# Natasha Richardson dies



## daedalus (Mar 18, 2009)

Natasha Richardson, 45 years old, died today after suffering a fall to her head during a beginners ski lesson. See CNN.com

According to the article, she had fallen on her head and seemednperfectly fine, getting up under her own power and talking and joking win ski patrol. Ski patrol examined her and found no sgns of head injury but insisted she rest and see adoctor. She was transferee to a hospital in new York where she later died.

This is a tragic situation but a wonderful learning oppertunity. Emts and paramedics need to learn the s/s of closed head injury,and their potential fatal progression from a seemingly ok patient to a dead one.


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## Aidey (Mar 18, 2009)

It sounds like the Ski Patrol did a pretty good job of encouraging her to get checked out once she started complaining of a headache. I wouldn't be shocked if it's determined she had a pre-existing aneurysm that was ruptured by the fall, or that she was on blood thinners or something. Even not wearing a helmet, a fall from standing isn't a very significant MOI.


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## VentMedic (Mar 18, 2009)

Aidey said:


> I wouldn't be shocked if it's determined she had a pre-existing aneurysm that was ruptured by the fall, or that she was on blood thinners or something. Even not wearing a helmet, a fall from standing isn't a very significant MOI.


 
This is even more reason to do a thorough assessment and NOT take a fall even from a standing position lightly. Too many just assume "it wasn't that far so no damage" when they should be assessing if there are any additional risk factors that may increase the chances of more serious injury. 

There is a good interview tonight on Larry King(CNN) with UCLA's Chief of Neurosurgery which is proving to be very interesting. Right now he is discussing that pain may not initially be present since he performs some neurosurgery without sedation.


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## Aidey (Mar 18, 2009)

Right, and what would a through assessment have found immediately after the incident? They could have done a through assessment, but if there is no pressure build up, there are no symptoms.


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## VentMedic (Mar 18, 2009)

Aidey said:


> Right, and what would a through assessment have found immediately after the incident? They could have done a through assessment, but if there is no pressure build up, there are no symptoms.


 
Risk factors? Blood thinners, head-aches, clotting disorders, previous head injuries or surgeries can build a case for a person to see a doctor sooner rather than later.

Of course if a Paramedic or EMT came along and gave her a "clean bill of health" that might have delayed her from going to the hospital sooner.


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## Aidey (Mar 18, 2009)

Sure, it may have revealed some flags in the history, but there would have been really no physical symptoms that quickly after the incident (unless she blacked out, I haven't read that she did or didn't in any reports).


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## VentMedic (Mar 18, 2009)

Aidey said:


> Sure, it may have revealed some flags in the history, but there would have been really no physical symptoms that quickly after the incident (unless she blacked out, I haven't read that she did or didn't in any reports).


 
There are those in medicine that do have knowledge of what can happen and see minute signs or who believe in erring on the side of caution. The ski instructor saw this by just understanding mechanism. Sometimes the "training" EMT(P)s get limit them to only the obvious. But, to EMS this probably would have been a BS call since there may not have been any blood or guts showing. This is why I am not for the treat and release or deny transport protocols until the education level is raised for Paramedics. More disease processes and assessments must be understood.


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## Aidey (Mar 18, 2009)

In my experience it's usually the patient that doesn't want to go (I never approach calls intending to not transport. I do not talk a patient out of going, period).  And sometimes no matter how much I argue otherwise they just do not want to go. I used to work in a place with a lot of patients that had the "There are no blood and guts I'm fine" mentality, not me. 

My stance is that if you've been hit in the head you should get checked out because the symptoms don't always show up right away. So just because you feel fine right now, doesn't actually mean you are fine (This is verbatim part of my speech to patients). I'm also not in the habit of kidnapping patients though, and if they think they are fine and don't want to go, I can only do so much. 

There is always the chance that the Ski Patrol members were not paramedics or had any training beyond basic FA, and thus weren't as educated on head injuries.


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## VentMedic (Mar 18, 2009)

Aidey said:


> My stance is that if you've been hit in the head you should get checked out because the symptoms don't always show up right away. So just because you feel fine right now, doesn't actually mean you are fine (This is verbatim part of my speech to patients). I'm also not in the habit of kidnapping patients though, and if they think they are fine and don't want to go, I can only do so much.


 
How many patients have been checked out by Paramedics only to be given a false sense of security of seeing "someone like a doctor"? Maybe the Paramedic says something like "I *don't see anything* obvious" or "There *doesn't seem* to be a problem" or "Everything is checking out *okay*" or "Your vitals are *normal"*. Whether you mean to or not you may have given patients the reasons they were looking for to refuse transport or not have a fuss made over them. 

Just like for chest pain, the patient hears the words that confirm their own denial.


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## Aidey (Mar 18, 2009)

And so you suggest what? Not telling the patient anything? Lying to them?


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## VentMedic (Mar 18, 2009)

Aidey said:


> And so you suggest what? Not telling the patient anything? Lying to them?


 
Lie to the patient? No, you tell them the truth. 

"Considering the fall itself and the fact that you are over 40 along with taking blood thinners, it might be a good idea you get checked out at the hospital since I am only able to do a limited assessment here at scene".

BTW, this may not be the facts as they pertain to Ms. Richardson since I do not have all the details but this is an example of what could be said.


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## Aidey (Mar 18, 2009)

Right and if they ask you "What are my vitals" and you give them numbers and so they ask "is that normal?" in your opinion we are doing them a disservice by saying "yes", so what is someone supposed to say?


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## AJ Hidell (Mar 18, 2009)

Aidey said:


> ...so what is someone supposed to say?


That "good" vital signs mean nothing more than you aren't dead yet.


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## Aidey (Mar 18, 2009)

Thats no better than any of the alternatives since patients stop listening after they hear the words good, ok, normal, etc from what Vent has implied.


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## VentMedic (Mar 18, 2009)

Aidey said:


> Right and if they ask you "What are my vitals" and you give them numbers and so they ask "is that normal?" in your opinion we are doing them a disservice by saying "yes", so what is someone supposed to say?


 
How would you even know if the vital signs are normal for that patient given different circumstances?

You can give numbers and make the statement: "Vital signs are not always the best indicators for all injuries or illnesses. Alot will depend on the medications you are taking and other illnesses in your history or the nature of the injury itself. As well, The anxiety of the accident and just having us here can change your vital signs. Do you monitor your BP and HR regularly?" 

What do you tell patients if they ask if your partner is a good paramedic even if you know he/she is the worst in your state? You can still give a decent answer so not to imply that fact but also not to lie about being that great either.

For patients, you can still be vaguely truthful while not lying. You can redirect the attention to do further assessment and remain in control of the situation by anticipating their questions and deflecting them back toward the patient.


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## zzyzx (Mar 19, 2009)

So if you were called to help Mrs. Richardson, and she told you that she slipped and fell, did not loose consciousness (I haven't read any reports that she KO'd), was not taking anticoagulants, and only complained off mild head pain (5 mintues after the fall), would you really urge her to go to the ER? 

I would have to say no, I would not. 

By the way, here's a link to an L.A. Times story quoting the UCLA doc:

http://latimesblogs.latimes.com/booster_shots/2009/03/richardsons-inj.html


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## VentMedic (Mar 19, 2009)

zzyzx said:


> So if you were called to help Mrs. Richardson, and she told you that she slipped and fell, did not loose consciousness (I haven't read any reports that she KO'd), was not taking anticoagulants, and only complained off mild head pain (5 mintues after the fall), would you really urge her to go to the ER?


 
Yes especially if she complained of a headache and there was a witness to her fall to describe the hit. Head and spinal trauma are two areas I would rather error on the side of caution. Both are difficult to diagnose even with good equipment inside the hospital and both can lead to debilitating deficits and/or death. If the patient insists on not going, provided I have not used any of the words I mentioned earlier to state a clear bill of health, then I will have to accept that but insist that the patient and family listen carefully to instructions for any signs of change and for them to schedule a follow up exam with a doctor before a refusal is signed.

As the interview also pointed out, by the time the more severe symptoms present, it may be too late.


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## firecoins (Mar 19, 2009)

I always tell people to go.  Always.  However I can not force people to go.  

I recently had a similiar call. When the patient insisted on an RMA,  I called Medical Control, informed them what was up and had them talk to the patient.  Vital signs were fine. Patient still insisted on the RMA.  I am sure the patient was fine but I was afraid of something like this.  At least I covered my behind.


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## zzyzx (Mar 19, 2009)

Vent,

Would an ER doc order a CT scan on someone who has no KO, not a senior, no med Hx, and no other symptoms other than some minor head pain a half hour after a slip and fall?

Should we really tell every patient that they absolutely must go to the ER after they bump their head? I'm not challenging you on this; just trying to learn because it just seems excessive to me, even after following the Richardson story with great concern.


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## reaper (Mar 19, 2009)

As, someone that has had many closed head injuries before. I can tell you that symptoms may not show up for hours or days. Even Dr's can miss them and have. So a pt may be just fine on scene and symptoms show up 3 hours later. So the Paramedics may find nothing wrong, on assessment. The Dr may find nothing wrong. sometimes it just takes time.

I always try and convince any head trauma to be seen at the ER. I explain how it can go from good to bad in minutes. It is all up to them, then.

Paramedic schools do not teach a lot on head injuries and that needs to change. Most do not even know that there are different grades of closed head injury. But, I have ran into a few Docs that did not know it either!


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## VentMedic (Mar 19, 2009)

zzyzx said:


> Vent,
> 
> Would an ER doc order a CT scan on someone who has no KO, not a senior, no med Hx, and no other symptoms other than some minor head pain a half hour after a slip and fall?
> 
> Should we really tell every patient that they absolutely must go to the ER after they bump their head? I'm not challenging you on this; just trying to learn because it just seems excessive to me, even after following the Richardson story with great concern.


 
A KO is not the only criteria for a CT Scan. The patient may even be held as a 23 hour obervation with another CT Scan done before discharge. 

If there is a witness to the fall that expresses concern, especially a ski instructor who probably sees a hundred falls per week with no concern, I would take notice. She is probably not the only celebrity he teaches so that may not have been an issue either for him to express concern. Did she have the speed of skiing to accelerate her fall? Did he see her head strike hard and even bounce off the ground or on an object? The fact that she did have some pain indicates her head may have experienced a violent motion. The area of strike may not be the site of injury since the jolt will move the brain. For Shaken Baby Syndrome, there are no external blows to the skulls. I also believe some states now have their trauma criteria for an "older person" with a fall starting age 50. At 45 a woman may also be more prone to osteoporous which can make them more prone to fractures and other injuries just from the aging process.

I can not give you a blanket statement for every situation you encounter. However, there are many factors about a patient that must be determined including how they fell. What the recipe book tells you may not fit all patients and a Paramedic may not be skilled enough to do a thorough neuro exam. But then, many ED doctors may also refer the patient to a neuro specialist for a comprehensive exam even if the CT Scan is negative. Most doctors will not display an ego or cockiness in their skills/knowledge when it comes to the head or spine and will gladly turn these patients over for a consult.


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## flhtci01 (Mar 19, 2009)

Aidey said:


> In my experience it's usually the patient that doesn't want to go (I never approach calls intending to not transport. I do not talk a patient out of going, period).  And sometimes no matter how much I argue otherwise they just do not want to go. I used to work in a place with a lot of patients that had the "There are no blood and guts I'm fine" mentality, not me.
> 
> My stance is that if you've been hit in the head you should get checked out because the symptoms don't always show up right away. So just because you feel fine right now, doesn't actually mean you are fine (This is verbatim part of my speech to patients). I'm also not in the habit of kidnapping patients though, and if they think they are fine and don't want to go, I can only do so much.
> 
> There is always the chance that the Ski Patrol members were not paramedics or had any training beyond basic FA, and thus weren't as educated on head injuries.




I deal with similar situations on an almost daily basis, yes, I am a ski patroller.

My experience has been the same, they seem fine, encourage them to go to the ER but for whatever reason they refuse.  It could be they don't think they need to go, they were having fun or they don't want to ruin someone else's trip, etc.    

On cases like this, I have learned not to rush through the paperwork and take my time because some small sign or symptom may pop up.  If they start repeating themselves 15-20 minutes into the event, they win a trip to the ER on altered LOC.  Makes refusal a little harder.  Another method is to explain to a relative (spouse, parent, etc.) exactly why the person should go to the ER.  A little persuasion from the spouse usually works.

I can't speak for Canadian patrollers but the National Ski Patrol training parallels basic EMT training.  Some areas require EMT-Basic or above certifications.


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## reaper (Mar 19, 2009)

According to the news report I watched this AM. The first Paramedic unit was cancelled, prior to arrival. They were told that they were not needed. So that puts all this on the shoulders of who ever was on scene with the pt. A second unit was called later to transport.


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## VentMedic (Mar 19, 2009)

flhtci01 said:


> I can't speak for Canadian patrollers but the National Ski Patrol training parallels basic EMT training. Some areas require EMT-Basic or above certifications.


 
I would trust someone who is well trained in falling to do a better assessment of some situations than an EMT(P). That is why a red flag would appear if a ski instructor expresses concern. The same for a martial artist, gymnast, roller derby player, pro wrestler choreographer and definitely an athletic trainer. The next time you watch a football game, look closely at which hits or falls get instant attention from trainers and which ones just get stares that say "get up already". EMT(P)s may just run through their protocol checklist and just do enough to cover themselves. 

Hang out at a busy city ED wait area and you may see several falls. Some will just get an "oops" from us. Some will get a cringe with a "that'll leave a mark" and some will be an "oh sh**!" fall. You can get the same observations at ice or roller skating rinks. 

Another question I ask is if the patient knew they were going to fall. This will also go along the lines of assessing injuries to the extremities from attempting to break a fall. Often a person will automatically protect their head if they are aware of falling. However, if a person slips on ice or water, that may be a direct unprotected hit regardless of what marks may not visibly noticeable. Of course, if a person tries too hard to break their fall, injuries to the spine must be considered from the twisting.

So there is not just one recipe for a blanket statement. It will depend on the patient's age (and yes there are some very old 40 y/os), weight, physical shape, conditioning, health, meds, ground surface, force, speed and awareness of falling.


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## Veneficus (Mar 19, 2009)

zzyzx said:


> Vent,
> 
> Would an ER doc order a CT scan on someone who has no KO, not a senior, no med Hx, and no other symptoms other than some minor head pain a half hour after a slip and fall?



Should we really tell every patient that they absolutely must go to the ER after they bump their head? I'm not challenging you on this; just trying to learn because it just seems excessive to me, even after following the Richardson story with great concern.[/QUOTE]

Can't answer for Vent, but the state I am from, the answer is absolutely there would be a CT done in the ER.

In addition to bleeds from the middle menigeal artery branches, a subdural can take hours to appear. There are also several "normal" anatomical variations, un DXed A/V malformations, as well as plenty of spaces (both real and potential) for occult bleeding.

please consider the physics behind the trauma.

velocity = v0 +at

in the real world this means somebody on skis has higher acceleration in a shorter time increasing the force on the impact site.

Distribution of force (sorry I don't know where the symbols are for this) 

Again in real world though, some areas of the head absorb or disperse forces better than others. So where the hit is matters as much as how far. In addition, the female and male skulls have a different shape as well as anatomical features to lessen impacts, particularly on males. So a female hitting her skull is more apt to injury than a male based on anatomical structure alone. This can also increase injury severity. Emissary veins are also no collapsable, so any injury to one of these (more likely in a female) could cause issues as well. (goes to location of hit)

Technically you can substract tissue density from the equation, but there is not much volume of soft tissue on the skull so I wouldn't rate it too high in my index of suspicion. Also in kids the cartiligous parts of bones absorb shock better.

I would also consider the athletic prowess. Many martial artists are quite good at falling down w/o getting hurt. Many people from sedintary or privileged lifestyles are not.

Not rying to pick on anyone, just figured i'd add some technical medical principles to the discussion as food for thought. All these things must come into play when deciding how much effort you want to put into "getting" somebody to go on a case by case basis. But just adding up what I mentioned in this case:

female over 20, lifestyle, skis, head plant, no helmet, I would highly encourage a hospital with words like "you might die."

I don't think there is a hard/fast rule on how to deal with head injuries, besides it would wreck my mantra of "sound clinical judgement."


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## flhtci01 (Mar 19, 2009)

VentMedic said:


> I would trust someone who is well trained in falling to do a better assessment of some situations than an EMT(P). That is why a red flag would appear if a ski instructor expresses concern. The same for a martial artist, gymnast, roller derby player, pro wrestler choreographer and definitely an athletic trainer. The next time you watch a football game, look closely at which hits or falls get instant attention from trainers and which ones just get stares that say "get up already". EMT(P)s may just run through their protocol checklist and just do enough to cover themselves.




I agree with what you are saying but that is just half of the picture.  We have a number of people who "Just rung my bell, I'll be fine" who do not seem to realize that they may have a more serious condition.  We inform them of the worst case scenario but some are in denial and think 'that won't happen to me.'  

So, if they show no signs of altered LOC, appear fully competent and refuse repeated recommendations to go to the ER, what is one to do until they exhibit an altered LOC, other than document the entire event? 



> in the real world this means somebody on skis has higher acceleration in a shorter time increasing the force on the impact site.



While the physics supports acceleration and greater force, I have seen skiers and snowboarders that were at a near standstill, fall and suffer a severe concussion.


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## VentMedic (Mar 19, 2009)

flhtci01 said:


> I agree with what you are saying but that is just half of the picture. We have a number of people who "Just rung my bell, I'll be fine" who do not seem to realize that they may have a more serious condition. We inform them of the worst case scenario but some are in denial and think 'that won't happen to me.'
> 
> So, if they show no signs of altered LOC, appear fully competent and refuse repeated recommendations to go to the ER, what is one to do until they exhibit an altered LOC, other than document the entire event?


 
This just falls under communication skills.  I can not give you a blanket recipe for what to say to every patient and some patients just won't go. 

 If you have ever followed sports seriously, especially boxing and football, you will know what happens to these players later in life from numerous repeated injuries, many of which were not treated.  You may also be familiar with some of the baseball players that have suffered career and life quality ending injuries.   I will sometimes use these former players as examples but it depends on the circumstances.  A lot of it just comes with experience and being able to read people to what will work if you really want to get them to the hospital.    While very unfortunate, this actress will also be a good example to use since may will be aware of this situation.


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## zzyzx (Mar 19, 2009)

I think Richardson must've had been knocked out briefly or had some period of ALOC. I find it hard to believe that they would've called for an ambulance if she had simply fallen down and gotten back up again w/o any signs or symptoms of a concussion or more serious brain injury. 

By the way, the latest news is that the coroner confirmed that she died of an epidural bleed.


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## VentMedic (Mar 19, 2009)

zzyzx said:


> I think Richardson must've had been knocked out briefly or had some period of ALOC. I find it hard to believe that they would've called for an ambulance if she had simply fallen down and gotten back up again w/o any signs or symptoms of a concussion or more serious brain injury.


 
Have you ever seen someone hit their head when their feet flies out from under them or an out of control skier taking a tumble? Read my other posts about watching people fall. Sometimes you just know it is going to be bad regardless of how the patient presents. While deep down hope you are wrong but often you are right. This is not uncommon for a patient to not feel something initially depending on the site of injury. It is however very commonly missed because too many go not by the first impression of the fall itself but by what they THINK a head injury should act like. The same goes for many spinal injuries. Many times the deficits are not immediate.


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## Veneficus (Mar 19, 2009)

flhtci01 said:


> While the physics supports acceleration and greater force, I have seen skiers and snowboarders that were at a near standstill, fall and suffer a severe concussion.



I suspect from a forward or backwards fall as there would still be some acceleration increase? Can you let me know?


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## zzyzx (Mar 20, 2009)

Here is the most informative newspaper article I've found so far, though, as the article mentions, there are still a lot of unanswered questions.

http://www.washingtonpost.com/wp-dy...2.html?hpid=moreheadlines&sid=ST2009031803239

And here's an interesting quote from the article:

"It is also not known whether Richardson lost consciousness, even briefly, after the fall, which would suggest a forceful impact...Physicians used to think that a person had to lose consciousness to have a serious head injury, but research in the past decade has shown that is not true. A study published in 2000 found that if a person with a minor head injury has a headache, vomits, is older than 60, is intoxicated in any way, has a problem with short-term memory, has a seizure or has an injury above the collarbones, then he or she should have a CAT scan."


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## Ridryder911 (Mar 20, 2009)

Well, we all know the _Washington Post _ is a credible medical journal


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## metivierm (Mar 20, 2009)

As a prehospital care provide in Quebec, firstof we have no "paramedics" really, only BLS support. Secondly, the ambulance showed up at the ski hill and a refusal of care was signed. Under quebec law a pt can refuse care if there is no altered LOC, pt is CAO 4x4 and no influence of drugs or alcohol. Not saying this is a great criteria, but unfortunately one were legally bound to abide by. After she was in her hotel room and complained of headache, she was rushed to a local hospital. From there she was transfered to a level 1 trauma center an hour away. Transfer was done by ground ambulance as there are no air ambulances in quebec, except for maybe the far north. Just trying to give everyone a glimpse of how things are in Quebec, probably the most a$$ backwards prehospital care system in north america...


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## zzyzx (Mar 20, 2009)

"Well, we all know the Washington Post is a credible medical journal."

Yeah, you got me there.


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## Veneficus (Mar 20, 2009)

metivierm said:


> As a prehospital care provide in Quebec, firstof we have no "paramedics" really, only BLS support. Secondly, the ambulance showed up at the ski hill and a refusal of care was signed. Under quebec law a pt can refuse care if there is no altered LOC, pt is CAO 4x4 and no influence of drugs or alcohol. Not saying this is a great criteria, but unfortunately one were legally bound to abide by. After she was in her hotel room and complained of headache, she was rushed to a local hospital. From there she was transfered to a level 1 trauma center an hour away. Transfer was done by ground ambulance as there are no air ambulances in quebec, except for maybe the far north. Just trying to give everyone a glimpse of how things are in Quebec, probably the most a$$ backwards prehospital care system in north america...



I don't think anyone in this case blames the providers, just pointing out where weaknesses may be. But as backwards as the system may seem, look at the level of education in a Canadian BLS provider compared to an American one. Canada makes the US look like the minor leagues of prehospital. Europe and Austrailia make both the US and Canada look bad.

But no matter where we are from we all have room to improve and should make every effort and spare no expense to do so.


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## Shishkabob (Mar 20, 2009)

Veneficus said:


> Europe and Austrailia make both the US and Canada look bad.



We still have better doctors!


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## Sasha (Mar 20, 2009)

Linuss said:


> We still have better doctors!



Matter of opinion.


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## Veneficus (Mar 20, 2009)

Linuss said:


> We still have better doctors!



I dispute that, I have to complete 2 years more education, months more clinicals, greater diversity of required clinicals and I have to know the latest technology and how to work without a CT scan or MRI


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## VentMedic (Mar 20, 2009)

Linuss said:


> We still have better doctors!


 
Many of our doctors were not trained in the U.S.


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## firecoins (Mar 21, 2009)

metivierm said:


> As a prehospital care provide in Quebec, firstof we have no "paramedics" really, only BLS support. Secondly, the ambulance showed up at the ski hill and a refusal of care was signed. Under quebec law a pt can refuse care if there is no altered LOC, pt is CAO 4x4 and no influence of drugs or alcohol. Not saying this is a great criteria, but unfortunately one were legally bound to abide by. After she was in her hotel room and complained of headache, she was rushed to a local hospital. From there she was transfered to a level 1 trauma center an hour away. Transfer was done by ground ambulance as there are no air ambulances in quebec, except for maybe the far north. Just trying to give everyone a glimpse of how things are in Quebec, probably the most a$$ backwards prehospital care system in north america...



http://www.lohud.com/article/20090321/NEWS/903210385


> It's impossible for me to comment specifically about her case, but what I could say is ... driving to Mont Tremblant from the city (Montreal) is a 2 1/2 -hour trip, and the closest trauma center is in the city. Our system isn't set up for traumas and doesn't match what's available in other Canadian cities, let alone in the States," said Tarek Razek, director of trauma services for the McGill University Health Centre, which represents six of Montreal's hospitals


.


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## Shishkabob (Mar 22, 2009)

VentMedic said:


> Many of our doctors were not trained in the U.S.



I didn't say we _trained_ better doctors, I just said we had them.


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