Je laisse passer pour ne pas raviver le débat, mais il fut assez uni-
directionnel, alors que les deux points de vue sont entièrement
défendables
Michel Garner
[email protected]
On 2-Apr-09, at 5:53 PM, Bernard Mathieu wrote:
C'est drôle que 2 ou trois personnes reviennent à tout bout de champ
avec des exemples ridicules comme ça et font passer la majorité des
gens qui croient à cette mesure de prévention pour des morons.
Franchement peut-on passer à autre chose?
Bernard
Le 09-04-02 à 17:19, Michael Garner a écrit :
Quoi ? Il avait un casque ??? :-)
En passant, sans vouloir raviver le débat, il y avait une lettre à
l'éditeur dans la Gazette comme quoi il faudrait imposer un loi
pour quye les danseuses nues portent un casque, parce que le
manœuvre du poteau, quand elles sont à l'envers, la tête en bas,
est nettement à risque...
Michel Garner
[email protected]
On 2-Apr-09, at 8:21 AM, Pierre Beaupré wrote:
En passant, épidural temporal G. hier soir. Glasgow à environ 15,
seulement un peu ralenti, mais souffrant.
Il aurait eu son TDM, mais l’histoire récente de Mme Richardson a
probablement contribué à accéléré les choses, le patient ayant une
douleur surtout en temporal. Hx de perte de conscience très
courte, Pas d’hélicoptère et stable pendant le transport.
Les épiduraux ne sont pas si fréquents. Loi des séries ?
Le casque avait pris le bord quand l’arbre qu’il coupait a frappé
à la porte.
PB
De : Alain Vadeboncoeur [mailto:[email protected]]
Envoyé : 2 avril 2009 00:08
À : Pierre Beaupré
Objet : URG-L: FW: Did Canadian Healthcare Kill Natasha
Richardson??!!
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 Natasha.”. 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 and surgical treatment. When treated early enough,
this injury is rarely fatal. It is, therefore, reasonable to ask
how different health 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
initially 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 neurotrauma center in Montreal. On the way she was
evaluated and stabilized at a community hospital with modern
imaging facilities. Apparently, 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 medical 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
service there is a fixed wing air ambulance service.. Fixed wing
craft require a landing strip but are much faster. In addition to
being used for long distance emergencies in this vast province,
several times a week, Quebeckers from remote regions are flown to
the city to obtain non-emergency medical care not available
locally. All of this is free to patients, who are covered by
Canadian Medicare. Other 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 care. I’ve seen it. Trauma patients are
disproportionately uninsured and are considered a high medicolegal
liability risk. Our entire emergency care system is overwhelmed,
in large part, due to lack of universal access to other health
care. As a result, all Americans are left to rely on a distorted
emergency system. When it comes to effective clinical emergency
care we should emulate Canada’s single payer system, not
congratulate ourselves on helicopter availability in 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
