Are We Safer than 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's 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 OK" 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 3 hours and 40 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 U.S. 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 health care system.

U.S. 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 U.S. 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 1990s. 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 U.S. health care 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.

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