Could actress Natasha Richardson’s tragic death have been prevented if her skiing accident had occurred in America rather than Canada?

This is a legitimate question because of how Canadian and American medical care differ. Canadian health care de-emphasizes widespread dissemination of technology like CT scanners and quick access to specialists like neurosurgeons. While all the facts of Richardson’s medical care haven’t been released, enough is known to pose questions with profound implications for both countries.

Richardson died of an epidural hematoma, a bleeding artery between the skull and brain that compresses and ultimately causes fatal brain damage via pressure buildup. With prompt diagnosis by CT scan, and surgery to drain the blood, most patients survive. Could Richardson have received this care? Where it happened in Canada, no. In many American resorts, yes.

Between noon and 1 p.m., Richardson sustained what appeared to be a trivial head injury after falling while skiing without a helmet at Mt. Tremblant in Quebec. Within minutes she was offered medical assistance but declined to be seen by paramedics. Some have attributed the reason her case was untreatable to this delay, common in the early stages of epidural hematoma when patients have few symptoms. It’s not unusual to face this type of delay and there is reason to believe her case wasn’t beyond hope at that point. About three hours after the accident, the actress was taken to Centre Hospitalier Laurentien, in Sainte-Agathe-des-Monts, 25 miles from the resort. Hospital spokesman Alain Paquette said the actress was conscious upon reaching the hospital about 4 p.m.

The initial paramedic assessment, travel time to the hospital and time she spent there was nearly two hours—the crucial interval in this case. Survival rates for patients with epidural hematomas, conscious on arrival to a hospital, are good. Richardson’s evaluation required an immediate CT scan for diagnosis followed by either a complete removal of accumulated blood by a neurosurgeon or a procedure by a trauma surgeon or emergency physician to relieve the pressure and allow her to be transported.

Sainte-Agathe-des-Monts is a town of 9,000 people. Its hospital doesn’t have specialized neurology or trauma services. It hasn’t been reported whether the hospital has a CT scanner; CT scanners are less common in Canada. Compounding the problem, Quebec has no helicopter services to trauma centers in Montreal. Richardson was transferred by ambulance to Hospital du Sacre-Coeur, a trauma center 50 miles away in Montreal—a further delay of over an hour.

Because she didn’t arrive at a facility capable of treatment (with the diagnosis perhaps still unknown) until six hours after the injury, in all likelihood by that time the pressure buildup was fatal. The Montreal hospital could not have saved her life. Her initial refusal of medical care accounted for only part of the delay. She was still conscious when seen at a hospital and her death might have been prevented if the hospital either had the resources to diagnose and institute temporizing therapy, or air transport had taken her quickly to Montreal.

What would have happened at an American ski resort? It obviously depends on the location and facts, but according to a colleague who has worked at two major Colorado ski resorts, the same distance from Denver as Mt. Tremblant is from Montreal, things would likely have proceeded differently.

Assuming Richardson initially declined medical care here as well, once she did present to caregivers that she was suffering from a possible head trauma, she would’ve been immediately transported by air, weather permitting, and arrived in Denver in less than an hour. If this weren’t possible, in both resorts she would’ve been seen within 15 minutes at a local facility with CT scanning and someone who could perform temporary drainage until transfer to a neurosurgeon was possible. If she were conscious at 4 p.m., she most likely would have been diagnosed and treated about that time, receiving care unavailable in the local Canadian hospital. She might still have died or suffered brain damage but her chances of surviving would have been much greater in the U.S.

American medicine is often criticized for being too specialty oriented with hospitals duplicating too many services like CT scanners. This argument has merit but those criticisms ignore cases where it is better to have resources and not need them than to need resources and not have them. One high-profile case rarely provides the impetus to re-evaluate provision of services (although Quebec is now reassessing the need for air transport in medical emergencies). But as information becomes available, policymakers should carefully examine the circumstances surrounding this case.

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