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

It’s just a numb leg. I can skate it off.

Time heals all wounds.  Actually, it’s time, physical therapy, medication, possibly surgery, and not pushing yourself for no reason.

In a show of truly spectacular self-defeatism, talented hockey players will often push themselves to come back before their body is ready.  How often do we hear about someone “Playing through it”?  And why are some injuries somehow more acceptable to play through than others?  Nobody would expect a player to suit up after an eye injury or a giant laceration (helloooooo Malarchuk), but this year we saw player after player limping through the playoffs on injuries that should have had them out for the duration.  Was Dany Heatley really contributing more by playing with a broken hand and a high ankle sprain than he would have by packing it in for the season?  Was that one point in the Western Conference finals worth the pain?  If you asked him he’d probably say yes.  How about Steven Stamkos – he hurt his shoulder in the Pittsburgh series, and played through to the Eastern Conference finals where he tallied seven points.  So absent of my sneaking suspicion that Stamkos is basically infinitely better than Heatley (sorry, Sharks fans), for him it probably was worth it.

Stamkos: He is tougher than you.

Daniel Alfredsson was the perfect example this year (and last) of playing with injuries that should have put him in the press box.  Ottawa Senators fans scratched their heads and wondered what was wrong as their captain’s point production dropped off towards the end of the 2009-10 season.  After the Sens were eliminated in the first round of the playoffs (as usual) by the Pens, Alfie admitted he’d been playing with a sports hernia since February (which isn’t really a hernia, but groin pain caused by any number of different injuries in the…  ahem…  area).  He still finished the season with 71 points, more or less on par with his usual production.

This year Alfie only played 54 games, and finished with 31 points – the fewest games and points he’s put up since he started with the Sens in 1995-96.  The problem this time was a back injury that he tried to fight through, and to which he finally conceded defeat in early February.  He admitted he’d been having weakness in his right leg, and today Ottawa GM Bryan Murray made the following statement:

“Daniel will have surgery on Friday.  He’s done a lot of rehab.  He felt to continue his career at the level he wants to, it’s the right thing to do.  It’s just to relieve a little pressure on the nerve that has taken away some of the strength in his leg and affected his skating and overall game, obviously…  It was a decision that he, during the latter part of the year and the off-season now, was hoping that he wouldn’t have to have.  I guess the fact the nerve is touching and being affected … in particular on the left side of his body … that he felt it was the right thing after much thought.”

Let’s go ahead and overlook the fact that all the interviews earlier this year said the problems were in the right leg, and discuss this injury, and the surgery that will (hopefully) fix it.

Theory: The stress of carrying around so much hair destroyed his spine.

The Injury

Although the interviews disagree on which leg was affected, the common thread is that Alfredsson has a lower back injury that’s causing one of his legs to be weak, tingly, and “heavy”.  Murray said today that there was pressure on a nerve that needed to be relieved.  The best way to understand why an injury in the back is affecting the leg is to learn a little something about the spine and dermatomes.

Whatatomes?

The nerves that make up the spinal cord exit the vertebrae through little canals called intervertebral foramina and proceed on to whatever part of the body they’re responsible for.  Those parts are very specific, and beautifully demonstrated by this fellow:

Best Halloween costume ever: A guy dressed up like dermatomes.

Each zone on the dermatome map represents the area that the specific listed nerve innervates.  So if you hurt L4 or L5, the top of your foot will suffer for it.

Your spine isn't this pretty. Sorry.

You have 24 vertebrae, plus 9 more that are fused to form the sacrum and coccyx (which make up the back wall of your pelvis).  The vertebrae are lettered and numbered according to where they are.  From the top, you’ve got

  • Cervical (neck) C1-C7
  • Thoracic (midback) T1-T12
  • Lumbar (lower back) L1-L5
  • Sacral (S1-S5 – fused) and coccygeal (also fused, don’t have a fancy letter, but have the distinction of being the oft-whacked tailbone).

The spinal nerves are named for the associated vertebra.  Those among you who are clever (or smartasses) have probably already noticed that although you have seven cervical vertebrae, there are eight cervical spinal nerves.  Feel free to impress girls at (nerdy) parties with the following bit of spine trivia: The spinal nerves exit the vertebral column above the associated vertebral bone until nerve C8 – the first one to exit below the bone (specifically vetebra C7) – cleverly paving the way for an extra nerve.

Bored yet?

The vertebrae are cushioned by discs, which are tough cartilage rings around a jelly-like center.  It’s a great design – they’re shock absorbers, allow for movement, and hold things together.  Unfortunately, they can also get badly out of place and cause awful symptoms.

When good discs go bad…

Injury or aging can cause discs to go to new and exciting places (that you’d rather they didn’t visit).  You can have a disc bulge – where the outer cartilage ring sticks out (usually posteriorly) from between the vertebrae and can put pressure on spinal nerves (or the spine itself).  A bulge can become a herniation, where the outer cartilage ring loses integrity completely and the jelly-like inside protrudes.  These injuries are best seen on MRI, like so:

Spot the disc bulges!

 

These are disc bulges at L3 and L5 – very common places for this type of injury.  This particular injury was the result of lifting a fat drunk kid out of a deep ditch in the rain after he drove mommy’s Lexus off the road.  But I’m totally over it.  Obviously.  I actually got lucky – I’ve been able to stay functional with exercise, responsible NSAID use, and being smart about lifting – let the fire department do it!  Kidding.  Sort of.  Not really.

If you look at the information available, it should be clear to you at this point that Alfredsson most likely has a disc bulge or herniation that’s pressing on one of his lumbar nerve roots.  He tried rehabbing the injury for a long time, and in fact there’s good data to show that non-surgical treatments are usually very effective for this sort of injury.  Pain control, steroids to relieve inflammation and physical therapy can bring relief in the majority of patients.  The exception is patients who have symptoms exceeding 6 weeks despite appropriate treatments, specifically those with neurologic deficits – Weakness, sensory deficit (numbness), and tingling.  This is Alfredsson’s picture.  Obviously he tried far longer than 6 weeks to avoid surgery, which was smart.  He also made loud noises after the all-star break about wanting to come back and play out the end of a dismal season, which was dumb.  There was no point, and there would have been a risk of worsening the injury.

FYI…

According to the World Health Organization, spinal manipulation (chiropractics) in the setting of a disc herniation is contraindicated.

The Surgical Fix

If Alfie does indeed have a herniation that’s pressing on a spinal nerve root, the likelihood is that he’ll be having a discectomy of some sort.  The operation is exactly what it sounds like – part of the disc is removed.  First a laminectomy is performed, where a tiny portion of the lamina (part of the vertebra) is removed to allow access to the disc and nerves.  The actual disc surgery can be done as an open procedure (cut the back open, remove part of the disc), percutaneously (through a small incision in the skin – less effective than open), or as microdiscectomy – where the surgeon operates using a special microscope allowing for more precise cuts and thus less damage to surrounding tissues.    A retractor holds the nerve roots out of the way while a device called a rongeur (what’s labeled here as ‘grasping device’ removes the offending disc tissue.  This should relieve the pressure on the nerve, allowing a return of strength and relief of pain.  The material that’s removed in surgery will eventually fill itself in with new disc material.

 

Discectomy Overview
A study out of Dartmouth cleverly called SPORT (Spine Patient Outcomes Research Trial) showed that patients with lumbar herniations showed significantly more improvement in pain and functionality with discectomy than patients who used non-surgical interventions.  Remember – these are the people with symptoms that persisted longer than six weeks with neurological problems and failure of non-surgical treatment.

After the surgery patients are encouraged to get up and walk as soon as possible, and physical therapy is started two weeks post-op.  It consists of stretching, strength training, and all the usual torture PTs put patients through (I love PTs, but they’re giant bullies – just ask one).

 

What we learned…

 

Alfredsson took from February until June to decide that he needed back surgery.  Although I admire his attempts to keep from being operated on, the research shows that if he was still having symptoms after 6 weeks he would have been better off just having the discectomy.  Did his hesitation stem in large part from his clear (and often-stated) desire to come back and play at the end of the season?  Probably.  With any luck, he’ll be looking at about a 6-week recovery, which puts him back in action at the end of July.  This should have him good to go for training camp on what is widely seen as likely his last season with the Sens.

 

- Jo

 

Eye injuries: From “No big deal” to “HOLY S*%T” Part 2

After years of scraping accidents off highways, there’s not much that skeeves me out any more.  There are a few exceptions: Beer vomit, stringy snot, snaggleteeth, and eye injuries.  Just in case you’re of a like mind, here’s your warning:  Gross pictures ahead.

What better time to explore the “HOLY S*%T” side of eye injuries than with the news that Manny Malhotra has been cleared to play just in time for the Stanley Cup finals.  The exact nature of his eye injury was never made clear, but he’s undergone two eye surgeries since the injury on March 16th, and may require a third in the offseason.  He’s also made it clear that he’s changed his view on the subject of vision protection:

“I realize the importance of it now,” he said. “I’ll wear the full face shield for the rest of this year and see what my comfort level is with different pieces of equipment.”

Manny Malhotra, eye surgery expert.

Having already looked at injuries to the surface of the eye, it’s time to look at their more serious, grosser cousins – blunt and penetrating eye injuries.

What’s in there?

There's a lot crammed into a little space

First, the contents of the eye.  At the front is the cornea, the clear covering that gets scratched when you don’t take care of your contacts properly (and you can get eye fungus, so don’t do that, okay?).  The iris is the coloured part of your eye, the pupil is the black bit in the middle (and isn’t really a thing per se – more like a hole), and the lens is the lens (duh) which focuses light (and thus images) on your retina.  The retina lines the inside of the eye and translates what you’re seeing into information your optic nerve takes to your brain.  The macula is a little spot near the center of the retina that’s responsible for central high-definition vision.

The largest part of the eye (the posterior chamber)  is filled with vitreous humour, a thick jelly-like material that helps the eye maintain its shape.  The front of the eye (the anterior chamber) – the space between the cornea and the lens – is filled with aqueous humour, a less viscous liquid that also serves in a shape-maintaining capacity.  Aqueous humour is constantly being produced in the eye and draining out via the vasculature.  Vitreous humour is a little more boring, pretty much just sitting there.

How much blood can the eye hold, anyway?

Like most things in your head, the eye is plenty vascular.  Also like the head, it’s basically a closed system.  The upshot?  If something in your eye is bleeding, there’s not really much of anywhere for the blood to go.  Let’s assume you’ve taken a puck in the eye, and the impact has torn a blood vessel in the anterior chamber.  You’re likely to end up with a hyphema – the fancy word for an anterior chamber full of blood.

Hyphema - Blood in the anterior chamber.

Hyphema can cause pain, light sensitivity, and vision disturbances.  The treatment depends on how severe it is.  A mild injury may heal on its own with rest, an eye patch (to protect the eye and make you look like a cool pirate), sleeping with your head elevated, and painkillers.  A serious injury can cause a rise in the intraocular pressure either by occupying space with blood, or through inflammation to the area where the aqueous humour drains.  Either way this is an emergency, and may require surgery to drain the blood out of the eye.

Careful, you’ll detach your retina!

Since the retina’s job is to receive the input from the lens and pass it along to the optic nerve, it stands to reason that it’s absolutely packed with nerve tissue.  Nerve tissue needs a blood supply to stay alive, and the blood supply comes from the back of the eye.  So it’s not hard to understand why a detached retina is an emergency – if the retina isn’t attached to the back of the eye, it’s not getting the blood supply it needs, and nerves will die (translation: vision loss).

A blow to the eye will briefly change its shape.  Remember the eye is filled with vitreous humour, which is attached to the retina at the optic disc (the area where the optic nerve enters and exits the eye).  If you change the shape of the eye, you’ll move the vitreous around, and this can result in traction on the retina.  The retina is thin and delicate, and traction will tear it.  It can also tear at sites of direct impact on the surface of the eye.  A retinal tear is bad enough, but when you add the fact that the vitreous takes advantage and starts seeping in between the retina and the back of the eye, you’ve got a serious problem.

This is bad news.

 

Retinal detachment comes with a scary set of symptoms – floaters, flashers (those are self-explanatory), shadows in the peripheral vision, and sudden vision loss.  Treatment is surgical – draining the fluid out from behind the retina, and attaching it back to the inside of the eye.  This can be done by laser (scarring the retina in place), freezing (same idea), instilling a gas bubble that sits over the tear (but the patient has to stay in a certain position – usually face down – for up to two weeks), or a vitrectomy – where the vitreous is actually removed from the eye and replaced by gas or silicone oil.  Gas will eventually be replaced by new vitreous, but oil must be removed with a later surgery.  Retinal detachment surgery has very high success rates – some sources quote numbers as high as 90%, although often requiring more than one procedure.

 

It’s all fun and games until…  You know.

One of the most obvious and impressive eye injuries is a ruptured globe.  That’s exactly what you think it is – a popped eyeball.  It’s not hard to figure out the mechanics between blunt or penetrating trauma and a ruptured eye.

 

Ruptured globe

 

Ruptured globes cause pain (obviously), vision disturbance (obviously), and may result in permanent vision loss (again, obviously).  The treatment is immediate surgery, assuming the eye can be saved.  The surgery is pretty straightforward – the patient gets a crapload of antibiotics, is anesthetized, and the holes in the eye are sewn shut after any foreign bodies are removed.  That’s a pretty heinous oversimplification, but the details of suture size and how you close each layer aren’t very exciting.  An injection of salt solution into the eye both restores the shape of the eye and tests whether the repair is waterproof.  More antibiotics are injected under the conjunctiva (the white of the eye), and the patient gets yet more antibiotics (topical and IV) as well as topical steroids.  Globe ruptures often go hand-in-hand with retinal detachment – either when the injury occurs or later on as vitreous sneaks under the retina.

 

The moral of the story…

It’s certainly possible to regain full vision after an injury like these, but of course it’s entirely dependent on the nature of the injury, how quickly it was repaired, and plenty of other factors.

Wouldn’t you rather get a Stamkos-esque nose laceration than a Malhotra or Berard-esque eye injury?  As we learned in an earlier post, visor use may result in facial lacerations of greater severity, but overall results in decreased injury to the face.  The simple truth is that while I’m pretty fantastic at sewing up your face, I’m not very good at fixing your eye.  You can guarantee that any NHL game will have a doctor on site who can stitch up your face.  There may or may not be an opthalmologist on staff, but the odds of a fully functional opthalmologically-outfitted OR are firmly parked at zero.  Your face can be repaired.  Your eyes?  Maybe.  Maybe not.  Hell of a chance to take.

 

- Jo

 

 

 

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

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