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:

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

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

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

– Jacques Martin, courtesy of the Montreal Canadiens.

 

A quick word about concussions:

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

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

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

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

Well, what did happen next?

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

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

So when will he be back?

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

The take-home message:

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

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

Get well soon, Max.

– Jo