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Natasha's Epidural Hematoma

Posted Mar 27 2009 10:54am

I have to admit that I was only marginally familiar with Natasha Richardson. Certainly I know of her husband and famous mother. Reading the news of her untimely death, it seems clear that she was one of the good people in the entertainment industry. Her death has brought some criticism of the Quebec medical care system from pundits in the media. Where where these pundits when Sonny Bono skied into a tree near South Lake Tahoe in 1998?

Now, let's look at the facts as they have become known. Richardson died of an epidural hematoma. An epidural hematoma is an injury that results from blunt head trauma. The blow to the head causes a tear in a relatively large artery called the middle meningeal artery. The blood rapidly leaks from the artery and quickly fills the cranial vault displacing the brain and rapidly causes permanent and often fatal brain injury. This injury has always been enigmatic to people because the patient will often appear quite normal for a period and quickly deteriorate. This period is called the "lucid interval." That said, epidural hematomas are actually fairly rare occurring in 1-3%of all head injuries. Typically, 1 out of 5 die.

Now, back to Richardson and her care in Quebec. Here's the science:

1. She refused a helmet. I am of the opinion that helmets help in some dangerous activities, but there is no evidence that helmets improve morbidity or mortality on the ski slopes. The fundamental problem lies with the mechanism of injury. Many traumatic brain injuries result from sudden deceleration (e.g., into a tree). While a helmet will cushion the blow of the head striking the tree, it does not cushion the movement of the brain in the cranial vault. The brain will slosh forward and strike the inside of the front of the skull (coup injury) and then slosh back and strike the inside of the back of the skull (contrecoup injury). This continues until all of the energy of motion has been dissipated. A helmet is not going to change this much if at all.

2. The Quebec ski patrol should have transported Richardson to the hospital. Civil liberties are just as important to the Canadians as the Americans. A person has the right to accept or refuse medical care. The signs and symptoms of an epidural usually take time to develop (as the cranial vault fills with blood). How could Richardson or the ski patrollers know that she had this injury if there were no obvious signs and symptoms? This is the American (lawyer-influenced) vision of emergency medicine. That is, something bad happened and somebody must be held responsible--often the government or the doctors. But, the truth is bad things happen to good people and that is just the way it is. The only way Richarsdon's death might have been prevented would be to stay off the ski slopes (but she could have been struck by a cab crossing 8th avenue on the upper west side). These are random, unpredictable events--nothing more, nothing less.

3. A neurosurgeon could have saved her life.
On this I will agree. A neurosurgeon might have saved her life if he or she had seen Richardson soon after the injury and operated. By the time she deteriorated, brain herniation was underway. And, most community hospitals don't have neurosurgeons. Small hospitals don't have the census or technology to support neurosurgical care. Unfortunately, ski resorts tend to be distant from major cities and if you decide to ski, you have to assume that a neurosurgeon is not going to jump out from behind a tree and do a burr hole to evacuate your epidural hematoma. You ski, you take the risks.

4. A helicopter could have saved her life. I call bullshit on this. There is absolutely nothing a helicopter transport could have provided to improve the overall outcome in this case. This is just the standard emotional response and the desire to blame somebody for the untimely death of a good person. Richardson wanted to ski and a bad thing happened--no more no less.

Patrick Swayze is dying of stage IV pancreatic cancer. The media has made sport of the fact that Swayze has smoked 3 packs of cigarettes a day for more than 35 years and this may have been a factor in his illness. They are blaming his illness on his personal choices and that is true. But, where is the blame for Richardson's death on her choices? See the double standard here? You pay your money and you take your chances.
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