Preventive Medicine Column March 27, 2009 Between Caution and Carpe Diem


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Preventive Medicine Column

March 27, 2009

Between Caution and Carpe Diem
Were I to mention that roughly 1.5 million Americans sustain a head injury each year, and some 50,000 die as a result (and in fact, I just did) I rather doubt it would bring a tear to your eye. It might not even compel you to think more about protecting your own head.

Were I instead to say the name Natasha Richardson, it might very well bring that tear to your eye. And at the very least, the name of this actress who died tragically of blunt head trauma from a fall while skiing certainly induces a painful pang in you, as it does in me.

The untimely death of Ms. Richardson harbors three important lessons about life, public health, and the pursuit of happiness. The first, quite simply, is that head trauma is a common and often preventable menace. The second is that names and faces are what matter to us when we contemplate risk. And the third is that public health tends to suffer from namelessness, and facelessness.

The result of combining the second and third is a prevailing tendency to magnify risk when it comes to us with a face and a name, and an even more concerning tendency to trivialize it when it doesn’t. Remediating these distortions to whatever degree possible is my mission in this column.

That Ms. Richardson’s untimely death riveted our attention is undeniable, as evidenced by the media attention the story has commanded. I was, and remain, somewhat preoccupied with this tragedy myself- perhaps in part because I, too, have a beautiful wife in her 40s who skis, but less expertly than I, who could very well be on a gentle slope taking a lesson while I was off elsewhere.  I couldn't help but process this story in that intimate, personal way- and so my heart was that much more rended for Ms. Richardson's family. 

The pain of loss is greatly compounded when it is untimely, more so when unexpected, and even more so when it is all but unfathomable.  It will doubtless take Liam Neeson and his sons quite some time just to acclimate to the reality of this dreadful loss of wife and mother.  My deepest and most personal sympathies are with them as they do.

But while this isolated tragedy is of obvious emotional significance, I am not convinced it offers a particularly clear public health lesson.

Ms. Richardson died of a subdural hematoma, blood that accumulates right under the dura, the outermost layer of the meninges, the lining around the brain. There is no room inside the skull for blood to accumulate, so a blood clot there starts to push on the brain, and it's not long before that becomes a lethal threat.  It also explains why there may be no signs of serious injury right at first- it isn't until a certain volume of blood has accumulated that real problems begin.

The unsatisfying part of this whole story is that there appears to be no good reason for Ms. Richardson to have had bleeding inside her head in the first place.  We know she fell.  But there have been no reports of a terrible fall.  She wasn't going fast, and she didn't hit a tree or another person.  So the force of impact must have been limited.

Nor am I sure that a helmet would have prevented Ms. Richardson's death.  If the bleeding was caused by the sudden jolt to the head, rather than the force of any object directing striking the scalp, that jolt might have been quite similar with a helmet on- although this is uncertain.

The real point of all this is that the stories of individuals command our attention in ways anonymous statistics do not. But it is, in fact, in statistical anonymity that the real lessons reside- because these tell us about prevailing patterns, and the actual probability of personal risk. It is the unfortunate burden of public health that to learn its compelling messages, we must part that veil of statistical anonymity- and attempt to make out the faces, and guess at the names, behind it.

I cannot fully account for Ms. Richardson’s death and find that adds frustration to sadness, but have long since reconciled myself to that combination as a by-product of caring for patients. So I cannot say her story offers any clear guidance to the rest of us. But the epidemiology of head trauma provides a clear and practical message: wear a helmet whenever you face the reasonable prospect of a blow to the head in some active sport, be it on skis, horseback, bike, etc.

Looking beyond this one variety of risk, recognize that that the less likely a tragic event, the more attention it will tend to get- and the more that will magnify the apparent risks involved. The more mundane a danger, the less attention it commands- no matter how clear and universally present that danger may be.

Head trauma is common- but heart disease, cancer, and diabetes are vastly more so. Applying what we already know with regard to healthy living, we could prevent roughly 8 out of 10 heart attacks; 9 out of 10 cases of diabetes; and as much as 6 in 10 cases of cancer. Each such event is a tragedy, too; each one avoided, a tragedy averted.

But there’s that statistical anonymity again- the lack of a compelling, human interest story. But recognize that the people in whom heart attacks and cancer don’t occur are REAL people- and might even be you, or someone you love. Behind the veil of public health is all the human interest we can handle.

If every tragic anecdote impels us toward anxiety, we might suffer from an excess of caution that squeezes out of life some of the pleasure it should accord. If we ignore the lessons of public health, we might succumb to eminently avoidable hazards. Somewhere between an excess of caution, and an unfettered exuberance for carpe diem lies a sweet spot where risks are managed reasonably, and life is still lived joyfully. Perhaps I can’t tell you exactly where it is, but I can encourage you to look for it.

Dr. David L. Katz;
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