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On 2-Apr-09, at 12:08 AM, "Alain Vadeboncoeur" <[email protected]
> wrote:
From: Laura Boylan [mailto:[email protected]]
Sent: 2 avril 2009 00:03
To: Laura Boylan
Subject: Did Canadian Healthcare Kill Natasha Richardson??!!
Thank you to all I communicated with who helped me in writing this
piece, particularly to my Canadian colleagues. I am grateful for
your input and suggestions. This will soon be posted on the
Physicians for a National Health Program blog and I encourage you to
use, quote, or distribute as you are moved to do! Thanks et merci!
Did Canadian Healthcare Kill Natasha Richardson??!!
In an example of the circus of fear and hyperbole surrounding the
health care debate, opponents of government involvement in health
care are exploiting Natasha Richardson’s tragic death from a skiing
accident. The New York Post reports “Canadacare May Have Killed Nat
asha.”. The blogosphere has headlines like “Canada’s Killer
Healthcare”. Here are the bare facts: Natasha Richardson died from
an epidural hematoma, a condition that requires urgent evaluation an
d surgical treatment. When treated early enough, this injury is rar
ely fatal. It is, therefore, reasonable to ask how different healt
h care systems handle this sort of emergency.
Ms. Richardson initial refusal of an ambulance cost about two
hours. With 20/20 hindsight we know this was a bad decision.
However, it’s also true that “feeling okay” after a minor head
injury is, in fact, a powerful predictor of a good outcome. But bad
things do happen. Patients with an epidural hematoma may initiall
y feel and look well, this is referred to as a “lucid interval.”
After the ambulance was summoned for a second time, only three hours
and forty minutes elapsed before Ms. Richardson arrived at a neurot
rauma center in Montreal. On the way she was evaluated and stabiliz
ed at a community hospital with modern imaging facilities. Apparen
tly, however, it was still too late.
Many have asserted that Ms. Richardson would have fared better in
the United States. This is far from certain. With epidural
hematomas, it’s all in the timing. The intervention required is one
of the simplest in neurosurgery. Helicopter airlift, or the lack
thereof, has been a focus of criticism of Ms. Richardson’s care.
An immediately available helicopter might have helped Ms. Richardson
if used to transfer her directly from the resort to Montreal. It’s
hard to know. However, it does not follow that the profusion of me
dical helicopter services in the United States makes Americans safer.
As reported by the Institute of Medicine, neurosurgeons are often
unavailable to provide emergency and trauma care in the US.
Detailed data on patients referred to specialty hospitals for
emergency neurosurgical evaluations is available for Cook County,
Illinois. This county, which includes Chicago, is densely
populated. Total time elapsed from arrival to a community hospital
to arrival at the specialty hospital averaged 11 hours. The
comparable time period for Ms. Richardson, who had an accident in
rural Quebec, was less than 3 hours. In Cook County most patients
would still be awaiting an imaging study at the first hospital.
The Austin American-Statesman reported in 2002 that a man with a
vertebral fracture after a fall waited 8 hours in an Austin
emergency room before being airlifted to Temple because no local
neurosurgeon was available. In Temple he waited two days for
surgery and was eventually billed over $4,000 for the helicopter.
In the end, it turned out that there had, in fact, been a
neurosurgeon available in Austin, however he worked at a hospital in
a competing network. This is just one case, but it does illustrate
how business incentives distort quality in our healthcare system.
US helicopter medical evacuation services are extensive, but tend to
address market rather than public health imperatives. Helicopters
are concentrated in urban rather than rural areas. Alarming
fatality rates due to accidents during medical helicopter
evacuations have led to headlines such as in “Critics Say Emergency
Medical Helicopters Are Overused and Offer Few Benefits to Patients”
(Wall Street Journal 2005).
It’s different in Canada. In Quebec, while there is no helicopter s
ervice there is a fixed wing air ambulance service.. Fixed wing cra
ft require a landing strip but are much faster. In addition to bein
g used for long distance emergencies in this vast province, several
times a week, Quebeckers from remote regions are flown to the city t
o obtain non-emergency medical care not available locally. All of t
his is free to patients, who are covered by Canadian Medicare. Othe
r provinces do have helicopter evacuation services, and these have a
better safety record than their US counterparts.
A really good emergency medical system addresses the continuum of
care from prevention to pre-hospital care to rehabilitation. Nova
Scotia, a not-wealthy largely rural Canadian province, has created a
model program of integrated services, which others have aimed to
reproduce. Dr. Ronald Stewart, who championed the program first as
a legislator and then as Minister of Health engineered the
replacement of fragmented private services with a unified public
system in the 90s. Innovation has thrived with a profusion of
influential research papers on, for example, medically appropriate
helicopter triage, head injury treatment guidelines, and detailed
reports of clinical characteristics and outcomes of all surgical
interventions on injuries of the sort Ms. Richardson had. The
average wait time for neurosurgical emergency treatment in Nova
Scotia, by the way, is less than in Cook County.
I have worked for years in a variety of different sorts of US
healthcare facilities including inner city hospitals, private
academic referral centers, rural community hospitals and the
Department of Veterans Affairs. A uniform truth, alas, is that
financial incentives play a major role in who gets what care and
when. We have scarcity in the midst of excess, to the detriment of
patients on both receiving ends. If you are uninsured and socially
undesirable you can die in Manhattan from an epidural hematoma,
despite rapid arrival to an emergency room and what must surely be
one of the world’s densest concentrations of medical subspecialty ca
re. I’ve seen it. Trauma patients are disproportionately uninsured
and are considered a high medicolegal liability risk. Our entire e
mergency care system is overwhelmed, in large part, due to lack of u
niversal access to other health care. As a result, all Americans ar
e left to rely on a distorted emergency system. When it comes to ef
fective clinical emergency care we should emulate Canada’s single pa
yer system, not congratulate ourselves on helicopter availability i
n Aspen.
Hyperlinks to information sources:
Institute of Medicine, 2006. Key Findings and Recommendations from
the series of reports on the Future of Emergency Care in the U.S.
Austin American-Statesman. Neurosurgeons in short supply, 5/19/2002.
Neurosurgery. 2008 Mar;62(3):709-16. Neurosurgical emergency
transfers to academic centers in Cook County: a prospective
multicenter study.
Air Ambulances Are Under Fire; Critics Say Emergency Medical
Helicopters Are Overused and Offer Few Benefits to Patients . Wall
Street Journal. (Eastern edition). New York, N.Y.: Mar 3, 2005. pg.
D.1
Air Ambulance Services in Quebec, provincial government website.
Emergency Service System in Nova Scotia, provincial government website
best regards,
Laura S. Boylan, MD
Clinical Associate Professor of Neurology
New York University School of Medicine
Department of Veterans Affairs
NY Harbor Healthcare System
http://www.med.nyu.edu/people/boylal01.html
212-865-0057
