Natasha Richardson dies

[VentMedic]

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.

 

[flhtci01]

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.

 

[reaper]

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.

 

[VentMedic]

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.

 

[Veneficus]

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."

 

[flhtci01]

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.

 

[VentMedic]

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.

 

[zzyzx]

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.

 

[VentMedic]

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.

 

[Veneficus]

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?

 

[zzyzx]

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."

 

[Ridryder911]

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

 

[metivierm]

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...

 

[zzyzx]

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

Yeah, you got me there.

 

[Veneficus]

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.

 

[Shishkabob]

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

We still have better doctors!

 

[Sasha]

We still have better doctors!

Matter of opinion.

 

[Veneficus]

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

 

[VentMedic]

We still have better doctors!

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

 

[firecoins]

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

.