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Head injuries and potential complications

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By Dr. Jai Ellis - email
Posted by Ellen Krafve - email

The injury and death of actress Natasha Richardson were untimely and tragic. While it reminds us of the frailty of life and its sometimes fleeting quality, we should take this time to reflect upon how we can make the safest decisions possible for ourselves and our loved ones.

The first issue that we should examine is the availability of emergency resources when we travel internationally or to remote locations. One of the factors that played a part in Mrs. Richardson's death was that she was vacationing in a resort town miles away from an ER without as much as a CT Scanner. Further, there was no Neurosurgeon in the region who might have been able to operate and evacuate her epidural hematoma. In order to avail herself of either of these resources, she would have had to be transferred to a Montreal hospital, 1-2 hours away by car. There has been a lot of heated debate among physicians as to whether or not this lack of resources was due to the imperfections of the Canadian healthcare system or just the specifics of this one resort town.

Either way, we should take pause and become more aware when we make travel plans, especially to places that are "off the beaten path". Some of the questions to consider and research are:
(1) Does the resort/hotel at which I am staying have its own emergency response team that can transfer a guest to the nearest ER?
(2) Does the resort/hotel at which I am staying have its own on-call physician 24 hours/day? If so, what is that person's expertise?
(3) Does the city/town where I am staying have its own hospital and ER? If so, does it have CT capability? Are there available surgeons and neurosurgeons? If the city/town is out of the USA, how does its hospital facility compare to US standards? The US Department of State has a web site which reports some information on this assessment. It comments on hospital size, census, number of patients per room, how the resources compare to American standards. The web site is www.travel.state.gov.
(4) If there is no hospital in the nearby vicinity, how far away is the closest facility? What is the response time of paramedics? How rapidly can a patient be transferred to this facility? Is there air transport or only ground?

Certainly for staunch athletes and thrill seekers, this information can be vital and may impact one's choice of destinations and/or accommodations. For those skiers, snow boarders, snow mobilers, horse riders, SCUBA divers, para-sailers, bungee jumpers, water and jet-skiers, among countless other outdoor enthusiasts, these concerns may take on a greater weight. Even if planning to rent a Moped and sight see on an island, being aware of local hospitals may come in handy.

If the choice of destinations will invariably include a location sans immediate and comprehensive medical care, then, for those activities for which it is feasible, wearing a helmet might be the next good suggestion.

Finally, do not be misled into thinking that pricier more exclusive resorts will necessarily boast these amenities. Because many of the places that do cater to the rich and famous are "in the middle of nowhere", in an attempt to ensure anonymity and privacy, it is impossible to have access to modern medicine while using their accommodations.

For many, escaping to paradise for a little R and R is the ultimate vacation. As we retreat from civilization and discover paradise in remote locales, we should be cautious not to unwittingly eliminate the possibility of rapid emergent care which is up to the standards that we, as Americans, find acceptable. The location of many resorts places them outside of the scope of this kind of care. We must be aware of this as well as the difference that may exist when comparing standards for medical care in countries that may not have our resources, population and ideology.

Therefore, call potential hotels in advance to inquire about these services. Alternatively, a travel agent might be able to offer insight and comparisons.

The Department of State also offers the American Citizen Services and Crisis Management (ACS), which is located at every embassy or consulate. It's purpose is to protect Americans abroad. It helps with such things as arrests, deaths, financial and medical emergencies. It will assist in obtaining private funds for citizens in need or it will supply a loan so that the person may obtain the medical or legal care that they need until other private funds become available. It will also help to return a deceased traveler or an ill traveler whom needs transport to an American facility. It is important to be aware of this service when planning any international travel. More can be found on the Department of State web site.

The next point of public awareness is that regarding head injuries and how to avoid missing a lethal problem.

In the case of Mrs. Richardson, it was reported that she felt fine and walked away from the accident. About one hour later, she began to experience severe headaches and may have had some slurring of her speech. Perhaps, if she had been assessed right away, there may have been time for transfer and treatment. We'll never know, but we should learn from her tragedy to always give ourselves the benefit of an assessment if we have sustained a trauma to the head.

It is important to know that epidural hematomas, which is what she suffered, may take anywhere from hours to several days to declare themselves. Therefore, we should be very aware of which criteria we should use when deciding whether an ER visit is warranted.

The first is to assess the type of injury that has occurred. As in Mrs. Richardson's case, any fall at rapid speeds presents a significant risk for a possible lethal injury. Even at 40 mph an impact to the human skull can be fatal. A fall from only a standing or sitting position can be just as lethal, especially if there was no protection or element to "break the fall".

Next, while loss of consciousness is the hallmark of a serious injury, many times, by the time that occurs, the patient is moribund and not much can be done. Consequently, more subtle signs to look for include:

-irritability;
-difficulty concentrating;
-insomnia;
-sensitivity to light;
-sensitivity to sound;
-nausea;
-confusion;
-decreased memory
-restlessness;
-clumsiness/lack of coordination.

More sinister signs include:

-unequal pupil size;
-convulsions;
-loss of consciousness;
-obvious fracture of the skull or face; facial bruising; swelling at injury site; scalp wound
-inability to move an extremity;
-decreased breathing rate;
-decreased blood pressure;
-severe headache;
-blurred vision;
-stiff neck;
-vomiting;
-unusually drowsy or lethargic;
-behaves abnormally

Because the signs and symptoms of a serious head injury can be delayed for 24 hours or more, if the person does sleep, they should be woken every 2-3 hours in order to check their neurological functioning. The following things should be incorporated:

(1) Ask if they know who and where they are and what year it is.
(2) Check that their breathing and heart rates are normal;
(3) Check that they have not vomited while asleep;
(4) Check that they can move all extremities and have normal strength in them.

What to do if someone appears to have sustained blunt force trauma to the head::

(1) Stabilize the head and neck keeping the head in line with the spine. Do not move the heads in case of a spinal injury.
(2) Check airway, breathing and circulation. Assess need for CPR.
(3) Stop any bleeding by placing a clean cloth over the area. If cloth becomes saturated, do NOT remove it; just place another one on top of that.
(4) If you suspect a skull fracture, do NOT apply direct pressure to area of injury. Do not remove debris from this wound. Cover with a sterile dressing.
(5) If the person is vomiting, roll the head, neck and body, AS ONE, onto the side to prevent choking on stomach contents.
(6) Ice packs to swollen areas.
(7) For pain, Tylenol may be given, but no NSAIDS (Advil, Motrin, Aleve, Aspirin) as they can increase bleeding.
(8) Do NOT remove the person unless absolutely necessary; wait for paramedics.
(9) Do NOT shake the person if they appear dazed.
(10)Do NOT pick up a child WITH ANY SIGN OF HEAD INJURY.
(11)Do NOT remove a helmet if you suspect a serious head injury, as this may place pressure on and decrease bleeding.

Being aware of some of the finer details and nuances of head injury may one day help to save the life of someone that you know. Perhaps Natasha Richardson's death will not have been in vain if it leads to more public awareness and safer practices in our day to day life.

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