Youth hockey

“Get off the ice!” my friend yells, calling his son by name: “Get. Off. The. Ice.” His boy is fast and skilled and this makes him a target. Number 55 (changed from actual) on the other side is going to hurt someone. Three times, he’s taken a run at a player against the boards. Three quick steps, elbow high as if he’s pulling an arrow through a bow, then the impact—elbow to the head. There have been three fights already. Parents are cursing each other in the stands. This game needs to end. These are tenth graders. This is absurd.The game seems dirtier this year. A couple of weeks ago, one of my son’s teammates was knocked out cold, a deliberate hit that sent his head into the boards. It was the second time that day that I’d been called out of the stands to tend to a player. Even the National Hockey League (NHL) has seen a “rising number of dangerous hits,” with players wanting safety on the ice. “I’ve talked to guys on our team, guys on other teams,” Dylan Larkin, the Detroit Red Wings captain said recently. “It’s hard to know how to protect yourself.”Hockey is a fast, physical game and with it comes risk of injury. Even professionals are almost completely covered in padding. Almost. Earlier this season, ex-NHLer Adam Johnson, playing in the British Elite League, lost his life when an errant skate sliced his neck. I watched the video once. It’s all I could handle and I’ve seen some pretty gruesome things. While I’m certain Matt Petgrave had no intent to gravely injure Johnson, it’s hard to understand why his skate went so far out of its way to find Johnson’s neck. Petgrave has been charged with manslaughter and the incident has prompted new neck guard mandates in international hockey tournaments such as the Olympics.It’s easy to see how number 55 might break someone’s neck, running at his opponents like a Spanish fighting bull. What then? Would hockey authorities look to add protective gear, or would they look into real deterrents to dangerous behaviour, something more than a few minutes in the penalty box and a one-game suspension?One tough patientLike my own son, Cam Francis (name changed) is 15. He, too, has played many years in this community. And although hockey circles are small and tight-knit, two months after Cam’s catastrophic injury, very few people even know that it happened.It’s mid-November on a Sunday night when Cam’s mother wheels him into a treatment room. They’re in Fast Track, an area of our ER for one-touch patients, those unlikely to require a great amount of time, testing or treatment. He stands and grimaces as he eases himself onto the stretcher, still wearing his requisite shirt and tie from his game a few hours earlier. “He took a hit,” his mother says. “It’s been a few hours and he’s still complaining of pain, so we thought we’d get it checked out.”I ask what happened, but other than “hard check,” I don’t get much.“Were you able to get back on the ice again?”“No,” he says. “I missed the rest of the game.”I glance at his vital signs. His heart rate is at the upper limit of normal, blood pressure at the lower limit, 95 over 60. Lying still, he looks OK, but when I examine him, his gut is tender, especially just below his chest. Fortunately, his abdomen is soft when I push, it doesn’t have the rigidity of someone who’s guarding a severe injury. Yet.“It’s probably just muscular,” I tell Cam and his mom. This is where I usually stop, telling player and parent to go home, rest and take some Advil. “But he’s pretty sore, so I’m going to send him for an ultrasound and get some blood work just to be on the safe side,” I say. “And just in case, don’t eat or drink anything just yet.”“OK,” his mom says. I say this several times a shift, “Don’t eat or drink anything just yet,” and almost no one asks why. I wonder how many know that the followup to this line is, “just in case you need surgery, we want your stomach empty before we put you to sleep so you don’t vomit and choke on your gastric contents.”I see several more Fast Track patients—kids with colds, a woman requesting a prescription, a couple of cuts requiring stitches. An hour later, Cam’s blood tests are back. His hemoglobin is down slightly at 126 (the mean for someone his age is 140). It’s a number I’d barely notice if his presenting complaint was something other than trauma. And shortly after, he’s back from ultrasound. The radiologist’s report is vague. All the organs appear normal in size, other than the spleen, which has a small lump at its base. The lump is smaller than a cherry tomato. Indeterminate splenic lesion, the report says. This most commonly represents a benign etiology such as a hemangioma. A followup elective MRI is suggested. The radiologist also notes a small amount of free fluid that may be post-traumatic in etiology.I explain the results to Cam and his mother. I tell them that it’s possible that there is bleeding internally and that it’s coming from the spleen. He’s still tender when I re-examine him, perhaps more so than before. “I’m going to get a CT scan for a better look and repeat his hemoglobin. If the number is dropping, it means that he’s likely bleeding and if so, I’ll know how fast.” I ask a nurse to take Cam to the acute room where he can have a bed with monitoring. “I’m also going to give you a medication through the I.V. called tranexamic acid,” I say. “It promotes clotting, so if there is bleeding, I want to get ahead of it.”An hour later, the radiologist calls. “Your patient with the spleen,” he says. “He has a pretty big laceration, there’s blood in the belly and I think I see active extravasation.” The CT scan was performed with intravenous contrast, and extravasation means the radiologist sees contrast leaking out from the spleen. In other words, he’s still bleeding.Fortunately, Cam’s hemoglobin has barely dropped—126 to 124. If he’s bleeding, it’s minimal. The surgeon on call comes down and we discuss his options. Most splenic injuries are treated nonoperatively. Patients are kept in hospital until the injury settles, and this is followed by several weeks of rest until healing is complete. In case of severe hemorrhage, the spleen has to come out. I’ve seen two catastrophic splenic ruptures from hockey injuries and both ruptured several days after the patient had left hospital. In both of those cases, my patients were rushed to the operating room for urgent splenectomy. There is, however, a third option that may be best for Cam. His injury is severe, Grade 5 on a one-to-five scale of severity. But his hemoglobin is basically unchanged so bleeding seems to be minimal. Embolization is an option. It’s a procedure in which a catheter is fed into the splenic artery so that it can be occluded to stop bleeding.The videoI’ve seen the hit on a small grainy video. I’ve watched it dozens of times. Cam is skating into the offensive zone with an opponent, practically on his back, giving chase. As Cam crosses into the opposing zone, another player skates into him from the left side. Just as this second opponent makes contact with Cam, he either falls or is pushed from behind. The resulting impact is the second player’s left knee into Cam’s abdomen. They spin, and then the player’s knee lands on Cam’s gut. “Shattered spleen,” a radiologist would say on the next day’s scan. And at the point of impact, there is cheering. As with my son’s games, the bigger the hit, the louder the cheering.Cam is transferred to the children’s hospital downtown. There, he is treated conservatively with bed rest. The following day, his hemoglobin is only slightly lower, at 119. A repeat CT scan shows a large amount of blood surrounding the spleen. On day three, Cam develops shortness of breath and requires supplemental oxygen via nasal prongs. A chest X-ray shows fluid around his left lung, just above the spleen. His hemoglobin is now 106, although his pain seems to be improving. On day four a chest X-ray shows an increase in the fluid around his left lung, but Cam is starting to get up and move around. From then on, he continues to improve until day 8, when he’s finally discharged home. He’ll be off the ice for at least eight weeks, but it could have been much worse.During an NHL game on New Year’s Eve, a Minnesota Wild forward jammed his stick deliberately into the face of his opponent. Jamal Mayers, a former player and hockey analyst with Sportsnet, defended his actions, calling it a message. “There is an element of meanness,” he said. “There is an element of not being nice out there. And if you don’t like that element then maybe you don’t like playoff hockey.”Fellow panellist, Jennifer Botterill, a Harvard Graduate and three-time Olympic hockey Gold medalist, served as the voice of reason: “You’re OK with that? If it’s your son playing? And he takes that two-hander to the face? That it was a good message to send?” She called it “archaic, cheap and dirty” and she is right. It isn’t a message, it’s assault with a weapon. But this is the way some people in hockey circles think. It’s a problem at the professional level and it trickles down to all levels of the sport.My son plays number 55’s team again soon. I’ve warned everyone to keep their heads up. It’s a dangerous game without dirty hits and deliberate attempts to injure. Players, parents, spectators and referees need to make safety their top priority at all levels because the game’s next serious injury is just waiting to happen.Dr. Raj Waghmare is an ER physician. He blogs at theoverheadpage.com. His stories come from more than 20 years of medical practice all over Ontario.

Youth hockey

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