Is it October yet? Part 2: Trent McCleary

This is the second in a series of posts looking at historic hockey injuries, intended to keep me busy and you interested while we wait for October to get here.

The history was provided by Jen aka @NHLhistorygirl. Jen is a librarian and graduate student at the University of North Dakota in the last stage of her MA in history: writing her thesis on the 1972 Summit Series, media, and notions of national identity.

 

Trent McCleary, huge frigging badass.

The history…

It’s a play we’ve seen hundreds of times: a player winds up for a shot, another player attempts to block it. The puck slides away, the players skate after it. No harm done. Every once in a while though, something goes wrong, and a player ends up bruised or needing a few stitches.

And in the case of Trent McCleary, it went horribly wrong.

On January 29, 2000, the Habs were playing the Flyers at the Molson Centre. Habs right wing Trent McCleary hadn’t logged much ice time (only 4:02) but he played aggressively. It was no surprise that he attempted to block defenceman Chris Therien’s shot.

The shot hit him directly in the throat, and McCleary fell to the ice, unable to breathe. He struggled on the ice for a few moments, then his instincts drove him to skate to the bench, where he tried to tell the trainer he couldn’t breathe before collapsing.

Not quite unconscious, McCleary’s throat was filling with blood and every breath became more difficult, causing him to thrash about frantically. His adrenaline level was so high that when Habs therapist Graham Rynbend tried to hold him down for examination, he threw Rynbend over the table.

When the doctor could not get a breathing tube down McCleary’s throat, he was then rushed to the hospital and directly to an operating table. McCleary had a collapsed right lung and a complex fracture of the larynx, two life-threatening injuries that required an emergency tracheotomy and putting him on a respirator.

Events happened so quickly that of none of McCleary’s equipment had been removed before emergency surgery. It was the first time the doctors had ever operated on someone still in skates. Had events not moved as quickly as they did, according to the surgeons, McCleary would have died. “It was a matter of seconds,” said Dr. Mulder.

Two days later, unable to speak, he wrote a note to his teammates (who were about to play the Hurricanes): “Doing well. Here’s $500 on the board for the win. I’ll be listening. Battle Hard. Go Habs. Trent no. 6”

After three surgeries and months of therapy, McCleary was able to regain his voice and resume a normal life. However, the tracheotomy site formed enough scar tissue to reduce his breathing capacity, and he was forced to retire.

 

The medicine…

Every patient assessment algorithm begins with the ABCs – airway, breathing, and circulation. If one of these elements is compromised, you can’t proceed until you’ve fixed it. McCleary’s injury brought the assessment algorithm to a screeching halt at A. When Therien’s shot hit him in the throat, it fractured his larynx, and almost completely occluded his airway. Without A, there’s no B. Without B, C quickly stops.

The Larynx

Bonus pro tip: Don’t pronounce this lair-nix. That’s wrong, and you’ll sound stupid. It’s lair-inks.

The larynx is a complicated combination of cartilage, muscles, and ligaments that sits just below the base of the tongue. It forms the topmost segment of the trachea (windpipe), and protects the vocal cords. It’s also an invaluable player on the airway team with a limited no-trade clause. With very, very few exceptions, you can’t live without it.

 

So THAT's where my larynx is!

 

What you know as your Adam’s apple is actually the front of your thyroid cartilage. Just below that you’ll feel a little gap, which is the cricothyroid membrane. That’s of huge significance in an injury like McCleary’s, as it’s an easily identified way of getting into the airway in a hurry.

 

The Larynx: It doesn't want to go to Edmonton either.

 

When Trent McCleary took a puck in the throat and fractured his larynx (i.e. the cartilage), two things immediately happened: He started bleeding, and he started swelling. The only method of getting air to his lungs was rapidly filling up with things air doesn’t like to go through. McCleary had the presence of mind to get up and move towards the bench, and with assistance made it off the ice before he collapsed. We have to assume that he was moving some air, as the brain won’t last longer than 4-6 minutes without it, and McCleary suffered no brain injury as a result of this incident.

A is for airway

McCleary was moved to the dressing room where team doctor David Mulder (a cardiothoracic surgeon) and trainer Graham Rynbend very quickly began trying to establish an airway. The usual way of doing so is intubation – sticking a plastic tube into the trachea (through the larynx) to provide a secure way of ventilating the patient. McCleary’s fractured larynx, along with swelling and bleeding, made tube placement impossible. Worse yet, the injury meant that the tissues of McCleary’s neck were beginning to fill with air that was leaking from his damaged trachea. This is called subcutaneous emphysema (if you’re a professional), or rice krispies (if you’re a paramedic or ER doc) because it really feels like there’s a layer of them under the skin.

With no way to intubate McCleary and what was left of his airway rapidly disappearing, some sources state Dr. Mulder performed a needle cricothyroidotomy with the assistance of Dr. David Fleizser, a surgeon who was a spectator at the game. Remember that little gap below your Adam’s apple? That’s the cricothyroid membrane, and a needle cric (say it like crikey without the y) involves punching through it with a big needle to provide a (very) temporary way of getting air into the lungs. The needle used is generally 14 gauge, which is about 2mm wide. To put it into perspective, 2mm is REALLY DAMN SMALL. Smaller than a drinking straw. The information we have doesn’t tell us if they stopped at the needle cric, or if they widened it to accomodate a larger tube. We do know that McCleary arrived at the emergency room 17 minutes after the puck hit his throat, and was immediately taken to the OR.

Dr. Mulder performed an emergency tracheotomy, a common surgical procedure that involves cutting a hole into the trachea at the base of the neck between the cartilage rings (which you can see in the figure above). The trach saved McCleary’s life by providing him with a way to get air past the horrendous damage in his throat. The A portion of the ABCs was complete.

B is for Breathing

Somewhere along the way, Trent McCleary also suffered a collapsed lung (pneumothorax). Pneumothoraces can happen in any number of ways – blunt trauma, penetrating trauma, and even spontaneously. McCleary’s pneumothorax could well have been a consequence of the air escaping his mangled larynx looking for places to go. The basic premise is that instead of filling the lung, air fills the cavity between the lung and the chest wall, keeping the lung from inflating and preventing proper ventilation. Keep in mind also that throughout this ordeal, McCleary was being aggressively ventilated, with air being forced into his mouth and nose by way of a BVM (bag-valve mask, or ‘bag’ – you’ve seen it on ER, and they’re always using it completely wrong).

Note the arrow pointing at the edge of the collapsed lung (which is conspicuously nowhere near where it should be)

A pneumothorax is a condition that can quickly become fatal. It’s not hard to figure out that if you fill your chest cavity with air, the heart and lungs end up getting shoved out of the way. Much as the brain is touchy about getting pushed around, the heart and lungs aren’t fans of it either. Your breathing suffers, your heart can’t fill or pump efficiently, and organs that need oxygen stop getting it.

Dr. Mulder inserted a thoracostomy tube (what you and I have lovingly come to know as a chest tube), which allows trapped air to escape the chest cavity and the lungs to reinflate. The tracheostomy was a more permanent answer to the B of the ABCs, and the chest tube ensured that the C of the ABCs wasn’t compromised.

The Aftermath

Once McCleary’s airway had been re-established, he was still left with the problem of a badly damaged larynx. He spent a few days on a ventilator, which is not surprising considering the extensive swelling and damage to his airway. It also takes practice to learn how to breathe with a trach, and patients who are intubated and on a vent usually take a little time to transition back to breathing on their own.

Several surgeries were required to repair the fracture (most likely with wire sutures), and his voice was restored with the final procedure (yes, you can suture vocal cords). Over the course of his recovery McCleary received his nutrition first by way of TPN, or total parenteral nutrition – essentially a solution of fat, glucose, amino acids and vitamins that’s administered via IV. He eventually graduated to a small-bore (narrow) feeding tube that was placed through his nose into his stomach. In time the tube was removed, as was the trach.

McCleary attempted a comeback with the Habs the next season, but scarring had narrowed his airway by approximately 15% and he found himself so out of breath that he couldn’t complete a shift.

Things I don’t believe:

In an incredibly boring video featuring Swift Current’s 5 most fascinating people of 2009, McCleary says that Mulder dislocated his jaw in his attempts to establish an airway. The way you open the airway of a patient who may have a spinal injury is by using a jaw thrust – placing the thumbs behind the angle of the lower jaw and pulling it forwards. This serves to straighten out the airway, making intubation easier, and limits movement of the c-spine. There’s plenty of yapping about whether or not this actually results in a jaw dislocation. All I can offer is that in 11 years of performing this maneuver, I’ve never dislocated a jaw (nor heard of one being dislocated). A search of the literature yielded very little on the topic, suggesting that mandibular dislocation isn’t entirely uncommon, but is generally seen in patients under general anesthesia. So is it possible? Sure. Do I think it happened? No, probably not. It takes a lot of force to dislocate someone’s jaw, especially if they’re not sedated. Does it matter? No. McCleary is fine now, and Drs. Mulder and Fleiszer and Mr. Rynbend are total badasses.

Speaking of badasses…

Note Trent McLeary’s gigantic cojones as he gets up and skates off the ice with a shattered throat. Absolutely amazing. Most of the credit in this situation probably needs to go to McLeary for getting up and getting help. Had he stayed on the ice and waited for the medical staff, his outcome might not have been as good as it was.

Enjoy a trip back to 2000 with this truly terrible quality video:

About Jo Innes
Who am I? I'm a paramedic turned ER doc with truly sub-par rec league hockey skills. And I have absolutely no problem sharing my opinion with you. You're welcome.

3 Responses to Is it October yet? Part 2: Trent McCleary

  1. Phil says:

    Really interesting post, Jo. Even tho your stuff always leaves me a little queasy.

    A “hockey” note on this: No doubt McLeary has huge cojones, but on this particular play his hockey sense was absolutely abysmal. It was the completely wrong way to block a shot (duh!).

    If you’re insane enough to want to block a shot with your body (I personally don’t recommend it unless you’re getting paid several hundreds/millions to do it), you need to slide in feet/shin pads first – anything else, and you’re just asking to be hurt. On that particular play he should have just gone in as a statue, legs closed in. Of course, easy for me to say…

    • Jo Innes says:

      Agree 100%, Phil. Shot blocking is pretty stupid. I’ve read some discussion somewhere about whether McCleary was actually trying to block the shot or if the whole thing was an accident. You don’t see too many guys blocking head first (no, Volchenkov, not you – everyone knows you love the feel of a puck bouncing off your face).

  2. Freddie says:

    Wow can I talk ,I’m in tears I’m a grown man sorry! I was a correctional officer in NC between 2000 2003 .During this time I worked hard on my martial arts training for self defense and loved it . JKD BJJ Vale Tudo and Tomiki Aikido I move to SW Fl. and stayed on my jetski playing in the water. One day I jumped a wave and the way whipped me up like being bucked off a bull, as I started down the ski road a wave back up toward me and impacted me as I impacted it (Double whammy!) My neck and jaw smashed into the front hatch leaving plastic particles in and also cutting my right ear. I found myself in the water and not breathing good. I remember the feeling of my head barley above water and not much air.This was a very awful feeling to be in water up to my head and not breathing good. When I looked to the right I saw my family including mom and dad ( Life Flash !) who were visiting and no one had seen my accident. I swam to my ski and came to shore. I told my wife Shelli don’t tell mom but I had a huge accident. I have pictures of my adams apple pushed to the left and my voice was croopy sounding ,I also could not get higher pitch sounds that I once could make singing or talking.I put off going to the doctor for 3 weeks but after all the great advise from friends like” Try to adjust it with your hands ” another said “go out in a field and scream as loud as u can!)” ?????
    An Irish Dr. here in Naples x-rayed my throat and then did a CT. When we were done he came to me very seriously and said “You were visited by providence!” Being a southern Baptist I said what does that mean? He said you should have died ( I don’t remember exact wording but something to the affect of – usually when an accident like this occurres the adams apple should of fallen down blocking your breathing and you should have died.
    I had surgery 2 weeks later and because I don’t have insurance I only returned once to my surgeon Dr Roberts but he said I was fine and go live your life. I have taken prevacid ever sense I want to do martial arts again ,but I’m afraid of a straight on blow which would mean lights out.I also got to see the CT images and my airway is more oval and less air comes through maybe not as bad as Trent McLeary’s breathing, but I had less zip when going to the gym I also felt like I had a pipe clamp with a big bolt on my adams apple every time I swallowed. That got better as I heeled. It still does a snap pop sound when I swallow. I also had to learn to concentrate when Iate because I’ve been without air because of a small food particle like a piece of lettuce . I learned I could push air out my self like a Heimlich Maneuver would do and I just make a huff of air this will clear out the food partical and I can continue to breath yeah ! Sadly I remember Dr. Robert when I asked could I train in martial arts ever again saying I would n’t . His reasoning was because cartilage heals but not as good as bone and a good hit to the throat could be the end.

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