear what the doctors at Lenox Hill Hospital would be able to offer that would not be available in the tertiary care facility in Montreal.<\/p>\n
If, in fact, that is what Ms. Richardson had suffered, the key to having good outcomes in epidural or subdural bleeding is early and aggressive attempts at diagnosis and surgery. Generally, this strategy of care is unfortunately not furthered when the patient has to undergo more than one intra-facility transfer.<\/p>\n