Of OxyContin and Alcohol

I was boredly scrolling through my Twitter feed this afternoon when this caught my eye:

The part about not mixing OxyContin and alcohol is absolutely right.  The part about how people with head injuries should never use it?  Not quite.  First of all, there’s a difference between an acute head injury and a concussion five months ago.  But I’m getting ahead of myself.  This was next:

What’s that link?  Why, it’s the oh-so-reputable Canoe.ca drug fact sheet!  And here’s what the renowned world experts at Canoe.ca had to say that apparently caught Steve’s eye:

Oxycodone should not be taken by anyone who:

- blah blah blah

- has a head injury

- blah blah blah

And then I think he stopped reading.  Yes, Derek Boogaard sustained a concussion on December 9th of last year.  No, the mix of taking oxycodone after having had a concussion five months ago didn’t cause his death.  What caused his death was a mixture of oxycodone and alcohol.

What is OxyContin?

OxyContin is the trade name for oxycodone, which is a synthetic opiate.

What are opiates?

You’ll often hear the terms opiate and opioid used interchangeably.  Technically opiates are natural derivatives of a certain type of poppy, and opioids are the class of drug that binds the opioid receptors in the body.  So opioids as a whole include the opiates (morphine, opium) and the synthetic and semi-synthetic derivatives (oxycodone, fentanyl, methadone, heroin).

What do they do?

Opioids bind to the opioid receptors, which are found in the nervous and GI systems.  These drugs are used for pain relief, cough suppression, diarrhea, sedation and to ease withdrawal from other drugs in the same class.

What’s the big deal?

Opioids have a lot of side effects – sedation, constipation, itching, etc.  Unfortunately, they also have a nasty habit of causing respiratory depression in larger doses or extremely potent forms.  Also unfortunately, someone who has been using opioids for a long time will establish a tolerance, meaning they require higher and higher doses to achieve the same effects.

Where do head injuries fit into this?

In Derek Boogaard’s case, they don’t.  He had a concussion five months ago – he was not dealing with an acute head injury.  The reason “head injured” people shouldn’t have opioids has to do with intracranial pressure (ICP), the potential for respiratory depression with these drugs, and the nasty connection between the two.  The reason I have “head injured” in quotes?  Because we’re talking about people with acute injuries.  Those are the people that will have increased ICP.  Remember there’s a finite amount of space in your head.  If your brain is injured it swells, and since there’s not much of anywhere to go, you get an increase in the pressure inside your skull.

Now remember back to middle school science.  When you breathe, you exchange carbon dioxide for oxygen.  So if you’re taking opioids to the point that you’ve depressed your respiratory drive, you won’t be exchanging gases adequately and you’ll have increased levels of carbon dioxide.

Still with me?

We’re moving on to bigger and badasser science.  Carbon dioxide causes vasodilation in the cerebral vasculature.  Put simply – too much CO2 causes the blood vessels in your brain to dilate.  If you’re head injured and already have or are at risk for increased ICP, the last thing you need is increased CO2.  You’ll have bigger vessels, which means more blood, which means more space occupied, which means even higher pressure.  You’ll be making a bad situation worse and risking your brain trying to find a pressure release, which involves trying to squeeze its way out of the bottom of your skull.  That’s called herniation, and that’s generally deadly.

Summarized:

- Head injury = increased pressure in your head (from bleeding or swelling).

- Lots of opioids = respiratory depression (shallow/slow breathing, or no breathing).

- Respiratory depression = too much CO2

- Too much CO2 = more pressure in your head.

- Not good.

The Boogaard connection

Derek Boogaard’s cause of death was said to be a mixture of alcohol and oxycodone.  There’s not a huge amount of research on the pharmacology/pathophysiology of mixing alcohol and opioids, but they’re both depressant medications and together they’re dangerous.  Some studies suggest that alcohol alters opioid metabolism, resulting in an effectively higher serum concentration, and thus greater effects.  Common sense suggests that if you take two substances that can knock you out, one of which can make you stop breathing, that you’ve got all the ingredients for a terrible outcome.

From a paramedic’s perspective:

Over the years I’ve seen a lot of overdoses that resulted in death.  Most of them were opioid overdoses, and very, very few of them were on purpose.  Heroin addicts with the needle still in their arm,  college kids that got hammered and took too many pills, chronic pain patients with a huge opioid tolerance that fell asleep and never woke up.  People on the street, people in million dollar houses, and people just like you and me.

Before we start judging Derek, we need to stop and realize just how easy (and common) this situation is.  We know he was trying to get help.  We also know from his family’s statement that he’d been dealing with pain for a very long time.  The suggestion that taking oxycodone five months after his concussion was what caused his death minimizes his struggle, and isn’t scientifically based in reality.

Derek Boogaard’s family has asked that donations be made to Defending The Blue Line, a Minnesota charity that helps military kids stay involved in hockey with equipment donations, camps, and grants to cover fees.  Donations may be made online or by mail:

Defending the Blue Line,

c/o Boogaard’s Booguardians Memorial Fund,

1206 N. Frontage Road Suite B, Hastings, MN 55033.

My heart aches for the Boogaard family.  All the best to them.

- Jo

Phaneuf v Moser, aka What Not To Do With An Unconscious Guy

Video of Dion Phaneuf’s hit on Simon Moser at a Canada/Switzerland match at the IIHF worlds is making the rounds today. Phaneuf delivers a solid hit, Moser gets up. Once on the bench, Moser passes out, and Hockey Expressen says it was because he “swallowed his tongue”.

STOP.

That doesn’t exist. Some freaky people can do freaky things that involve freaky tongue gymnastics. Granted. In this case, however, what the video shows is poor management of an unconscious patient. Let’s watch, shall we?

What do you notice there? An unconscious guy that some dude is holding upright while his head flops back. That makes my inner paramedic cringe in horror. While you can’t technically swallow your tongue, it can block the hell out of your airway. Especially if some Swiss dude is holding you upright while you’re unconscious. The thing about unconscious people is they can’t do a little thing we like to call “protecting your own airway”. ie. keeping things out of there – your tongue, vomit, etc. In fact, the most common cause of airway obstruction in unconscious patients is the tongue. And here’s why:

Throat Anatomy

Your tongue is huge. When you’re unconscious, you’re not in control of voluntary muscles like the ones in your tongue and lower jaw. So if you’re upright, on your back – or in any position that lets gravity take over – your tongue is going to slide back and occlude your airway. You don’t swallow it. To wit:

Sneaky bugger.

So how do you keep this from happening? Well, if there’s no chance of a spinal injury, you’d roll them onto their side into something called the recovery position:

The right thing to do with an unconscious dude/dudette

The patient needs to be on their side, head extended, limbs positioned to keep them stable. The point of this is that the tongue won’t slide back, and vomit will drain out, not down. If there is a question of spinal injury, then someone will hold c-spine (a hand on either side of the head to maintain the head, neck and spine in a straight line) until the patient can be secured in full spinal precautions (which the Slovakian paramedics in the video have on their stretcher), and you can still roll them onto their side. Carefully.

So what should the Swiss trainer have done? Get Moser on the ground. You can pass out from trauma, or you can pass out from things that deprive your brain of adequate oxygen – things like hyperventilating, vagal nerve stimulation (remember Bush choking on a pretzel?), low blood pressure, and standing up too fast (ask any skinny girl about this). Moser was not immediately knocked out by the hit, so it’s possible one of these things took him out. Best way to get blood (and thus oxygen) to the brain? Get the brain on the same level as the heart and it won’t have to pump so hard. If the loss of consciousness was due to some kind of head pathology (like bleeding or concussion), lying him down is about 500% better than trying to haul him upright and letting his head flop around.

Take home points:

- Your tongue will block your airway given half a chance.

- Unconscious people can’t protect their airway.

- The recovery position is good.

- Protect the c-spine if there’s any question of injury.

- Slovakian paramedics have jazzy red jumpsuits and it takes four of them to run a call.

- Everyone should take CPR. Stat.

Jo

ps – the recovery position is also ideal for people who’ve passed out drunk. Nobody wants barf in their lungs. Scientific fact. Nobody.

Eye injuries: From “No big deal” to “HOLY S*%T” Part 1

Pardon the extended absence – med school is a complete timehog.  Having just taken my final exam in psychiatry (and subsequently diagnosing everyone I know with personality disorders), I finally have time to sit down and bring you some nasty pictures of injured eyes.

Eye injuries go with hockey like mullets and missing teeth.  In this series I’ll be explaining the various injuries that can happen, and how they’re diagnosed and treated.  I’ll be going from least gross to most obscene, and as such we’ll be starting with injuries to the surface of the eye.

Corneal Abrasion

One of the least exciting types of eye injury is the corneal abrasion – a scratch on the surface of the eye.  Unless of course you’ve ever had one, in which case you know that it feels like there’s an entire tree branch lodged in there.  Corneal abrasions can be of varying severity, but generally speaking they’ll heal in a couple of days with minimal intervention.  This is the most common eye injury doctors see.

Corneal abrasions cause eye pain, a foreign body sensation (fancy talk for “it feels like there’s something in my eye”), redness, and a watery eye.  The diagnosis is made by putting fluorescent eye drops in the eye and examining it through a special lens (a slit lamp).  The drops (fluorescein) will fill the abrasion and make it glow.

Corneal abrasion after fluorescein drops

Corneal abrasions are generally treated with anesthetic drops before the slit-lamp exam, then antibiotic drops or ointment are prescribed for the healing period.  If the pain is particularly bad, there are NSAID eye drops (like Advil for your eye) or regular oral pain medications if needed.  There’s some debate as to the value of patching the affected eye.

Corneal abrasions are common from misuse of contact lenses, but in the context of hockey this is the sort of thing you might end up with if someone’s stick, hand, or a puck found its way into your eye.  The average abrasion will feel better in about 48 hours, but it can be as long as 6 weeks before the surface of the eye returns to its pre-injury state, so it makes sense to protect your eyes after something like this.

Corneal abrasions can be deep enough to cause an ulcer in the surface of the eye, and infection can grossly complicate the healing period.  A deep abrasion, or one that healed poorly, can scar and leave lasting vision deficits.  Proper management of an injury like this is the key to successful healing and no complications.

Subconjunctival Hemorrhage

Trauma to the eye can also result in one of the more impressive-looking and yet least medically impressive injuries – subconjunctival hemorrhage.  The conjunctiva is the white of your eye, and a subconjunctival hemorrhage is exactly what you’d think – bleeding underneath the white of the eye.  This is usually spontaneous, but obviously can also be caused by trauma.  There are normally no symptoms of pain or actual bleeding from the eye, but it looks extremely badass.

Subconjunctival Hemorrhage

This will generally heal on its own in less than two weeks (hence medically unexciting).

And here’s Steve Yzerman showing us what happens when you take a puck in the face and end up with a corneal abrasion, subconjunctival hemorrhage, and a fractured orbital bone (that’s the one your eyeball actually sits in) which required surgery.

Yzerman: So badass he gets all the eye injuries at once.

Yzerman played with a visor post-injury, and now as Tampa Bay Lightning GM he’ll be asking his players to wear them next season.  Vinny Lecavalier took a stick in the eye at the beginning of this month resulting in a corneal abrasion, and put it best with his comment to the St. Petersburg Times on visor use in the NHL:

“If I never took it off, I’d be fine with it.  But once you take it off and you see perfect, when you put it back on, you feel a little restricted. It fogs up. The right thing to do would be to come from junior and never take it off.”

- Vincent Lecavalier

Is the suggestion that visors should be grandfathered in, much like helmets were in the 90s?  Nobody complains about having to wear helmets now – it’s an accepted part of playing hockey.  My hope (and the hope of ophthalmologists everywhere) is that visors will follow the same path.  15 years from now this should be a non-issue.

Next time: Our parade of eye grossness takes a step forward with blunt eye injuries.  We’ll talk about what happens when your eye gets squished, and just how much blood you can fit inside an eye.

- J0

The NHL vs. Everyone Else (Part 3): The Eyes Have It

When a puck or a stick meets an eye, bad things happen (see: Malhotra, Manny; Berard, Brian).  The current debate is whether visors should be made mandatory in the NHL, and whether they actually do anything.  The fact of the matter is that you can find research on almost any subject to support either side of an argument.  Ready? Go:

Visors cause more injuries!

“Oh, so visors are dangerous!”

No, not necessarily.  This was a study done in the ECHL that compared injuries in players with visors to players with no facial protection.  The study found that lacerations to the forehead and cheek were more severe in players with visors, but contusions due to collisions were more severe with no facial protection.  The researchers concluded that since high sticking caused the most facial injuries, and sticks could slip under a visor, that visors may not provide adequate protection.  Here’s the problem: Were the visors properly fitted?  How many players do you see with a loose chin strap and their helmet tilted back?  A visor only works if it is properly worn – low enough that it covers the eyes and the lower edge of the nose.  Could something still slip under it?  Yes, probably.  Is it less likely?  Obviously.  The point is that you can’t go from “Players in visors have lacerations of greater severity” to “Visors are dangerous/not helpful”.  That’s not a leap that makes sense.

Now for the other side of the argument:

Visors prevent injuries!

“Oh, so visors keep you from getting hurt!”

This study looked at NHL injuries in 2001-02, and concluded that visor use resulted in decreased eye and non-concussion head injuries, but did not affect concussion rates (I think I’ll file that last point under “Duh, really?”).

Here’s another.  This study looked at injuries in elite amateur hockey players and compared injuries in players with full facial protection, visors, and no facial protection.  Since full facial protection isn’t something the NHL will be seeing any time soon (other than what you’ll see occasionally on players healing certain facial injuries), I’ll just note that all injuries were reduced with full protection.  The study found that overall facial injury was twice as likely with no facial protection, and eye injury was 4.7 times greater.  Interestingly, the study also found that players using full and partial facial protection did not have an increase in neck injury or concussion (because I know someone was going to try to make that argument).

So there is definitely evidence that visors are protective, and one study that says players who wear them have more severe lacerations (but doesn’t reliably establish a causative link).  My conclusion: Wear a visor, save an eye.  Let’s face it – a laceration is something you can repair relatively easily – especially compared to a detached retina or a ruptured eyeball.  Every complaint about fogging or scratching or not looking cool seems petty when the alternative is losing an eye and a career.

Also, this guy has figured out how to permanently anti-fog glass and plastic surfaces.

Next time: I’ll take a look at the variety of eye injuries hockey players can get, and explain the treatments for them.  Advance warning – eye injuries are not for the squeamish.

- Jo

Helmets: The NHL vs. Everyone Else (Part 2)

Part 1 of the helmet series dealt with rules in various hockey organizations.  Part 2 will deal with the equipment itself – How it works, and why it works best when worn properly.  I’m not just talking about helmets, but about all the equipment currently in use in the NHL that protects the head and face – the helmet, visor, and mouth guard.  Let’s begin with…

The Helmet

What’s its job?

The helmet’s job is to protect the head.  Although that’s obvious, it’s not immediately obvious that there are things the helmet is good at, and things it sucks at.  Helmets are good at preventing direct injuries  – things like pucks, sticks, skate blades or the ice causing an injury to the surface of the head.  Helmets are not good at preventing indirect injuries, i.e. concussions.  The reason is the science behind how a concussion happens.

A quick trip into concussions…

A concussion refers to a brain injury causing a change in brain function.  Concussions vary in severity from very mild (feeling momentarily dazed) to severe (career ending – intractable vomiting, vision changes, permanent changes in balance, etc).  Concussions can result from a direct blow to the head, or a sudden head movement due to forces acting elsewhere (like a bodycheck on a player who doesn’t see it coming).

The brain essentially “floats” (snugly) inside the skull in cerebrospinal fluid (aka CSF, the stuff that surrounds your brain and spinal cord).  When the skull suddenly changes direction/stops/starts, the brain has to do the same.  In normal day-to-day life there’s no problem – the brain rides happily around in your skull changing direction as you do.  When there’s a sudden force applied that’s strong enough to move the head, the brain is inclined to stay where it is – remember Newton’s laws of motion? An object in motion tends to stay in motion until an external force is applied to it.

Translation: The brain wants to keep going in its original direction until something stops it.

During a hit, that inclination to keep going puts traction on the so-called “anchor point” of the brain – the midbrain – home to a lot of very important stuff, including the nucleus of the oculomotor nerve (the op center of the nerve that controls most of your eye movements).  This is where the term “rotational force” that you’ve been hearing tossed around with relation to concussions comes in.  Basically the brain is rotating on a somewhat fixed point, and when that happens you get an interruption in normal function.  The brain isn’t fond of stretching, moving, rotating, or really doing much of anything but happily riding in your skull.  Honestly, the brain is a bit of a jerk that doesn’t like to be touched, has its feelings hurt easily, and doesn’t like to be consistent about recovery.

The brain hates rotating.

It should be fairly clear now why helmets aren’t great at protecting against concussions.  They aren’t completely useless – they spread the impact across a larger area and the foam liner absorbs some of the energy, but the fact is if you hit your head hard enough your brain will move in a way that isn’t good for it.

So what’s the solution?

First, wear the helmet properly.  As we learned in part 1 of this series, the IIHF, Hockey Canada and USA Hockey require that equipment be worn “…in the manner for which it is designed”.  In fact, the IIHF goes so far as to specify how the helmet should fit: “A helmet shall be worn so that the lower edge of the helmet is not more than one finger-width above the eyebrows, and there shall only be enough room between the strap and the chin to insert one finger.” Failure to wear equipment properly results in a misconduct.

Toews, seriously?

A helmet will do a player absolutely no good against any injury if it doesn’t stay on his head.  Shane Prince of the Ottawa 67s found that out the hard way March 11th after a hit from the Niagara Ice Dogs’ Tim Billingsley resulted in his helmet flying off and the back of his head hitting the ice.

Prince got off relatively easily with a mild concussion, and is expected to return to the ice for the OHL playoffs this weekend.

Second, wear a better helmet.  Until the mid/late 90s there were still a few players in the NHL wearing the practically useless Jofa 235 (Gretzky, I’m looking at you), a helmet that was about as protective as a toque with a chinstrap.  NHL rules now vaguely state players must wear an “approved” helmet, but unlike the rest of the world, don’t specify who has to do the approval.  Regardless, sanity prevails and NHL players are keeping the fine people at Reebok, Easton and Bauer in business.

The Messier Project, which is Mark Messier in association with Cascade Sports, have come out with the M11 helmet, which they state has been proven to distribute impact forces better than traditional helmets.  In addition, they’ve shown that the M11 helmets protect better in successive impacts than traditional helmets.  The helmet also has what they call the Pro-Fit System, a ratchet at the back of the helmet that snugs it under the occiput (that big bump on the back of your head) for a more accurate fit.  What truly sets the M11 apart is the so-called Seven Technology.

Seven Technology

Instead of being padded only with foam, the helmet has several plastic units each made up of seven small interconnected plastic tubes.  These units deform under force – they flatten out and then rebound to their original form.  This absorbs and displaces the energy of the impact, meaning it’s that much less the brain has to take care of.  The Messier Project offers a great animation of how the technology works that does a far better job of explaining it than I can.

I would totally wear this.

Early iterations of this helmet were poorly reviewed because it was considered bulky, unattractive, and was poorly vented, but the M11 in its current form reviews well.  The Messier Project is currently gathering data from teams using their helmet.  They claim to have nine NHL players currently wearing their helmet, interestingly mostly Anaheim Ducks.

Third, rule changes and/or better enforcement.  Ideally the best way to avoid a concussion is to avoid getting hit in the head, or getting hit elsewhere in a way that results in sudden acceleration/deceleration of the head.  Since this is NHL hockey and I’m not stupid, I know that’s not going to happen.  Don’t get me wrong – I love hockey and I’d hate to see it diluted down to something unrecognizable.  I don’t, however, love head injuries, and I get particularly bent out of shape at avoidable head injuries.  So from a medical point of view I think it’s fair to say that wearing good equipment properly is a positive step towards at the very least reducing concussion incidence (and hopefully severity).

 

- Jo

New NHL Concussion Guidelines: Let’s Get the Doctor Involved!

There can’t be a hockey discussion without a head injury discussion.  It’s no surprise that day one of NHL GM meetings in Boca Raton has already produced policy changes that aim to increase player safety and reduce injury.  Some of the changes will go into effect almost immediately, some will be implemented at the beginning of next season.  Commissioner Gary Bettman laid it out in five steps:

  1. Equipment changes – reduce the size without reducing the safety.
  2. Revise concussion management protocols – have a doctor (not a trainer) make immediate return to play decisions.
  3. Hold club and coach responsible for players with repeated offenses leading to supplemental discipline.
  4. Study changes to rinks that can improve player safety – implement short-term fixes now, get rid of seamless glass for next season.
  5. Establish a committee dedicated to continued study of the issue.

Can we talk about step 2?

Currently, players with suspected concussions are evaluated by the trainer, generally on the bench.  The trainer’s evaluation has two possible outcomes – no concussion suspected and the player returns to the game immediately, or there is a suspected concussion and the player is removed to the dressing room and evaluated by the team physician.  If the physician’s evaluation is suspicious for concussion, the NHL Protocol for Concussion Evaluation and Management kicks in and the player is kept out of play pending certain testing.  The length of time is determined by the patient’s performance on neuropsychological tests (be patient, we’ll get into what those are), and the team physician makes the ultimate decision as to when the player can return.

The current NHL protocols are stringent with regards to keeping players off the ice once they’ve had a concussion, but don’t go far enough to get them off the ice in the first place – a determined player could insist to the trainer that he’s fine and end up back on the next shift.

The new protocol requires that the player be evaluated by a physician if he exhibits any of the following:

  • Loss of consciousness
  • Motor incoordination/balance problems
  • Slow to get up following a hit to the head
  • Blank or vacant look
  • Disorientation
  • Clutching the head after a hit
  • Visible facial injury in combination with any of the above

The physician will perform the evaluation in “…a quiet place free from distraction” (i.e. not the bench), and will use a standardized assessment tool – the NHL SCAT 2 (sports concussion assessment tool).  After training the trainers and doctors in the specifics of the new concussion policy, Bettman stated he expects it to go into effect by the end of the week.

Neuropsychological testing?  What?

Neuropsychological testing is a way of determining if someone’s brain is working properly by testing their ability to answer questions and perform simple memory and physical tasks.  The roadside sobriety tests that cops perform are a great example of simple neuropsychological testing.

The big deal here is that players are going to be evaluated immediately using the SCAT 2, and not by being asked “Are you okay?  You good to go back out?”.  The SCAT 2 is a series of (neuropsychological) tests that was developed in 2008 at the 3rd International Conference on Concussion in Sport, and represents revisions to previous concussion assessment protocols.  The SCAT 2 was designed for use by physicians, athletic trainers and other medical professionals.  If you’d like to have a copy of your own, it’s available for free download.

The NHL is already using the SCAT 2 (as are the IIHF, FIFA, and several other big name sports organizations), but the bench is absolutely the wrong place to do it, and it likely wasn’t happening unless the trainer made the decision to pull the player for physician assessment.

What exactly is the SCAT 2?

SCAT 2 Explained

Symptom evaluation: The patient is asked if he has any of 22 different symptoms that you’d normally associate with a concussion (nausea, dizziness, headache, etc), and grades them on a scale of 0-6 (none to severe).  This assigns him a symptom severity score.

Cognitive and physical evaluation:

  • Number of symptoms (out of 22)
  • Physical signs: loss of consciousness or balance problem.
  • Glasgow coma scale: Measures the ability to properly verbalize, follow motor commands, and open one’s eyes.  This is a test commonly used on trauma patients to get a quick assessment of their overall level of consciousness.  This is also a gross simplification on my part.  Want to know more?
  • Maddocks’ questions: A set of questions related to the game at hand and recent sport-related events (Where are we playing? What period is it? What team did we play last?”) that provides another gross overview of orientation and mental status.
  • Cognitive evaluation: Includes orientation (Day, Date, Year, etc), immediate memory (give the player a list of words and ask him to repeat them back to you), concentration (give the player a list of numbers, have him repeat them back in reverse order; have the player say the months of the year in reverse order).

Balance testing:  The player is asked to close his eyes and is given three 20-second standing trials -  feet together, on one foot, and heel to toe.

Coordination testing:  The player is asked to sit with one arm outstretched to the side.  He’s then asked to bend at the elbow and touch his nose five times in quick succession.

More cognitive testing:  The player is asked to recall the list of words from earlier in the test.

On my best day I’m not convinced this is a test I could ace.  It should be pretty clear now why it’s essential that this be performed in a quiet area with no distractions.  The SCAT 2 assigns the player a score, which is actually not used to determine if he can return to play.  What it does do is provide a great way to keep track of the player’s deficits over serial tests (i.e. give the same test multiple times and track the scores over time).

Return to Play

The SCAT 2 gives a great outline of a protocol that could be used to determine when a player could get back on the ice.  First and foremost, it suggests that a player suspected of having a concussion should not return to play that same day (I’m looking at you, Crosby).  It goes on to recommend that the player gradually resumes activity over a period of days (weeks, months, never) based on what he’s capable of doing – any limitation by symptoms means activity levels don’t progress upwards.  The progression of activity would be:

  • Complete rest until symptom-free
  • Light aerobic exercise
  • Sport-specific exercise
  • Non-contact drills
  • Full-contact drills after medical clearance
  • Return to competition

The SCAT 2 and the NHL Protocol for Concussion Evaluation and Management leave plenty of room for the team physician to decide if the player is ready to get back in action.  That, of course is the art of medicine.  That’s also fodder for another huge debate – whether team doctors are looking out for the athlete’s best interests, the team’s interest in getting their player back on the ice, or the athlete’s insistence that he’s fine, Coach.  Just fine.

Feel free to have that discussion amongst yourselves. Until I’m a team doctor I won’t be making assumptions.

- Jo

 

Helmets: The NHL vs. Everyone Else (Part 1)

Part 1: Helmet Rules

Since 1979, NHL players have had to wear helmets.  Frankly, there hasn’t been much progression in their equipment policy since then.  The only thing the NHL has to say about helmets is the vaguely worded rule 9.5:

“All players of both teams shall wear a helmet of design, material and construction approved by the League at all times while participating in a game, either on the playing surface or the players’ or penalty benches.”

Okay, so what exactly is a League-approved helmet?  It’s not specified in the publicly-available NHL rules.  A very scientific process involving googling pictures of NHL players has determined that it’s basically anything CSA/ASTM certified.

Dude, seriously.  Speak English.  What’s CSA/ASTM?

The CSA (Canadian Standards Association) and the ASTM (American Society for Testing and Materials) are organizations that set standards for and do testing of hockey protective gear (among several thousand other things).  The helmet standards these organizations set cover the actual construction of the helmet (ie. it can’t be leather, although that would be an interesting look), shock absorption (sorry, Wayne — the Jofa won’t cut it), penetration (can a puck or stick get through it?), retention systems (straps), field of vision, and the markings required on the helmets (the stickers on the back that prove it’s an approved helmet).

Clearly the NHL specifies that players must wear helmets that are adequately safety tested.  The kicker is that they don’t specify how the helmets must be worn, like just about every other major hockey organization does.  When a helmet flies off, it’s likely because the player wasn’t wearing it correctly.  Properly adjusted helmet straps should keep your lid in place.

Let’s Compare Head and Face Protection Rules…

For the sake of ease, I’m going to compare the NHL, the IIHF, Hockey Canada and USA Hockey.  I won’t go into goalie requirements – that’s a different animal altogether.  I also won’t discuss adult rec leagues, as some may choose to follow Hockey Canada or USA Hockey rules, and some may not.  The collection of garbage equipment that hits the ice every Sunday in my league tells you everything you need to know.

NHL:

  • Helmet: You have to wear an approved helmet while on the ice or on the bench.  No helmet required during warmups.
  • Visor:  Permitted but not mandatory.
  • Cage: Rule 9.6 actually prohibits “…pads or protectors made of metal.” but goes on to specify that “A mask or protector of a design approved by the League may be worn by a player who has sustained a facial injury”, like the visor combo Brad Stuart of the Red Wings has been wearing after suffering a broken jaw earlier this year.
  • Mouth guard: Not required, although many players wear one.  Many players also gross me (and Johan Franzen) out by chewing on them instead of wearing them properly.

IIHF:

  • Helmet: Required in the game and in warmups.  Fit is specified: “A helmet shall be worn so that the lower edge of the helmet is not more than one finger-width above the eyebrows, and there shall only be enough room between the strap and the chin to insert one finger.”
  • Visor/cage: Full face masks or visors are recommended for all players.  Women and players under 18 are required to wear a full face mask.  Players born after 1974 must wear a visor at minimum.
  • Mouth guard: Mandatory for players under age 20.

Hockey Canada:

  • Helmet: Required in the game and in warmups, with strap securely fastened.
  • Visor/cage: Under 18 and women — Full-face protection.  Over 18 — Visor.
  • Mouth guard:  Compulsory if you’re wearing a visor.

USA Hockey:

This warms my heart: “USA Hockey strongly recommends that all players and goalkeepers in all age classifications properly wear an internal mouthpiece, a HECC approved helmet and a HECC approved full facemask for all games and practices.”  FYI, HECC is another standards organization.

  • Helmet: Required in games, warmups and practices, with strap securely fastened.
  • Visor/cage: Full-face protection is required for all players below adult level.
  • Mouth guard: Required for females 19 and under, and in all players through midget level (including high school).

This is a good time to stop and point out that the IIHF, Hockey Canada and USA Hockey require that equipment be worn “…in the manner for which is is designed” (IIHF) or the player can be given a misconduct.

The wrong way to wear a helmet. (photo: Andre Ringuette)

College Hockey (bonus section):

  • The NCAA requires full face masks and mouth guards (and helmets, obviously).
  • The CIS (Canadian Interuniversity Sport) requires a helmet and at minimum a half visor.  Mouthguards are mandatory with visors.

Obviously everyone is stricter than the NHL when it comes to face protection and equipment fit.  To an extent, head and facial protection is self-policed, in the sense that the players decide if they want to wear a visor, a mouth guard, etc.  There is absolutely no question that more protection leads to fewer injuries, and plenty of excellent research to prove it.  The question is why players who grew up in systems that require facial protection and properly-fitted equipment decide to take a step back once they’ve gone pro.  There are complaints of visibility problems, discomfort, etc., but if that’s what you grew up wearing, one would think you’d be used to it.  I’ll spare you the discussion of the visibility problems and discomfort caused by a stick or skate to the eye (see: Berard, Brian).

Next time I’ll get into the medical reasoning behind a properly-fitted, properly-worn helmet, facial protection, and mouth guards.  I’ll also discuss arguments for and against them, both reasonable and stupid.

- 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

How Taylor Hall’s Ankle Got High

Thursday, March 3rd Edmonton rookie Taylor Hall had his first career NHL fight against Derek Dorsett of the Columbus Blue Jackets.  The end result was, at best, lame as hell.  After much sweater-holding and getting whacked by Dorsett, the two fell and Hall’s left ankle twisted in a truly awful way.

John Ulan - The Canadian Press/AP

The upshot of all of this is Hall’s season is likely over, and an MRI the day after the fight showed he has a high ankle sprain.  This of course begs the question…

What’s a high ankle sprain, exactly?

Let’s start at the beginning.  A sprain is a stretch or tear in the ligaments that hold a joint together.  Sprains can be mild (just a stretch), or catastrophic – completely torn ligaments, resulting in joint instability.

Ankle sprains are pretty common – usually a result of a twist or misstep – and generally mild. The average ankle sprain is to the anterior talo-fibular ligament, or ATFL – which is fancy talk for “the little ligament that connects the leg bone to the foot bone on the outside of the joint”.  Generally mild sprains heal in a few weeks with no problems and little intervention – rest, ice, maybe an ace wrap, keeping your foot propped up while you mope around the house itching to get back on the ice.

Severe ankle sprains are a different (and ugly) animal.  When ligaments are torn and joints are unstable you’re looking at several weeks of immobilization, medications, and rehab.  Weeks can often extend into months.  Therapies can sometimes extend to surgery.  People who’ve had severe sprains will tell you they can be harder to heal than fractures.

The high ankle sprain in particular is tricky, because it involves several ligaments that actually hold the two bones in the lower leg (the tibia and fibula) together.  The injury is usually because of an outward rotation of the lower leg (see above – feet aren’t supposed to do that).  The problem with a severe high ankle sprain is that obviously you’re going to have a leg that not only hurts, but that can be very, very unstable. Those two bones in the lower leg need to work together as a unit, and if you tear the ligament that holds them together (the interosseus ligament) you’re left with a leg that’s very painful and weak, especially with any kind of twisting motion.

Tearing this is bad news.

A regular ankle sprain can often be braced so that an athlete can return to action sooner with added support in the injured area.  Tape or a plastic brace are used to minimize ‘rolling’ of the ankle joint.  With a high ankle sprain, trying to stabilize the connection between those two bones verges on the impossible – you can’t just squish them together, you have to account for rotational forces as well.  If the damage in a high ankle is bad enough the repair can involve casting the lower leg for several weeks, or a surgical repair (using a screw, wire, or thick suture to fix the tibia and fibula together until the ligaments heal).

Obviously we don’t know how extensive the damage to Hall’s ankle is.  All we know is the basics of the injury.  With luck it’s not severe, and after a few weeks of immobilization and rehab he’ll be back to skating.  It’s safe to assume he’s done for this season, though.  Sorry, Edmonton.

- Jo

What makes YOU so smart?

I never claimed to be smart. Okay, I actually probably have. Okay, honestly I know for a fact I’ve made that claim. Modesty, however, I probably wouldn’t own up to.

After nearly a decade of schlepping stretchers and scraping mistakes off of interstates as a paramedic, going to medical school seemed like a good idea. I traded my time dealing with the Friday night urban gun and knife club for time in the anatomy lab and the OR. I also decided my 30s was a great time to learn how to play hockey, a direct contradiction to my claims of being at all intelligent.

Now here I am almost a doctor, a completely terrible right winger, and I find myself very interested in the place where medicine and hockey meet. What the hell is a lower body injury, anyway? Why does one guy take a hit from behind and come back in the same game, where another is gone for months? Where do all those teeth go?

Injuries during play, hockey health policies and equipment issues are always at the forefront of discussion by the media and its fans. If you’ve been looking for a blog that discusses all of these topics and more, you’ve come to the right place.  Stick around, there’s plenty more to come.

- Jo

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