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[EDITOR'S NOTES]

Life-Threatening Emergencies

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 4 - APRIL 2021


In late January, during an NHL game, forward Trent McCleary of the Montreal Canadiens slid across the ice in an attempt to block a slap shot. This is a fairly routine maneuver in hockey, but this time the puck struck McCleary full force in the throat. With help, he made it off the Molson Centre ice in great distress, indicating by waving that he couldn't breathe.

In the Molson Centre clinic, which is one of the best in the league, treatment was very difficult because of the large amount of blood coming from McCleary's mouth and the aggressive behavior typical of extreme air hunger. He also developed massive subcutaneous emphysema of the neck and anterior chest wall. Attempted intubation and angiocath insertion into the trachea were unsuccessful. An ambulance was in the building, and technicians were available for transfer. The medical team called ahead to the Montreal General Hospital (a level 1 trauma center), which then held an elevator and readied an OR for their arrival. During the 4-minute ambulance transport, a simple jaw-thrust maneuver produced sufficient reduction of the laryngeal fracture to permit a modest stridorous airway and allow ventilation with 100% oxygen by mask.

By the time of emergency surgery, about 16 to 18 minutes after injury, McCleary was in critical condition, and endotracheal intubation was successful in the OR. Tracheostomy was done promptly, but continued arterial desaturation led to the recognition of a severe right-sided tension pneumothorax due to the associated barotrauma. This was also treated immediately and successfully by insertion of a chest tube.

McCleary is now doing very well. Said team physician David Mulder, MD, later, "It's the first operation I've done where I looked down afterwards and the patient still had skates on" (1).

I had the opportunity to speak with Dr Mulder, who led the medical team in McCleary's care. There were many fortunate circumstances that worked in McCleary's favor: Mulder is an experienced cardiothoracic surgeon with ATLS instructor status who has written book chapters on airway management; the nearby hospital was Mulder's home base; and commands were issued from the arena and acted on rapidly, setting in motion the efficient arrival at the OR. Indeed, the fact that the angiocath could not be inserted might have been fortuitous: When questioned about the role of cricothyrotomy in patients who have a fractured larynx, Mulder points out that, generally speaking, cricothyrotomy is contraindicated with laryngeal fractures. In this situation, the cricothyroid membrane may also be fractured, and an attempted cricothyrotomy may compound airway obstruction.

Contemplating McCleary's story, I wonder what might have happened if Mulder's expertise had not been available and the environmental circumstances were more hostile. And then comes the next question: "Would I be ready?" It's a question all of us involved in sideline care for a contact sport need to consider. Of all the types of work we do in sports medicine, I cannot imagine anything more fulfilling than saving someone's life. On the other hand, I am troubled at the thought of a situation in which, despite a contingent of physicians and athletic trainers on a sideline, the medical team is unable to put in place the sequence of procedures needed for proper emergency care.

The toughest element of preparedness is the fact that serious events are rare. It is difficult to practice for something that is unlikely to happen. Yet preparedness is all we have when it comes to an emergency of the sort Mulder and his colleagues were faced with. Emergency preparedness is like life insurance. It is seldom needed, but the experts highly recommend it. Why? Because without it, a catastrophic problem can become a hopeless situation.

Three elements of preparedness that physicians should not overlook are equipment, education, and practice. The emergency kit for sideline care should be simple, easy to use, not cluttered with paraphernalia, kept for emergency use only, and readily accessible (2). Physicians involved in the care of athletes who risk severe injury (downhill skiers, gymnasts, football and hockey players, etc) should be ATLS- and ACLS-certified and current. The best way to stay current is through reviewing and practicing emergency protocols for situations relevant to a given venue. Ultimately, executing emergency procedures properly rests on the shoulders of the team or event physician. Although it is somewhat tedious to practice these protocols (and difficult to assemble all the personnel), that is the only way to know whether your medical team is ready to coordinate critical care.

Mulder says that careful analysis of the McCleary event has taught his medical team a great deal. Many factors were working in their favor, he says, but the medical team was impressed by the effectiveness of basic ATLS principles. The use of the jaw thrust, for example, bought the 5 minutes needed to get to an OR. The event raised new questions as well, such as the ideal choice of anxiolytic agent in this situation. Mulder's group is now in the process of defining emergency equipment, facilities, and protocols to allow all sports physicians to deal with this injury in a more effective way.

McCleary's accident and others like it send shivers up and down the spines of many physicians. Our hats go off to Dr Mulder and his colleagues for the outstanding job they did. We hope that this month's Clinical Techniques article, "Sideline Airway Access: Emergency Cricothyrotomy," by senior associate board member William O. Roberts, MD, can help you begin your preparations.

Best,
Gordon O. Matheson, MD, PhD
Editor-in-Chief

REFERENCES

  1. McCleary recovering from life-threatening injury. CP, Montreal; January 30, 2021. Available at: https://www.canoe.ca/HockeyMontreal/jan30_mcc.html. Accessed March 2, 2021.
  2. Matheson GO, Ford P, Brukner P, et al: Emergencies on the field: preparation for emergencies in sport. In Safran MR, McKeag DB, Van Camp S (eds): Manual of Sports Medicine. Philadelphia, Lippincott-Raven Publishers, 192021, pp 37-43


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