Is it October yet? Part 3: Bob Baun

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

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

Badass Bobby Baun

The history…

Bob Baun is not afraid of pain. During Game 6 of the 1964 Stanley Cup Final, he was hit in the ankle by a Gordie Howe shot. He continued playing, but when he circled to clear the puck from the zone, he heard an audible pop and went down.

The trainers carried Baun off the ice on a stretcher, and an examination of the ankle in the dressing room revealed major swelling and a large welt. Baun insisted the trainer inject painkillers and tape the leg to keep the swelling down. With his leg wrapped from foot to nearly his knee, Baun squeezed back into the skate and finished the period.

For whatever reason though, the painkiller wore off quickly, and so Baun needed several more shots. When he returned to the bench in overtime after one of the shots, coach Punch Imlach was sending Carl Brewer and Kent Douglas onto the ice. Baun took Douglas’ place, caught the pass from Bob Pulford, and scored the game winner, tying the series with Detroit at 3-3.

On the train back to Toronto, Baun knew his leg was broken. Imlach knew it too, ordering Baun to see the team doctor at 9 am the next morning. Rather than see the doctor and sit out Game 7, Baun packed an overnight bag and went to a friend’s farm to hide out. He refused to even tell his wife where he was.

After almost two days of hiding, rest, and ice, Baun appeared at Maple Leaf Gardens 30 minutes before Game 7, because he knew that was “too late for them to check me out and stop me from playing.” He suited up and played a shift or two in the 4-0 victory over the Red Wings. He wasn’t allowed to celebrate much, as he was sent almost immediately to hospital, where x-rays revealed a jagged fracture immediately above the ankle, in the fibula.

The medicine…

As broken legs go, fibula fractures are among the most interesting, and yet they get the least attention. Poor fibula fractures. No respect.

Fibuwhat?

The fibula. It’s that other bone in your lower leg. The one you don’t think about. It’s not part of your shin, it doesn’t bear much weight, and when it breaks it doesn’t look anywhere near as spectacular as a broken tibia. It’s also fairly scrawny.

Tibiwho?

The tibia. It’s the bone in your lower leg that you know and love. It’s your shin. It’s the weight-bearer. It’s the one you whack on the coffee table in the dark. When it breaks, it’s generally pretty obvious, and pretty gross.

Anterior (front) view of the right leg

The question is how Bob Baun could last two days and a hockey game with a broken leg. The answer is because it was his fibula that was broken, and because he was an enormous badass. Generally when you break your lower leg, you break the tibia, or the tibia and fibula (which we call a tib-fib fracture because that sounds cooler). The tibia and fibula are attached together by a flat ligament (the interosseous membrane), which is why they’re frequently broken together. In Baun’s case, the isolated lateral force from Howe’s shot resulted in just a fibular fracture.

Treatment

Fibular fractures are fairly easy to treat assuming they’re not open (bone poking through skin), displaced (bone going somewhere it shouldn’t), or comminuted (bone broken into multiple pieces). The first order of business is pain control. Bones are covered by periosteum, a membrane that has the distinction of being lousy with pain receptors. That would be why broken bones hurt so much (SCIENCE!).

Since the fibula is non-weight-bearing (or minimally weight-bearing – a distinction we won’t get into, but that orthopods love to fight about), simple fractures are treated with a cast for the first two or three days, and a pair of crutches if needed. That gives you time to get into the ortho office, where they’ll put you in a walking cast or a cam walker, which you can buy on Amazon, but probably shouldn’t.  They’ll also take away your crutches if you’re still using them. After three to four weeks of immobilization, the cast comes off, and a splint is used on an as-needed basis for exercise. Athletes can generally return to light training after just a few weeks, but full recovery is a six- to eight-week process. Sports that consist of a lot of twisting and trauma to the leg (like hockey or soccer), however, can require a much longer healing period (as much as 18 to 24 weeks) in order to prevent refracture.

As with any injury, the healing process for fibula fractures is helped along by physical therapy, consisting of strengthening exercises and getting yelled at.

The Take-Home

Basically, Bob Baun was a complete animal. He had a fracture that you can walk on, but broken bones HURT. He sucked it up and hid out so he could play in game 7. Smart decision? No, probably not. Understandable? Yes, probably.

Oh, and in case you weren’t aware – hockey season starts again soon. I know, I know, I’m excited too. Many thanks to Jen for collaborating on this series!!!

Is it October yet? Part 2: Trent McCleary

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

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

 

Trent McCleary, huge frigging badass.

The history…

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

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

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

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

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

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

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

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

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

 

The medicine…

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

The Larynx

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

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

 

So THAT's where my larynx is!

 

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

 

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

 

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

A is for airway

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

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

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

B is for Breathing

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

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

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

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

The Aftermath

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

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

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

Things I don’t believe:

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

Speaking of badasses…

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

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

Is it October yet? Part 1: Ace Bailey

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

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

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

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

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

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

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

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

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

Bailey and Shore

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

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

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

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

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

Why did Ace seize?

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

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

Coup-Contrecoup

Treatment

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

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

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

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

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

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

Post-Surgical Complications

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

SIRS – Systemic Inflammatory Response Syndrome

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

PAID – Paroxysmal Autonomic Instability with Dystonia

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

Decerebrate posturing - A very distinctive response to head injury

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

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

Torn pectoral? Gross, dude.

Want to know what it takes to gross me out? This:

Gross.

That’s Scott Howson, GM of the Columbus Blue Jackets. I could easily fill a post on the subject of how kickass it is that there’s a GM on Twitter (solid PR move, Columbus), but let’s talk about the pectoralis major and what happens when you tear it (other then me getting grossed out).

Pectoralis Major (aka the pec, pec major, moobs, etc.)

Pectoralis major

Pectoralis major is the muscle that makes up the bulk of what your personal trainer calls your pec. You’ve got one on each side, and if you’ve ever benched too much, then you know exactly where they are.

The pec originates at the sternum, clavicle and aponeurosis of the external abdominal oblique, and inserts on the bicipital groove of the humerus.

Huh?

The pec is connected to the sternum, collarbone, top of the abs, and the upper arm.

That’s better.

It has several jobs, mostly involving shoulder movement (and holding your arm on), and the NCAA guide to “Ice Hockey Officials’ Signals” will illustrate them nicely:

Arm flexion

Arm flexion: In order to get your hands up in front of you to signal cross-checking, you’d first have to raise them up in front of your body. That’s arm flexion.

Arm adduction

Arm adduction: To signal kneeing, you reach across your body and slap the opposite knee. To do this you have to adduct your arm (the opposite of raising it away from your body to the side).

Medial rotation of the humerus

Medial rotation: Delay of game? Well, actually this isn’t really close. Imagine your arm is bent at the elbow with your hand pointed straight in front of you. Rotate your arm so that it’s across your chest (like you’ve got it in a sling). That’s medial rotation.

Deep inspiration: The NCAA can’t help me here. If you take a really deep breath, the pectoralis helps expand your chest.

Assorted scapula (shoulder blade) jobs: Flex your pec and you’ll have a better idea of what it does to the shoulder blade than I could possibly explain.

Holding your arm on: Obviously your arm is connected to the rest of your body by a lot more than your pec, but it definitely contributes. The tendon that attaches the pec to the humerus (upper arm) is about 2 inches wide – that’s not insignificant where tendons are concerned.

The Injury

Pectoralis tears aren’t exactly common, which just as well because they’re painful and take a long time to heal. The tear generally happens during the bench press, and results in sudden pain, swelling, bruising, and a dimple above the armpit (from the missing muscle). This is a gross injury on a lot of levels – there’s horrible pain, your arm stops working properly, and many patients who’ve had this injury say they actually heard their muscle tearing when it happened.

Two thirds of pec tears involve pulling the tendon off the humerus. The rest are scattered amongst pulling off one of the other attachments, or rupture of the pectoral muscle itself (which is thankfully uncommon).  Since rupture of the tendon that holds the pec to the arm is the most common, that’s what we’ll be looking at.

The Repair

The best results are achieved with a quick repair. Older or sedentary patients can be managed conservatively and non-operatively, but since the majority of these injuries occur in athletes, they’re almost always repaired surgically. The repair involves opening the shoulder, scraping what’s left of the tendon off the bone, and re-attaching the severed end of the pectoralis tendon. Traditionally the repair was done by drilling holes through the humerus and threading suture through the holes and the end of the tendon.  Recent research has shown that you can get as good a result using absorbable sutures threaded onto an anchor that’s screwed into the bone (which is a far easier surgical technique).

Anchor suture

The suture takes years to be absorbed, and maintains full strength for 5 months – plenty of time for the tendon to heal to the bone.

The Recovery

The ugly part of this injury (other than hearing your own muscle ripping) is the recovery. After surgical repair, it can take four (more likely six) months to get back to pre-injury activity:

  • The first four weeks: The patient has to stay in a sling and isn’t allowed to bear weight or move their arm in any of the ways the NCAA refs are showing us above.
  • Weeks four to six:  Simple range of motion exercises start – they’re allowed to move the arm, but not to lift it up or twist it away from the body, as these movements put too much stress on the tendon.
  • Six weeks post-op: The sling comes off and all range of motion is permitted.
  • Eight weeks post-op: Isometric training begins – no weights, just contraction of the muscles by pushing or pulling a fixed object. I’m bored just thinking about it.
  • Three months post-op: Light resistance training begins.
  • Four months: Heavy training begins.
  • Six months: Full activity resumes.

As with any major injury, it can take a long time to feel good again. The same study that looked at absorbable sutures found that at fourteen months post-op all patients were happy with their result.

What this means for Kristian Huselius

He’s in for a long, long rehab. He could be back mid-November at the earliest, more likely early January. He may not feel right or play to his fullest for a year. On the other hand, he could heal quickly and be fine. This is one of those injuries that would be a bad idea to rush back with (honestly, there’s no good injury to rush).

Things I didn’t mention, and will spend very little time discussing

Steroids: Yes, steroids can weaken tendons. No, this is no way means Huselius was using them. Tendon rupture with steroid use is frequently seen in older patients taking steroids for other reasons (like respiratory problems), and the rupture is usually atraumatic (i.e. it just happens out of nowhere). Jumping right to a steroid conclusion here would be stupid. Don’t do it.

Pectoralis minor: Pec minor is a tiny version of pec major that lives directly underneath it. It attaches to the underside of the scapula (shoulder blade) and the top few ribs. Its job is to hunch the shoulders forward. Boooooooring. That’s why I didn’t bother discussing it.

Many thanks to the NCAA refs for beautifully demonstrating the actions of pec major.

- Jo

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.

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

 

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