Is it October yet? Part 1: Ace Bailey

This is the first 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. 

The first all-star game: A benefit for Ace Bailey

The night of December 12, 1933 was just like any other game night at Boston Gardens. The Bruins had a two-man advantage. The Leafs sent Ace Bailey and Red Horner out as part of the penalty kill. Red checked Bruin Eddie Shore into the boards, picked up the puck, and headed for the Bruins net. Bailey moved into Horner’s defensive position near the blueline. It’s the last thing Bailey would remember about that night.

Shore mistook Bailey for Horner, and took Bailey’s feet out from under him.  In an era without helmets, this was a dangerous move on Shore’s part. Bailey hit the ice head first, and began convulsing.

While Bailey’s teammates gathered around and the Boston trainers frantically tended to him, Horner punched Shore, who also hit the ice, bleeding. In the stands, a fan taunted Bailey, calling him a diver. Leafs owner Conn Smythe punched the fan, knocking teeth loose.

Bailey was awake when they took him to the dressing room, where Shore asked his forgiveness.  Bailey replied, “It’s all part of the game,” before losing consciousness and falling into convulsions again.  He was transported to Audubon Hospital, where he was diagnosed with a fractured skull. By morning, his condition was critical due to cerebral hemorrhaging.

He was moved to City Hospital, where neurosurgeon Dr. Donald Munro operated to relieve the cranial pressure on two different occasions. After the second surgery, the doctor pronounced Bailey’s chances as “very slim” and a priest was called to give Bailey last rites.  His pulse was 160 and he had a fever of 106. Newspapers had an obituary written and waiting. Reportedly, Bailey’s nurses would slap his hand or his cheek if it appeared he was slipping away. They kept telling him his team was down two men and needed him.

His condition finally improved, though Bailey says he did not regain full consciousness for fifteen days. With his playing days over and a plate in his head, Bailey asked the league’s permission to suit up as a linesman. Worried that any hit may cause Bailey further serious damage, his request was denied and he served many years as an off-ice official for the Leafs.

Bailey and Shore

Ace Bailey suffered what’s obviously best described as a devastating head injury. It’s amazing that he lived, even more so when you consider this happened in 1933. Penicillin had just been discovered (but wasn’t in widespread clinical use yet), and the concepts of tracheal intubation (breathing tubes) and IV anesthesia for surgery were brand new.

It’s hard to say exactly what Bailey’s specific head injury was. As such, this can really only be a look at a condition he may have had. There’s really no way to know what actually happened. We know his head hit the ice, he seized, was briefly awake and lucid, seized again, then stayed unconscious for a long time. During that period he had intracranial bleeding requiring surgical intervention, and developed an extremely high temperature.

The description of Bailey’s lucid interval could suggest he suffered an epidural bleed, which is the result of torn arteries between the skull and the dura mater (the tough covering around the brain and spinal cord). This is an uncommon type of traumatic head bleed, but made headlines in 2009 when actress Natasha Richardson died two days after a head injury sustained while skiing. She initially refused EMS care, then after a few hours was rushed to hospital with head injury symptoms and later died.

The stereotypical textbook progression of loss of consciousness-lucid interval-loss of consciousness actually doesn’t happen in most epidural bleeds. Patients can lose consciousness (or not), and may wake up (or not). The thing about the lucid interval is that’s the classic wording healthcare providers associate with the injury (and it’s extraordinarily unlikely to see it in other head bleeds).

A theory on why this happens is that the impact of the initial injury causes a loss of consciousness (from which the patient awakes), and the lucid interval represents the bleeding taking time to affect the brain as it happens between the hard skull and the relatively unyielding dura. Of course it’s important to note that this is just a theory, and the lucid interval can be of varying duration – anywhere from seconds to hours.

Why did Ace seize?

Seizures happen when the neurons in your brain aren’t firing in the nice, orderly pattern they’re used to. Seizures can be the result of a seizure disorder (like epilepsy), or an insult to the brain (like trauma, stroke, lack of oxygen, etc). In Bailey’s case, the impact of his head on the ice would have caused a cascade of events that set him up for seizure.

When his skull hit the ice, it stopped. His brain stopped when it hit the inside of the skull. The brain is a delicate thing, and it doesn’t like sudden changes. Not only would an impact with the skull likely cause a contusion (bruise) on the brain, it could potentially cause another on the other side thanks to something called a coup-contrecoup injury (French for blow-counterblow). The brain hits the skull on the side of the impact, and then in essence bounces back and hits the skull on the opposite side, causing a second contusion. Now you’ve got two areas of pissed-off brain that could misfire and cause a seizure.

Coup-Contrecoup

Treatment

Current treatment for a head injury of this type would start with transport to a trauma center. Obviously the treatment would also include the basics of pre-hospital trauma care (which I’ll grossly oversimplify here): Management of the airway with intubation if necessary, spinal immobilization, and IV fluids to replace volume loss from bleeding.

On arrival at the ER, head injured patients are often placed into the ominous-sounding medically-induced coma, which is to say they’re sedated and intubated. There are a lot of reasons this is done – for the patient’s comfort (they’re in pain, and probably scared to death), to have complete control of the airway (there’s no better airway control than having a tube stuffed into it), and for the now-controversial practice of reducing their intracranial pressure (ICP) by hyperventilating them. As we learned in this post, carbon dioxide (CO2) causes the vessels in your head to dilate, which would increase the amount of blood in there, and thus increase pressure. If you force hyperventilation, more CO2 is exhaled, reducing blood flow and therefore ICP. Hyperventilation of head injuries is falling out of favour now, as studies have shown that it doesn’t improve outcomes, and in fact can lower brain perfusion (which is bad for obvious reasons). CT scans and x-rays determine the extent of the injuries, and the patient is given IV steroids to reduce brain swelling. The patient may receive anti-seizure medications whether they’re seizing or not (to stop or prevent a seizure).

At this point the smart kids take over (that would be the neurosurgeons) and decide what sort of surgical intervention is needed. In rare cases epidural bleeds can be managed non-surgically with just steroids and observation. More often, however, the blood that’s filling the space between the skull and dura has to be taken out.

Epidural hematoma - Big red arrow provided for those who are immune to the obvious

Assuming you’re in a trauma center with neurosurgery on staff (as opposed to asleep in their golf course home with a pager on the nightstand) the treatment is craniotomy, evacuation of the blood, and ligation of the artery that’s bleeding. Translation: Take off part of the skull, suck out the blood, find what’s bleeding and tie it off. The piece of the skull may go back on at this point, or it may get stored in a fridge in the hospital basement until they’re sure the brain is done swelling and they can put it back on. If you’re in some outlying hospital with no hope of a neurosurgeon for a while, studies have shown that drilling a burr hole in the skull at the injury site is a good bridge to definitive care (yes, I saw that episode of Medical Incredible too).

As far as Bailey goes, it’s hard (impossible) to say what the two surgical procedures that he had actually were.  He’s said to have had a plate in his head, which suggests fragments of his fractured skull were removed (hello, craniotomy) and replaced. Why did he have two surgeries? Good question. It’s possible the bleeding wasn’t controlled the first time, and it’s possible it was done as a staged procedure – the first surgery to take the skull fragments out, and the second to put in the plate.

Post-Surgical Complications

After his two procedures, Bailey developed a pulse of 160 and a fever of 106, neither of which is part of a healthy recovery. There are two possible reasons for these symptoms, both of which have catchy acronyms – SIRS and PAID.

SIRS – Systemic Inflammatory Response Syndrome

SIRS is basically whole-body inflammation. It can be a result of infection (as one might get from brain surgery in 1933), or non-infectious events (trauma, burns, severe allergic reactions, etc). In Bailey’s case it could have been either. SIRS manifests as a high heart rate, a very high or very low body temperature, rapid breathing, and a very high or very low white blood cell count (those are the ones that fight infection). SIRS is pretty common in both the medical/surgical and trauma ICUs. Generally it’s treated with symptomatic management and control (where possible) of the cause (i.e. antibiotics). In 1933 it would have been treated by cooling Bailey, and having nurses slap him to keep him from dying. Super hi tech, and apparently pretty effective.

PAID – Paroxysmal Autonomic Instability with Dystonia

PAID is a scary complication of severe head injuries where the body loses its ability to control the autonomic nervous system – that’s the one that does all the automatic things you don’t pay attention to. Things like controlling your body temperature, your heart rate, digestion, and sweating. Patients with PAID have episodes of elevations in pulse, respiratory rate, blood pressure and body temperature. They also have dystonia – episodes of rigidity or posturing (abnormal body movements in response to brain injury).

Decerebrate posturing - A very distinctive response to head injury

PAID is generally seen in low-functioning head-injured patients in the ICU and rehab setting. It’s treated with medications to manage the symptoms, including muscle relaxants, beta blockers to lower heart rate, anti-hypertensive medications, and more. PAID can persist for months in these patients, and those who have it generally have head injuries so severe that they rarely return to full function. PAID seems like the less likely of the two possibilities, mostly because Bailey was awake within about two weeks of the injury, and went on to lead an essentially normal life.

Ace Bailey suffered a significant head injury by 21st century standards. The fact that he did it in 1933, had serious complications, and lived a full life afterwards is frankly amazing. An injury like this is unlikely now given the mandated use of helmets, but as we’ve seen in all the players whose lives and careers have been permanently affected by concussion, it doesn’t take a broken skull to change things forever.

Mason Raymond: So you’re an expert?

After Mason Raymond’s hit from Johnny Boychuk in game 6 of the Stanley Cup final, nobody could have been more surprised than I when he left the ice on his feet after what seemed like several minutes of face-down on-ice discussion with a Vancouver trainer. When a player goes down (and stays down) for that long, we’re used to seeing them stretchered off in full spinal immobilization.

The purpose of full spinal is to keep the spine still (amazing, I know). It involves being strapped to a hard plastic spine board with your head held completely still looking straight ahead (or straight up, as is the case once you’re laying flat on your back). There’s an algorithm used to decide who needs full spinal precautions – at its simplest it’s a question of whether there’s potential for a head, neck, or back injury. Is there neck pain? Spine board. Head injury? Spine board. Penetrating injury that could compromise the spine? Spine board. Too drunk to stand up and fell off the porch/bicycle/moped/roof of your brah’s SUV? Spine board.

So the question is why Raymond left the ice on his feet. There are actually several reasons this could have been completely appropriate, despite what Twitter’s many, many experts seem to believe. I kicked off a Twitter explosion the likes of which I hadn’t previously seen with two simple tweets:

Lots of criticism for skating Raymond off. Trainers aren’t stupid, guys. Guarantee they tried to get him on a spineboard and he refused.

And as if that weren’t enough expert-bait, I followed it up with:

So let’s give up the “Skating him off is malpractice!”. Were you there? Are you an expert? Cue Andy Sutton.

Now let’s back it up just a bit and take a look at the hit:

 

The first thing worth noticing is that Raymond doesn’t seem to lose consciousness. He’s also moving his arms and legs. Next, he and Canucks head trainer Mike Burnstein actually spend a full minute in discussion before Kesler and Higgins help Raymond up and off the ice. In an injury situation a minute is a really, really long time. Usually the way it goes is you get the equipment you need, get the patient on it, and get the patient out. You know what situation usually gets in the way of keeping things moving? Arguing. My suspicion is that Burnstein was doing his best to convince Raymond to get on a board, and ultimately couldn’t do it. That wasn’t malpractice, Vancouver’s trainers are experts, and I’ll gladly explain why.

The Algorithm

To be clear, there are two types of spinal clearance algorithms. The kind that determines if an injured person needs to be on a spine board at all (used in the field by EMS, athletic trainers, and other first responders) and the kind emergency physicians use to determine if someone with a spinal injury can come off of the spine board, and if they need imaging (x-rays). I’m talking about the first algorithm. Let’s walk through it.

1. The patient gets injured. The ambulance gets called.

2. Spinal exam: Do they have neck and/or back pain? This can be on movement or palpation.

3. Neuro exam: Are there any focal neurological deficits? Examples would be numbness, tingling, weakness/inability to move.

4. Mechanism of injury: Is it significant? “Significant” is different just about everywhere. Several state EMS formularies define it as such (and yes, most of these relate to motor vehicle crashes):

  • Ejection from the vehicle
  • Death in the same passenger compartment
  • Fall greater than 15-20 feet (or some places use twice the patient’s height)
  • Vehicle rollover
  • Vehicle vs pedestrian
  • High-speed collision
  • Motorcycle crash
  • Unconscious or altered level of consciousness following injury
  • Penetrating injury to head, neck, torso

Common sense (and the more clever formularies) add axial loading to this list. An axial load is a force applied to the head that causes spinal compression (or loading). Think of someone jumping into a pool and hitting their head on the bottom. The Canadian Journal of Emergency Medicine did a nifty little study wherein they found that in non-car-crash incidents, you’re at greatest risk for a spinal fracture with axial loads, falls, diving accidents, and motorized non-car vehicles (ATVs, snowmobiles, etc – If anyone’s interested I have a great rant about why you should stay the hell away from those evil, evil, contraptions).

5. Impairment: Is the patient impaired (ie. by drugs/alcohol)?

6. Distracting injuries: Does the patient have any painful injuries that might distract from their spinal issue? For example, if your leg is hanging off, we’re probably not going to spend time discussing whether you need a spine board.

If you answered yes to any of those questions, the patient needs to be immobilized. Problematically, some people still refuse. Even more problematically, those people are often sober and intelligent.

Okay, so what do you do if someone needs to be put on a spine board and they refuse?

Well, contrary to what the Twitter experts believe, you don’t force them. You explain to them the consequences of their actions. You beg. You plead. You might bully a little bit. You might even threaten just a touch. Have I ever told someone that by refusing treatment they could die? You bet. Have I had a patient actually die as a result of refusing treatment? Almost. It’s hard to understand just how completely useless you feel trying to explain to an unwilling patient that you’re trying to help them. So let’s spend a moment in Mike Burnstein’s shoes, and in Mason Raymond’s skates.

In Raymond’s case, he’s just hit the boards ass-first in one of the most important hockey games he’ll ever be a part of. Maybe he’s in pain, maybe he isn’t. Spinal compression fractures are tricky little beasts – usually they’ll present with midline back pain, but they can also present with pain in a completely unrelated area (the lateral back, buttocks, hip, etc.) or no pain at all.  Since none of us are Mason Raymond, none of us know where or if he was hurting. There’s no way of knowing what his neuro exam was, but he was definitely moving his extremities after he went down. As far as mechanism goes, the video of the hit makes it look like there was probably an axial load from Boychuck driving him into the boards. Did Burnstein know that? Probably not. Did Raymond know that? If you’ve ever taken a hit (or been in a car wreck, or had any kind of sudden trauma) you know that even if you aren’t knocked out, you’re usually not able to immediately describe the mechanics of what happened. And let’s be honest – Raymond probably didn’t care what the mechanics were. More than likely he just wanted to get back up and keep playing.

Given Burnstein’s extensive training and experience, you have to assume he was trying to get Raymond on a board. Any assertion that he doesn’t know what he’s doing or committed malpractice makes about as much sense as trading Chara for Daigle (which is actually kind of a dumb example since that actually happened). To soothe the Twitter experts, why don’t we go ahead and define medical malpractice, just so it’s clear why Burnstein’s actions don’t qualify.

Malpractice: There’s more to it than you think.

Medical malpractice may vary from state to state, province to province, and country to country. I’m not a lawyer, so don’t expect any complex legalese here. This is just an overview of what’s involved. There are four requirements for a charge of medical malpractice:

  • Duty to act: This is the care provider’s responsibilities within his job/training. In Burnstein’s case, as the head trainer he has a duty to respond to and treat injuries to players. His level of training allows him to recognize Raymond’s injury and then to direct that he be immobilized and transported to the hospital. That’s assuming Raymond consents to the indicated treatment (we’ll look at consent in a second – that’s significant in this case).
  • Breach of duty: A breach occurs when the provider fails to provide the care that’s indicated (and permitted by his level of training). If you want to argue that Raymond needed immobilization (which it’s safe to say he probably did), then you may also want to argue that Burnstein committed a breach of duty. I’ll argue that he didn’t, under the assumption that Raymond wouldn’t consent to immobilization.
  • Injury resulting from the breach: Failure to provide the indicated treatment causes injury to the patient. This is hard to argue either way in this case. Raymond broke his back when he hit the wall. There’s no way to say if skating off the ice made it worse.
  • Damages: This refers to emotional distress or monetary loss – i.e. if someone didn’t receive the indicated treatment and as a result was unable to work. The damages must be as a direct result of the breach of duty. In this case you’d be hard-pressed to argue that there were any damages. Yes, Raymond will miss ice time, but his injury was from hitting the wall, not from skating off the ice. And as I just said, it’s impossible to know if skating off made it worse. Most significantly, damages don’t exist unless there’s a plaintiff to claim them. There can’t be malpractice unless Raymond makes a claim for it.

So is Burnstein guilty of medical malpractice? No. Clearly not. If you’re not convinced, then maybe a quick discussion of consent will help.

Consent: Wherein medical providers would rather not assault people.

In order to administer treatment to a patient, a health care provider must first obtain that patient’s informed consent (unless the patient is unable to provide consent and the treatment is absolutely required, in which case consent is implied). Informed consent consists of informing the patient of:

  • Their diagnosis (to the best of the provider’s knowledge at that time) – In Raymond’s case, it would be as simple as Burnstein telling him that he could have a back injury.
  • The treatment or procedure that’s indicated and its risks/benefits (spinal immobilization to prevent any movement in the spinal column).
  • Any alternative treatments and its risks/benefits (not really applicable here).
  • The risks/benefits of refusing the treatment (Risk: making it worse. Benefit: full spinal is uncomfortable).

If your patient doesn’t consent to the treatment and is in possession of their faculties (not drunk, not high, not a minor, not head injured, etc), and you treat them anyway, then you’ve just committed medical battery. That’s a real thing, and people get sued for it. It’s defined as violating a patient’s rights to direct their medical treatment, and involves the unauthorized touching of a patient. Health care providers are acutely aware of what they can and cannot do, and assessing a patient’s ability to make an informed decision is a skill that comes with time and experience. Any Twitter expert assertion that “They should have just made him get on the spine board!” is frankly ignorant. It’s never that simple. You can’t just make someone do something.

Trying to paint the Raymond incident in black and white strokes isn’t possible. There are a lot of factors involved, and screaming malpractice doesn’t make sense. Yes, Raymond broke his back. Yes, he should have been immobilized. The long and the short of it is that Burnstein knew that, and more than likely tried to make it happen. In the end he had to get Raymond off the ice and into treatment, and when he was transported to the hospital it was reportedly in full spinal immobilization.

Still not happy? The Globe and Mail had a few experts of their own opine on the incident, among them a spinal surgeon and a physiotherapist. You’ll notice that one of the physicians in the article states that “…the team should err on the side of caution and insist he be taken off on a stretcher” – didn’t I say something about this not being black and white? Again this comes down to one’s ability to convince/cajole/bully the patient into doing what’s appropriate. In Raymond’s case, it seems like it just didn’t work.

Raymond’s Injury

Raymond suffered a compression fracture of the L5 (lumbar aka lower back) vertebrae. Per Vancouver GM the fracture is through the belly of the vertebrae, which is to say the big fat round part in the front.

Here’s what’s broken.

These fractures can be managed through injection of special cement into the vertebrae, or surgery to immobilize the bone from the inside through the placement of plates or rods, although this is generally a last resort.  Most often this is treated with a back brace to immobilize the spine, pain medication, time, rest, and physical therapy. The brace generally used in injuries like Raymond’s is the TLSO (thoracic-lumbar-sacral orthosis) brace, which you can conveniently buy on Amazon (although you probably shouldn’t).  Raymond is expected to miss 3 to 4 months.

In case you have no idea what the Andy Sutton reference is all about, here you go. I will never, ever tire of this.  Ever.

- Jo

What’s worse than a concussion? A concussion and a broken neck.

Max Pacioretty of the Montreal Canadiens took a huge hit from Boston’s Zdeno Chara last night that led to him leaving the ice on a stretcher after several minutes of immobility.  Chara knocked Pacioretty into the support post for the glass between the benches, and you can very clearly see his head make contact (go to :46, and be warned – it’s ugly).  Huge hit, scary outcome.  Montreal’s Jacques Martin spoke to the media today to update Pacioretty’s condition:

“Max Pacioretty has a severe concussion, as well as a fracture of the fourth cervical vertebrae, but it’s not displaced,” explained Martin. “Max will remain at the hospital for further observation. There will be no other prognosis for the time being, but he will obviously be out indefinitely. The most important thing for our organization right now is Max’s recovery. We will continue following recommendations from the doctors and of course, Max and his immediate family would appreciate privacy in this matter.”

- Jacques Martin, courtesy of the Montreal Canadiens.

 

A quick word about concussions:

There’s disagreement among experts about how to define ‘concussion’.  In the simplest terms, it’s a temporary loss of brain function as a result of an injury, with no evidence of physical damage on imaging (like a CT scan or MRI).  It’s considered to be a functional, not anatomical state.  It’s known, however, that repeated concussions have cumulative effects in both brain structure and function (see: Probert, Bob).

Concussion severity is graded by the patient’s symptoms, and there are several grading systems in use.  For simplicity’s sake (and because neurologists are smart), I’ll use the American Academy of Neurology‘s system as an example:

  • Grade 1: No loss of consciousness, temporary confusion, symptoms resolve within 15 minutes.
  • Grade 2: No loss of consciousness, temporary confusion, symptoms last longer than 15 minutes.
  • Grade 3: Any loss of consciousness.

The fact that Pacioretty looks to have been knocked out makes his a grade 3 concussion.  Treatment is as you saw it – keeping his spine aligned (by placing him on a backboard and keeping his neck still), and taking him to the hospital for an exam and imaging (x-rays, CT scan, maybe MRI).  The exam and imaging results, not to mention the patient’s symptoms (pain, nausea, dizziness, etc.) after an injury like that determine what happens next.

Well, what did happen next?

In addition to his concussion, Pacioretty was found to have a C4 vertebral fracture.  Plain and simple: He broke his neck.  Your neck is made up of 7 cervical vertebrae.  Bend your head forward and feel the back of your neck.  Feel the bone that sticks way out?  That’s C7.  Now count up to C4.  That’s what he broke.  The fracture is non-displaced, meaning the bone didn’t go anywhere, it just cracked or was crushed.  Vertebrae are complex little critters, with lots of parts and lots of nearby nerves.  The ones in your neck obviously have very important jobs.  The nerves associated with C4 are responsible for sensation just below your collarbones, and they help run some arm/shoulder and neck muscles, not to mention your diaphragm.  You need that to breathe.  Hey, and let’s not forget that your spinal cord runs through your vertebrae.  Has the seriousness of the injury set in yet?

It’s really not possible to know for sure what treatment Pacioretty’s neck will need without knowing the extent of the injury.  It could be as simple as a neck brace for 6-8 weeks or as complex as surgery to fuse vertebrae — putting in rods or plates.  The fact that he was breathing and moving and the the fracture is non-displaced really shouldn’t be downplayed.  That’s all great news.  He could potentially heal with no lasting effects, and obviously that would be the ideal outcome.

So when will he be back?

Go ahead and stop asking.  Not for a long time.  A grade 3 concussion necessitates being out for an absolute minimum of two weeks – that’s assuming he’s free of symptoms.  The likelihood of being symptom-free after a concussion like that?  Ask Savard or Crosby.  But ask quietly, and in a dark room.  Concussions suck.  Recovery sucks.  And now that he’s had one concussion, Pacioretty is at increased risk for future concussions, and for having worse symptoms each time.  Add the broken neck, which could be anywhere from 2 to 6 months, and who knows.

The take-home message:

  • Concussion: Potentially very long recovery time, increased risk for future injury.
  • C4 fracture: Hopefully an uncomplicated healing process, but potential need for long-term or invasive therapy.
  • Potential for return to play: Unknown.  Pacioretty could be fine, or this could be a career-ender.  And it felt really, really gross to even type that out.
  • Much respect to the Habs and Bruins medical staff for their handling of Pacioretty’s injury.  It’s obvious in the video that they took incredible care with him.  Nobody wants to make a broken neck or head injury worse.

Did anyone else get a bit misty at Gionta, Hamrlik and Kostitsyn helping load Pacioretty onto the stretcher?  No?  Uhh…  Well then, me neither.

Get well soon, Max.

- Jo

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