April 8th, 2009
12:34 PM ET

Calculating the risks of skiing in Quebec

By Dr. Sanjay Gupta
CNN Chief Medical Correspondent

I just returned from Mont Tremblant, Quebec. It is one of the more beautiful ski resorts in eastern  Canada, and it is also the place where actress Natasha Richardson fell and suffered a fatal brain injury. What caused her death is now well known, but there were some other details that struck me while I was there. Let me try and work through this with you.

[cnn-photo-caption image=http://i2.cdn.turner.com/cnn/2009/images/04/08/gupta.mont.tremblant.jpg caption="Dr. Sanjay Gupta on assignment in Mont Tremblant, Quebec."]What no one knew at the time was that she had hit her head hard enough to cause a fracture in her skull. Just underneath that fracture is a small blood vessel that runs just on top of the brain, and it was that blood vessel that started to bleed. By many reports, Richardson got up after her fall and felt well enough to go back to her room and wave off paramedics who had been called. In neurosurgery, we refer to this as a lucid interval. She may have lost consciousness briefly, but now felt fine. The problem for Natasha or anyone with an epidural hematoma is that the pressure continues to build up in the brain. (See what an epidural hematoma looks like).

A little while later, now in her room, Natasha started to feel sick. The most likely symptoms were headache, nausea, disorientation and lethargy. 911 was called again, and now the clock was definitely ticking. If you ask a dozen neurosurgeons, how much time someone has after starting to develop the symptoms Natasha had, you will get varied answers. Anywhere from a few minutes to 90 minutes, but the message is the same: Speed matters. The problem for Natasha was she was nearly two hours away from a trauma hospital by ambulance, and there was no helicopter available to take her more quickly.

By the time she got to the hospital, too much pressure had built up on her brain and we know she died 24 hours later. The medical care in Canada is world class and the neurosurgeons there could have performed a lifesaving operation, if only she had arrived sooner.

There are doctors in Canada who have been calling for more air ambulances, long before we learned about Natasha Richardson. Others argue that the cost-benefit analysis comes down on the side of not having them. (Read more here) Based on our research, helicopters typically cost around $6,000 per hour to operate, not including other associated costs. So, here is something to ponder: Should ski resorts have access to helicopter services at all times or is there a certain amount of risk you accept if you ski in a remote location? Is it worth the cost to have this benefit?

Watch my full report Thursday on AC 360 at 10 p.m. ET.

soundoff (107 Responses)
  1. Lorenzo

    I have allot of respect for your reporting but i have to dissagree with you, this unfortinate event happened in a insolated area and not in a big city that´why there´s no close hospital. Anywhere in America you wouln´t have provided better service. Health care in Quebec is among the best in the world and contrary to your system it´s affordable for everywone rich or poor.

    April 12, 2009 at 07:44 | Report abuse | Reply
  2. France Lafond

    Dr. Gupta,

    A fact has been overlooked in USA reporting of medical services relative to Natasha Richardson's skiing accident. If the Mont-Tremblant medical centre would have had the opportunity to examine Mrs. Richardson and diagnose her problem, they would NOT have sent her in an ambulance, they would have requisitioned an emergency medi-vac from a public or private airport or heliport. The victim would have been transferred to a Montreal hospital in a very short time and would have received the necessary care. Could she have been saved? Nobody knows. But believe me, but there are a lot of helicopters or planes that can be requisitioned in the Mont-Tremblant area, they don't need to have an helicopter parked full-time outside the heath clinic.

    I worked in an hospital a thousand kilometers north of Mont-Tremblant, in the James Bay area. Whenever a patient's condition requested it, an emergency medi-vac was organized in a matter of minutes with an air travel provider and the patient and medical personnal were on their way South.

    The most important messages are overshadowed by the bad rap given to Mont-Tremblant: wear a helmet when you practice a dangerous sport, and if you do fall, go to the hospital or medical clinic for a check-up. It's as simple as that. We all wish Mrs. Richardson would have done that.

    France Lafond

    April 12, 2009 at 10:40 | Report abuse | Reply
  3. Christopher Phelan

    As a lifetime skier and resident of Mont Tremblant, I have watched this tragic story unfold with persoal interest. The whole debate about helicopers seems to miss the point, the resort is not "remote",the problem is not in the transport time. A .rushing ambulance could reach the Montreal Neurological Instituei in less than 1.5 hours. This is on a 4 lane, all weather highway. Other major hosipals such as the Cite de la Sante (Laval) and St Jerome are within one hour of the resort.

    It would appear to me that the protocol in the case of head injury should point to immediate dispatch to a neurology unit, without stopping at the local hospital for assessment. There is a physician right at Mont Tremblant who could be asked to make this assessment. Indeed, what would be the cost of going the extra 50 miles to ensure that the necessary service was avaiable., should a surgical intervention be required.

    This death was avoidable. Had she worn a helmet, had she gone immediately to a major trama centre by ambulance, we would not be having this misleading debate about helicopters.

    April 12, 2009 at 15:46 | Report abuse | Reply
  4. Simon Gulden, Markham (Toronto) Ontario

    Regratably air ambulance service was not readily available for Natasha Richarson at Mont Tremblant, Québec, notwithstanding that she refused initial medical attention.
    For almost 20 years, I take two ski trips a year to Colorado-Vail, Breckenridge,Keystone, Copper, Beaver Creek; and other than the excellent Vail hospital facilities, where I have been treated for ski injuries, I am not ware of on-the-spot-air ambulance services at those resorts. So while reporting no such ready-on-the-spot-service in Québec, you might also report lack of similar service at most ski resorts in both the USA and Canada to be fair and even-handed.
    Simon Gulden, Markham (Toronto) ON Canada

    April 13, 2009 at 19:39 | Report abuse | Reply
  5. W. Ryan

    This was certainly a horrible tragedy, but trying to make political points on it is unfortunate. Americans constantly point their fingers at the Canadian health care system and use unique tragic examples for illustration (caricature?). The truth is, sadly, that Ms. Richardson refused to wear a helmut AND refused treatment. In those circumstances, what good would an air ambulance have done? It would have sat idle as well. As to the larger question of health care, if our system is so bad, why do we have much lower infant mortality rates, much higher life expectancy rates, and why do no Canadians have to sell their homes in order to get medical care?

    April 14, 2009 at 09:26 | Report abuse | Reply
  6. Savant

    As many know we have 'public' health care in Canada. However, the only thing common about public health care is that there is a federal law that says 'there is public health care in Canada'. The actual health care delivery is done by each individual province. (This can lead to head-scratchers where a borderline-elective surgery may be covered in one province and not in the other – but that's another story.) Asking the federal government of Canada for comment is like asking the President to comment on how long it is taking to fix potholes.

    In Canada, ambulance services are the responsibility of the individual cities. In towns that are too small, or can't afford it, they will receive provincial ambulance service in its place. Hospitals never have their own choppers here since almost all the hospitals are not-for-profit and would never be able to justify the cost to keep a helicopter on standby. So it falls back to each province to provide air ambulance service. Some provinces don't need it because they are so small, for others its a must have.

    In Ontario they have a fleet of helicopters since the province is roughly the same size as all of the American states east of the Mississippi River put together. (Right now they have a dozen choppers and 4 airplanes on active duty, and they have contracts with other companies should they need extra aircraft in a pinch. It is the largest and most sophisticated civilian air ambulance system (ORNGE) in North America, averaging 17,000 calls a year!) However, none of this would have made a difference in Natasha Richardson's death.

    First off, no one would have called for a helicopter because someone 'bumped their head' or was complaining of a headache. I don't care who it is, people bump their heads all the time, you can't call a chopper for each one. (Unless you are the president.) Plus she rejected the ambulance when it arrived. So what about when she was at the local hospital later and needed to be transferred to the 'trauma unit' in the main city? OK, here are the details on that...

    When she complained of the headache at her hotel she was taken to the local hospital in Sainte-Agathe-Des-Monts. When it got serious they planned to send her to Montreal, the nearest major city with a trauma unit. Montreal is ~85km(~53mi) from Sainte-Agathe-Des-Monts by road, and it is a pretty straight drive, right to downtown Montreal. If you want to see the route, punch in the following to Google maps 'driving directions':
    Source: 234 Rue Saint-Vincent, Sainte-Agathe-Des-Monts
    Destination: 5400 boulevard Gouin Ouest, Montréal

    We can assume, from common practice, that they wouldn't keep an air ambulance out in a small town since use would be rare. They would keep it in Montreal since that's where most of the calls would be. (Traffic accidents and such etc. – As for the debate about having a helicopter at the resort, that is a private resort respobility, not a public health care one.)

    Ontario Air Ambulance uses a Sikorsky S-76, which is common for this kind of thing and used in many U.S. states for air ambulance duty. The top flight speed of this helicopter is 155 knots, which is ~175mph/~285kph. Since no one would ever fly a helicopter (or drive an ambulance) with the accelerator wide open, let's say they travel at ~150mph/240kmh. If we round the flight distance to 50 miles (to save on a few cut corners) you end up with a 20 minute flight time EACH way. Now you have to add an extra 5 minutes for the preflight sequence to start and warm up the helicopter before lift-off. So we are looking at a 45 minute trip.

    An ambulance, since it would be waiting at the hospital, would be ready to go as soon as they brought her downstairs. The road between Sainte-Agathe-Des-Monts and Montreal is a 6-lane freeway, (3 lanes each way) which means a highway speed of 100kph/62mph, but no one ever drives that speed, most people drive at 120kph if not faster. However, for safety's sake, let's say the ambulance only goes 105kmh/65mph. That means the trip would take 48.6 minutes, which we can round up to 50 minutes to account for travel on a few side-streets once off the freeway.

    So in the end, there is no meaningful time saved by using a helicopter in this case. (Unless people want to bicker over 5 minutes – if 5 minutes was enough to make a difference then she probably would never have been transported.)

    As one can expect, there will be cases when it can help, but this is not one of them. I think people automatically assume that helicopter automatically equals faster. If you park a helicopter at every single hospital and every mountain resort, I'm sure it does. However I don't think anyone in the world has that kind of coverage. Heck, why not do away with ground ambulances altogether and switch to helicopters? Wouldn't that save lives? Of course not. Helicopters are not a magic wand that can fix everything.

    So the issue of a helicopter is really a straw man, since it wouldn't have made any real impact in this case, in my opinion anyway.

    April 14, 2009 at 11:20 | Report abuse | Reply
  7. Mary

    Yes, Ms. Richardson should have worn a helmet. She did not expect that a fall on a bunny slope would be a big deal, and usually it would not. Yes, she should not have refused the ambulance at first, however, as someone who has experienced head trauma, I can tell you that a blow to the head will often leave your thinking temporarily fuzzy ( or permanently). You cannot expect that a person who has experienced trauma to the head will necessarily be aware of the possible future danger, or functioning quite normally....this is often not the case. So, no, I don't think it is quite fair to blame Ms. Richardson for refusing the ambulance at first. It seems that someone might have pushed on her a LOT to go ahead and have them check her for safety's sake. A tragedy....

    April 16, 2009 at 21:05 | Report abuse | Reply
  8. Nydra

    My brother had a brain bleed in January. He lives in Pender, NE, 1500 appr. population and did not identify the problem until 2 AM. He began to throw up early evening and assumed it was the flu.
    At 2AM, he was taken by life flight to Sioux City, a town of 50,000 appr.
    To drive is 45 minutes but lifeflight flies right into the hospital grounds. He is almost himself now although he was in a coma when he was picked up.
    Why does a town of 50,000 have a helicopter when there was none available for Natasha?
    Capital expenditures aren't high on the list when the capilism, free market, has been driven out. In Sioux City, they can charge for those rides so supply and demand work there.. not in Canada, it appears.

    April 21, 2009 at 19:01 | Report abuse | Reply
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Get a behind-the-scenes look at the latest stories from CNN Chief Medical Correspondent, Dr. Sanjay Gupta, Senior Medical Correspondent Elizabeth Cohen and the CNN Medical Unit producers. They'll share news and views on health and medical trends - info that will help you take better care of yourself and the people you love.