OK, it's 1.30 and our next session, as I said, will be with Bill Daly, the Deputy Commissioner of the National Hockey League who's been kind enough on holidays to spend the next 30 minutes with us. So, as I said, Bill's the Deputy Commissioner and Chief Legal Officer of the National Hockey League. He's been with the NHL for just under 30 years and really has overseen major international hockey agreements, collective bargaining, and he has a law degree from NYU and did his undergrad at Dartmouth. I think, you know, working on a few of the league's committees over the years, I think I found Bill to have really an amazing ability as a non-medical person to synthesize all the medical information and really ask really good questions to the team docs, the therapists, and he also has assembled a very good both legal and medical team with the NHL with Julie Grand, Jamie Hacker, Wynn M. USA, and Kim Harmon. So Bill, thanks for joining us. Can you hear us all OK? Yeah, I can hear you, Garren. Thank you for having me. I apologize for the kind of unprofessional background. I happen to be in a car, but I'm not driving, so people can feel assured that I'm safe and other people are safe. Yeah, no, thank you for having me, Garren. I'm happy to be here. Perfect. So we're going to start off. You know, I have three main topics I'm going to chat with Bill about, and he'll spend about five minutes or so on each topic, then we'll open the field to questions. So the first one is, Bill, can you talk a bit about the approach that the NHL has with respect to player equipment and the playing surface, playing environment, and how you guys have approached that over the years? Yeah, for sure. Obviously, it's becoming more of a focus of our health and safety committees, and I think that's probably a good thing. I think 10 to 15 years ago, our primary concern with player health and safety had to do with the behavior of the players on the ice. And I think to a large extent, due to the efforts of the Hockey Operations Department, player safety, our Department of Player Safety, and our alignment with the National Hockey League Players Association, I think we have largely removed serious concerns about player conduct on the ice vis-a-vis one another. We see it from time to time, and I'll get to it later, I think, in the talk, but that shift in the way the game is played on the ice, and it being safer today than it was 15 years ago, has led us to, or allowed us, really, to transition to looking at other elements of the game and things that are important to injury and injury prevention. And I'll take a step back. I mean, I think our current framework for injury diagnosis and management works through a joint committee that we formed with the NHL Players Association as a product of our 2012-2013 collective bargaining negotiations. And it starts with what I'll call an umbrella committee, which is our Joint Health and Safety Committee, which kind of includes, really, a potpourri of different skill sets. Obviously, there's NHL participation and NHL representative participation on that committee, NHLPA representatives on that committee. Then there's, and Dieron, you alluded to them, we have retained our own medical people, starting with Winnemosa, who's worked with us probably for 15 to 20 years now, more recently, Kim Harmon and Ruben Echimendia, who is a co-chair of our concussion subcommittee and is our neuropsychologist on the Players Association side. Scott Delaney joined the Players Association maybe a year and a half ago, two years ago, took over for John Rizos, who continues to consult and participate on some of the committees as well. And Paul Comber works with Ruben as a co-chair on the concussion subcommittee. Under that joint health, and in addition to the medical representation we have on that committee, we also have representation from team medical, team doctors, athletic trainers, in some cases, equipment managers, depending on the subject matter of the committee. We have general managers, team general managers who are engaged on these health and safety committees and attend the meetings on a regular basis. And we have coach and assistant coach representation. Typically, the coach is filled by an assistant coach or maybe a retired coach or a coach between jobs. But they have played a role as well. Underneath the joint health and safety committee, there are, I think, nine standing subcommittees and that number grows over time and has grown over time. That includes the longest standing medical committee we have, which is our concussion subcommittee, which meets regularly four times a year to discuss the current state of conditions for concussions around the league and what's causing them and how we're dealing with them. We have a medical standards committee. We have an electronic medical records committee. We have a prescription medication committee. We have a protective equipment subcommittee, which was the initial question and I'll get to. And we have a playing environment subcommittee. The last two committees are ones that are very active currently, just in terms of trying to get our arms around risk factors associated with playing the game related to equipment and player equipment, but also relating to the playing environment and things we can do to improve the player environment, soften the playing environment, make it more player friendly. In terms of our protective equipment subcommittee, we obviously we rely on the efforts of our equipment managers to kind of log and keep track of all the information or all the equipment being used in our locker rooms by our players. Equipment, for the most part, other than certain standards they need to reach or meet is totally a player choice matter. The players choose which equipment feel the best for them and serve their purposes. And there's always a trade off between protection and performance, as you might imagine. And that's a balance that the players ultimately make themselves. We've also retained the biomedical or mechanical engineering firm. David Kashu, the firm of ARCA, has worked with us for the better part of a decade, more than a decade, currently tests for and ranks the protective qualities of various pieces of equipment, most notably skates. And as new models of skates come on the market, we try to update that testing. Also, player helmets, which is our current focus now and a new testing method that David has has gotten approval to conduct on player helmets and their protective qualities, and then on goalie masks as well. In the past, we've done tests on gloves and the protective qualities of gloves. All that information is taken. And while we don't have the ability to change the design or the way our manufacturers manufacture those equipment, we communicate back the information to them. As I said, we rank the equipment by their protective quality. We also feed that information to the clubs and to the players so that they're aware of what they're wearing and the qualities and perhaps demerits of some of the equipment they choose to wear. I will say that we've been doing this probably about five years now. I think we're starting to pick up some traction with the manufacturers. I think they are being responsive and receptive to making improvements, maybe the low hanging fruit, but improvements nonetheless. And I think our equipment is getting more safer and more protective over time. Obviously, club personnel can play a big role. While they can't dictate to players what equipment to wear, they certainly can play a big role in encouraging and recommending usage of certain types of protective equipment. The protective equipment that has been focused on most publicly recently are cut resistant equipment. This is something that's been on our radar for quite some time. Rod Pazma of our hockey operations group has taken a personal interest in increasing player usage of cut resistant equipment. In some instances, skate cuts can be considered rare, but they also can be catastrophic. And I think everybody is starting to recognize that and respond to it in a positive way. We've had cut resistant socks in our league for probably 10 to 15 years now, and I think that's pretty standard usage among our NHL clubs. We've been pushing wrist and arm protection, cut resistant protection for a couple of years now. While we have not mandated it as a league and don't have the players support to mandate it, at this point in time, we've certainly increased utilization pretty significantly over the last couple of years. And this past year, we produced an educational video that was kind of mandatory for our players to witness and watch during the training camp prior to the 23-24 season. During the course of this season, as most of you probably know, there was a tragic fatality in a British professional hockey league game. With a skate cut to the neck. And as a result of that, there has been a surge of effort and support towards making neck protection. Certainly strongly recommended, if not mandatory at this point in time, it has become mandatory. It has been legislated by all the major hockey organizations, with the exception of the Continental Hockey League in Russia, and our league. We do have kind of a pending proposal to the Players Association to make mandatory neck protection usage by our players, though that proposal was reported on by the Players Association as I understand it. This past summer at the player meetings. And while they're not the players have not indicated approval of moving forward with that mandatory rule. It certainly remains on the table and I think they're going to continue to work through their educational efforts to make players, understand and recognize the importance of neck protection. Only a couple words because I'm probably over my five minutes to do and gave me on the subject on the plane environment. It is what you would think it is it's it's making sure our ice conditions in our each of our 32 arenas is as high quality as possible, so that players aren't suffering injuries from bad ice and that that certainly can happen. Well, actually historically, and then again more recently, we've been testing the flexibility boards and glass systems, we are finding that the predominant amount of our concussions are from contact with the environment and boards and glass around the perimeter and making this as soft and environment as possible as important. We also have instituted in our arenas, several standards related to the plane environment, whether it be removal benches, so that we can respond to emergencies in the bench areas or trauma areas and and proximity of trauma areas as well as the staffing rooms, and the like so all under the guise of improving the planning environment so those are some of the things we're doing through the committee process. Well, that's great bill there. I mean we basically build it a great job of just outlining the detail the NHL does in their in their subcommittees. One of the subcommittees you mentioned is a concussion subcommittee. And it's the longest standing committee. For those of you who watch hockey and I know as a team physician, sometimes we will get what we what they call a mandatory concussion evaluation by a spotter and and you know it as a team physician. bring bring the player back and go through the NHL's version of the, the, the scout. So maybe Bill, if you can just comment on maybe a bit about that spotter program, how it evolved and and you know how you think having that extra set of eyes is helpful for the team medical staff. The genesis of the spotter program was a study that we in the Players Association undertook with respect to whether we could identify visible signs of concussion on the ice, or at least red flags that we could use to assess the possibility of concussion, whether some of those visible signs to the eventual diagnosis of concussion, and it was a multi year study where we had people hockey people coding events in every game of the season. We did it historically so not on a real time basis but, you know, we had people who came in and watched you know 20 games a day to look for visible signs of concussion I think we that that results of that study was reported back to the concussion The concussion subcommittee then created a visible signs kind of system where if certain things are spotted on the ice. There's a response in one of two ways, either a mandatory removal for the player for mandatory concussion evaluation off the ice in a quiet place or discretionary removal, and we can get into a little bit more about that. Obviously mandatory removals. We, we dictate in cases of a player lying motionless on the ice, possibly unconscious motor and coordination is an automatic mandatory referral blank and vacant looks by players that are observed by ice personnel is a mandatory removal. We also have a hybrid one was slow to get up following a hit to the head or torso, which is one of our more recent mandatory removal obligations discretionary removal are in the case of or helmet or holding the head or a helmet or standard slow to get up type situations where a player may be staying down for a variety of reasons, one of which may be a head injury but there may be other injuries suffered by the player in the certain cases and there may be just an attempt to draw penalties, which still happens in our game. In terms of what that means in terms of the mandatory and discretionary removals and mandatory case, it's clear that the player has to be removed from the bench area in the discretionary case we allow club medical personnel, usually, in this case to do a mini screen in the bench area to be satisfied themselves that no head injury has been suffered. Obviously, a little trickier and not perfect this the whole system's not perfect, but it's a lot better than what we had in terms of how we spot these things we go about spotting these things. We have in arena spotters in every arena that monitor every game these are actually off ice officials who are employed by the league, and who are trained in invisible signs of concussion. We also have an employee for what we call central spotters who work out of the player safety department in the league office. They also watch every game they actually they work with our player safety crew, who will flag, any, any concern about a visible sign of concussion for review by the concussion spotters the central concussion spotters. These are have to be hockey people. They're usually ex hockey trainers or trainers, and they're, they're ultimately responsible for any decision on on visible signs, they communicate with the arena spotters, and ultimately communicate with with club medical personnel on removals of players from play. So that's a, that's my summary of where we are in concussion spotting. That's great. And very detailed again so really in the NHL we have those mandatory and then discretionary the mandatory, you know, really the players out of play for about 15 minutes for the evaluation, where the discretionary is usually a conversation with with the athletic therapists, usually in the bench or maybe in the tunnel area to see if a more further evaluation is needed. So we have about 1010 minutes left I think I do want to ask you build this. My last question I had, and really, you know, when you go to make rule changes. There's a lot of stakeholders. And I think Bill alluded to this is, you know, there's the Players Association. in order to make that happen. Yeah, I guess I would identify our most significant safety related rule change in recent years to to the adoption and approval of Rule 48, which is, which made for the first time in our game, illegal certain hits to the head that that rule has been modified over time and change. Currently, that has to be the principal point of contact and contact that could have otherwise been avoided to be a penalty in our league that can be a minor major. And obviously there can be supplementary discipline that comes from illegal hits to the head. So that's one example of kind of a rule change that was made for health and safety related reasons. In addition to the Joint Health and Safety Committee, who certainly is in a position to make recommendations on rule changes. Playing little changes on the ice are also governed by the our competition committee, which is also another joint committee staffed by Players Association representatives and NHL representatives. The competition committee can adopt or make their own recommendations on rule changes. And then it goes to our general managers who consider what's being recommended, and they ultimately would make the recommendation. recommendations to our Board of Governors, who typically if they've received all of those recommendations from all those various levels of expertise would would approve recommended rule changes so it's a complicated process. But it's, it's an important process. From, from that standpoint, we will also made health and safety related rule changes, you know, with regard to use of helmets over time. Adopting the double IHS helmet off rule as as causing a stoppage of play. If the player doesn't remove himself from the ice, we've made, along with the Players Association support obviously player helmets in in warm ups mandatory where they used to not be on a grandfather basis we've we've added advisor requirements so we've, we've made a lot of rule changes over time that are centered on player health and safety. So thanks so it is a complicated it's not all George Paris's fault. Despite what you see on on Twitter or x. He's not here to defend yourself, defend himself but you know he's still a lot bigger than me so I won't say anything else. So we have some time for questions. Anyone has questions and I know, Dr. Nelson is manning the, the online questions, but we'll open it up, open it up to the floor. If anyone has any questions from the floor for for Bill Yeah, there's there's one coming in here. That is correct. And so the team physicians need to be sports medicine trained and certified, correct? Yes, they do. And those standards are really constantly under review, monitored and where appropriate changes are made. We had a session just recently that led to some changes of some of the standards that were being recommended originally by the standards subcommittee, medical standards subcommittee. So that is accurate, everything you're saying. So, I have one question that's through here. Can you, Bill, do you guys regularly collaborate with the other leagues with respect, I mean, you know, some leagues are very different in their sport, NBA versus NHL, but do you have a regular, at an executive level, of collaboration talking about health and safety? We do. I would say most of, or a lot of that is informal there, it's, you know, sometimes we'll agree to get together in the same room. A lot of times when we have questions with respect to the way other sports leagues deal with certain situations and conditions, we'll pick up the phone, we do have that direct line of communication. We do have a kind of also a formal organization of collision sports that we were invited to be part of several years ago, which involve a number of the North American leagues, but also involves a number of leagues internationally, you know, rugby, football, and the like. And we regularly meet with that group of leagues to compare notes, compare best practices, see what's being done. Those meetings are more formal in nature where presentations are actually made, PowerPoint presentations, questions and answers sessions are had, and, you know, it's over a multi-day period. So, the answer, the long-winded answer to your question is yes, we regularly consult with other organizations, sporting organizations, on matters of common interest, including health and safety. Excellent. We have one last question. Tony Colucci from Detroit. Hey Bill, how you doing? Good, Tony. How are you? Good. No question, but I want to thank you guys. I want everybody here to recognize that the support that the NHL provides, the Medical Standards Committee that I chair for all the changes, the improvements that we do for player safety, and like I said, I can't thank you enough for the support you guys give us. Thank you, Tony. I appreciate that. And I would similarly like to thank this group for all you do on a regular basis, on a daily basis to make our game safer and as safe as it can be for our players. It's a remarkable group I've come to know over my time at the National Hockey League. I think the NHL has the oldest internal organization of team physicians, I think going back to the mid-1980s, and I've been honored and privileged to be kind of put on that role and put on that watch for the last 27 years. I would say I'm very fortunate I have really good people like Darren Noded, Julie Grand, and her group has taken a lot of that off my plate over time, but I've really enjoyed my association with this group. And again, thank you for your efforts. Well, thanks so much, Bill. Just as you guys, as I said on the outset, Bill's on holidays. When we contacted him about doing this, there was absolutely no hesitation. He got back to us within hours from an email. So thanks, Bill, and enjoy the sun. Thank you guys. I appreciate it. Thanks for having me. So we're going to move on to our next session. That's a two-hour session with some cases at the end. We're going to touch on airway, cardiac, vascular, and facial and dental emergencies, and then have an ortho panel. So I'm happy to invite Ryan Lingor from the New York Rangers to moderate the next couple of hours of our on-ice emergencies. Thanks, Darren. We've had an awesome schedule so far this morning, so I want to thank the people responsible for that. I'm really excited for this next session on on-ice emergencies, and we've got a great lineup for you. As the famous philosopher Mike Tyson has been quoted, everyone's got a plan until they get punched in the mouth. And it's one thing to have a plan, and a whole other thing to be able to execute that plan and to face adversity when seconds count and someone's life is on the line. So with that, our first speaker is Dr. Ed Berdusco, who's the head ER doc with Edmonton Oilers, and one of the team physicians, and he's going to be talking about airway management. Thanks, Ryan. Thanks, everybody. Pleasure to be here. As you see, Ed Berdusco, that's me. I am an eMERGE doc in Edmonton, and I've been an eMERGE doc in a tertiary care facility for over 20 years now. So I've seen lots of the craziness of a tertiary care eMERGE. There's not much that goes on in my eMERGE where I'm comfortable that makes me worried these days. But when you take me out of there and put me in a rink, there are three things that make me worried. The first is a cardiac arrest on the ice. The second is a big vascular injury, in particular, to the neck. And the third one is an airway injury, and in particular, a blunt airway injury. So somebody gets injured by a puck, something else that causes an airway injury. And that's what I'd like to concentrate on today. So I have no financial disclosures. The talk today, what I'd like to do is go through a case presentation, and then a bit of a background, and then some anatomy, a little bit about the management, and then a flowchart on treatment of blunt injuries, and then follow-up for the case presentation, and then we'll just talk a little bit about the wrap-up. So the case presentation here is a 21-year-old defenceman. He was in front of the net, slap shot from the point, went off his stick, up and hit him in the neck. So he was able to skate off and went directly to the dressing room. As you know, these guys, that's their safe place. They get injured, they go to the dressing room. So went to the room, complained of discomfort in the anterior neck and some difficulty swallowing. No real C-spine tenderness or no C-spine tenderness at all. He wasn't coughing or throwing up blood at all, and then had a little bit of hoarseness to his voice. So that's our case. So we'll talk a little bit about background now. Blunt airway injury, it's an uncommon injury. There's not that many, thank goodness. But it is a hockey injury, and it's a hockey injury because there's a fast-moving puck, we have sticks, elbows, fists, and even the blunt edge of a skate can cause it. There's a couple of reports in the literature of kids, one kid that hit the boards that gave himself a laryngeal injury. The anatomy of the neck is quite complex. We have airway, we have vascular, we have digestive, neurologic, and then there's also bones in there as well. I would say for any of these that preparation and practice is the key for these to treat any of these. And you have to do it. And I think that the debrief after that is so important as well, because you really have to go to make sure that all of the roles that needed to be fulfilled were fulfilled, so that you can make yourself that much better the next time. So a little bit about the anatomy of the neck. This is the larynx here, and this is the hyoid bone. This is the front. This is the back here. The thyroid cartilage, cricoid cartilage, the arytenoids are here. This is the cricothyroid membrane, so when we do a surgical airway, that's where we try to go into. And this is looking down from the top onto... These are the vocal cords and onto the larynx. There's the epiglottis here, there's the thyroid cartilage would be out in the sides, arytenoids at the back here, and then this is the esophagus down here. And then we've got the vertebral bodies down here. So if they got hit by a puck on the front here, they've got a hard object coming into the front, and they've got the vertebral bodies all lined up at the back. So this is what takes... Where the injury occurs is the crush of the larynx there. So when we talk about airway, we have to think about both oxygenation and ventilation. And some interventions that are relatively simple to do to improve oxygenation and ventilation, assuming that your C-spine is clear and that the helm has been removed. You can certainly apply oxygen. You can do a chin lift where you pull up underneath the chin, extend the neck out, a jaw thrust, two fingers behind the angle of the jaw. You can put in a nasopharyngeal, and that's this one here, or an oropharyngeal airway, oropharyngeal to again lift the structures anteriorly in the neck. You put a bag valve mask on to apply a little bit of positive pressure, and you can use the supraglottic airways or an eye gel. Although in the setting of a laryngeal injury, a little bit concerned with putting an eye gel into an area that already has some distorted anatomy or possibly distorted anatomy. So beyond the basics of that, in the NHL room, we essentially have a trauma bay that's been put into our room now. And certainly through the last few years, it's been a huge increase in what we can do in there and the fact that the NHL has said, you know, you should have this, you should have that. So IV access, we have all the monitoring there. We have wall suction there. I don't like the manual suctions. I don't find they work very well, but I like the battery-operated suctions. And then we can do endotracheal intubation. And when we talk about endotracheal intubation, we have four main reasons why we do it. Obtain and maintain an airway to correct the gas exchange, to protect the airway in someone that's got decreased level of consciousness, or to secure an airway early if there's clinical deterioration expected. And one of the things we worry about with laryngeal trauma is it continues to get worse, and that's where we would say that that's needed. Certainly we also think about things like a surgical airway there. We also have all the medications there. We have induction as well as paralytics for endotracheal intubation. So if there's an injury, we want to get the athletic therapist to the player as fast as possible. If the player is able to skate off, usually they are with this injury, you want them to skate off and then take to the dressing room if they're able. And then we want to look at some of the signs and symptoms of injury. And for a laryngeal injury, some signs that we see, some anterior neck swelling, some laryngeal tenderness, tracheal deviation, a respiratory distress, some abrasions or a laceration on the neck, subcutaneous emphysema or the Rice Krispie sign, and then drooling, which means that they're unable to handle their secretions. So you'd really worry about something going on then. Some of the symptoms that we have, there's hoarseness, hematemesis or throwing up blood, hemoptysis or coughing up blood, some dysphonia, it hurts them to talk, and then stridor or a cough. And these are the big, you would certainly look at those and go, something's going on here, we need to do something about this. So in a professional league, after we've got the player in the triage room, we would do an examination, get some vitals, start an IV, and ensure that EMS is alerted. And when we're there, we know that it's easy to get EMS because they're right there. We just have to say EMS to the dressing room over the radios. Then we prepare for transfer, because we know we're not keeping that athlete there. And then we also prepare for an advanced airway, and then I would make, or whoever is the emerge doc on for that night, would make a call to the receiving hospital, letting them know sort of what's coming in. In a non-professional league, certainly again, get the player off the ice, ensure that the C-spine is clear, do an exam, and alert EMS. Again, the EMS is going to be your friend. This could also be during a practice as well, that EMS has to be involved right away there. And then prepare for transfer. If there's any airway compromise, you want to start with your easy stuff, so oxygen, chin lift, jaw thrust, OPA, or an NPA. So from a flow chart here, if we have an airway injury, we want to get them to where we can work on them. If we have to work on them on the ice, we will, but take to an area there. If there's no obvious injury but a really good mechanism, I think those players still need to be transferred. The downside to missing an injury with a delayed compromised airway is huge, so you'd want to make sure that all of those players get transferred. If there are positive signs or symptoms that we just talked about, but the player is protecting their airway, I think we just transfer them urgently, so we get them underway right away. If there's airway compromise, we're going to start our airway adjuncts, as we discussed, and then we're going to set up for our intubation. And we'll do this while we're doing this. If we have a successful intubation, again, we're going to continue sedation and transfer that patient. And I think that all of these should go to a tertiary care facility, where they have ENT and they have all the specialties that you need. If it's unsuccessful, then you would do your cricothyroidomy or tracheostomy, and then again transfer. And any time that you set up for the attempted intubation, you should also be setting up for your surgical airway as well. So to continue our case presentation, the player was protecting his airway, discussed with ENT at the receiving hospital. They asked for dexamethasone to be given, which is a steroid. Was transferred to the tertiary care facility, underwent CT and endoscopy. CT demonstrated no fracture, but when they did the endoscopy, they described a lazy left vocal cord. So he did have an injury. He was kept overnight for monitoring and then returned to play shortly thereafter. This is the CT of the player. And on the right, this is a normal vocal cord here. And you can see that this one here is just not the same as this one. And that's what was described as that lazy vocal cord. So as a wrap-up, blunt airway injuries are uncommon. Thank goodness. There's multiple structures in the neck, including airway and vascular. Airway maneuvers such as a chin lift, OPA, NPA may be of benefit. And there may be a delayed swelling or compromise. So we need to maintain a high index of suspicion with these injuries. And investigate all injuries with a significant mechanism. I think that intubation and cricothyroidomy are also available at the NHL rink for compromised airway. And you really need to practice these injury scenarios again and every year to make sure that we get them as well as run as we can. Thanks very much. I would also like to thank Colleen Chelland, who is one of the other eMERGE docs that works with me, for her help with this. And Duran as well. Thank you. That was great. Any questions for Dr. Berdusco? Okay. So we're going to continue on with our next speaker, Dr. Kenton Feibel, who's joined us from California. Dr. Feibel is the medical director and team physician for the Anaheim Ducks. His actions, along with the team that he leads, saved the life of Jay Beaumeister in February 2022, I think it was. And who had a cardiac event on the bench at an away game in Anaheim. So, Dr. Feibel, thanks for joining us. Thanks so much for having me. I wish I could be there in person, but honored to have an opportunity to present today. So, I'll get started. I have no disclosures. I'm going to start with a video of what one of these events might look like. So, I'm going to start with a video of what one of these events might look like. And so just briefly I'll touch on again the role of an EAP. I know you guys had a great talk already earlier this morning, but it really is important to stress that within my shared or my experience and then also just again some key points at the end. So again, as you guys heard earlier today, I mean the role of an EAP is really to have some pre-planned actions as you're really trying to respond to these life-threatening catastrophic events. It's the only way that you can be prepared in any way. All these can be very different at different times, different places, but the more you can establish protocols, define roles, maintain standards in your equipment, have good teamwork and collaboration with your own staff and your EMS services, and then really to create an efficiency so that you can stabilize this patient before they get to a higher level of care. Again, you want to identify necessary emergency personnel, where your personnel is going to be located in your venue, their role delineation, emergency equipment necessary, location of where this equipment is, what your communication system is going to be, and then directions for your EMS. When we look at chest trauma and sudden collapse, you really want to focus on those chest compressions. And so I always remind people really your CABs, you really want to focus on the circulation and the chest compressions initially are going to be enough to move that air in and out of the lungs. So again, really stressing the importance to get on the chest as soon as you can. When we look at, again, the data as far as survival, the sooner we get on the chest and begin chest compressions and you get your AD and potentially defibrillate, this is your best chance at increasing that survival. And so really every minute that goes by, you're losing another 10% or so for this athlete to have a positive result. And so, again, I think it's just stressing the importance that time is critical. And that, again, is why the EAP and any practice that you can do with your organization, with your staff is very important. When we look at a cardiac trauma or collapse, always want to assume the worst, right? So someone goes down, you want to check their carotids. It's the best way to really assess whether they have a pulse. You don't want to waste any more time than 10 seconds. You want, again, as we talked about earlier, as far as beginning with your compressions, which are more important initially, and your goal is to have that AD on the chest within minutes. And again, the sooner, the better. You should at least defibrillate once before trying to move the athlete, just because time, again, is of the essence. ADs for other venues and other sports is okay in the rain and snow, so not to be afraid of that in bad weather. Obviously, in hockey in a closed arena, that may be a little bit different. But you want to attempt several rounds of really CPR defibrillation prior to attempting to transfer the athlete. Of course, this can vary, but this really just has to do with the type of quality of CPR that you can administer while you're moving someone and getting them on a gurney. So usually where that athlete is as best you can is really where you want to attempt to do this as quickly as you can. Looking at a couple of entities, so blunt cardiac contusion, the results can vary. This can be ranging from asymptomatic to EKG changes to sudden death. The thought is that children are more susceptible just due to chest wall compliancy, and this can happen in a variety of sports. I'm going to show this video that was in 1998, a playoff game between the Red Wings and the Blues. I talked to Chris just to make sure he was comfortable with showing this, but I want to, again, play this and then we'll talk through it. So Pat's going to go across the defense when he's going to take a slap shot and hits Chris Prager directly in the chest. As you can see, it initially goes down and then gets up. And so he's just gone into cardiac arrest here. And so this is similar to what Demar Hamlin and the Buffalo Bills experienced last year. And so commotion coronis can happen with blunt trauma. It can be minimal impact, and it happens when you have that trauma that is just before the peak of the T wave in the cardiac cycle. And so you have brief periods of consciousness as you saw, and not to be fooled that this is something that is benign, but these athletes will tend to take a few steps and initially stumble and then suddenly go into defense. So it's important to recognize that this athlete is in trouble. The best way to really resuscitate them has been shown in the literature is really getting that AD on as soon as you can to defibrillate and start your CPR. For Chris, he actually didn't require defibrillation. He was actually, from my understanding, back in sinus rhythm by the time that they had gotten to him and transferred him off for this entity because there's no significant cardiac abnormality. As long as there's an appropriate workup and you feel like you've ruled out any more significant issues, there's really no long-term exclusion from return to play. And so actually a couple nights later, he played in the next playoff game. I'm again going to play this video, which we started with, which was actually from our event that happened, oddly enough, against the St. Louis Blues as well. And this happened on February 11th of 2020. And so this was actually during a TV timeout. And so again, we don't get to pick and choose when these events happen. So this was during a TV timeout, and I'll talk through it. It's a player on the opposing bench. So Jay Bowmeister was just grabbing a drink of water after completing a shift and went into sudden cardiac arrest. Joe Huff, our trainer, is running over. He sees that their staff is already there with them. The players clearly are recognizing they're trying to move the bench. Joe Huff knows his role, and he's now trying to help properly remove the bench to give us more access. Our assistant athletic trainer at the time, Chad Walker, is putting his fist up and waving over from our physician sitting in the stands after he had already gone over to alert our EMS that's over by the Zamboni. So again, a replay showed that he appeared to just be grabbing a drink of water after his shift and then slowly fell to his left side on the bench. He had suffered a cardiac event, and after successful resuscitation measures, he was taken to UC Irvine Medical Center, which is our level one trauma center, where he underwent additional testing, and then he eventually had an ICD placed. Again, this leads back to the role of your EAP and why practice is so important. Joe Huff, who went over to the athletes, saw that their training staff was already with them. And so his role at this point was to give us better access. And so as the players are trying to help, you can see how that bench is not in a great position, and so Joe understands that he needs to go over and remove that portion of the boards. Our other athletic trainer, again, recognized that there was already a tension with the athlete, and so his job was then to activate EAP and to notify the EMS as well as our physicians in the stands. I like to show this picture because it's just important to recognize that you need to know your venue well. It may not happen in your home arena. It may happen in a visiting arena. It may happen in your practice facility. And so these are just important to recognize how you're going to get to this athlete. The green arrow is where the ER physician was sitting, where he came down from the stands onto the ice. I usually am sitting closely behind him, but was actually seeing another athlete in the dock room. And so I'm actually the orange arrow that's coming underneath from the tunnel into the visiting bench from that direction. And then the red arrow is from our EMS that's coming out from the Zamboni tunnel. And so, again, these things can happen any time. As I said, they can happen in locker rooms on the ice. They can happen in your practice facilities. So it's always important just to remind yourself that the game is continuing, even when there's maybe not action on the ice. This was just during a TV timeout, and so it's always just being aware of your surroundings. I always discuss with our ER physician consultants that, you know, try to be in your seat as much as possible, or we understand that sometimes you're getting, you know, something to drink, or sometimes you have to use the restroom, but try to have your phone on and have some way of communication. And then, again, emergencies can really happen at any time. This is just showing the teamwork that's going on. So, again, this is just showing the teamwork that's going on. Again, we have practice sessions at our annual meetings and at our home ice facility, and also at our practice facility, and sometimes you're going to have different staff and resources as well. So, again, this is just showing the teamwork that's going on. So, again, we have practice sessions at our annual meetings and at our home ice facility, and also at our practice facility, and sometimes you're going to have different staff and resources available. So, when we do practice at our practice facilities, we like to have people that will be there versus what may be available at a game. It's important just to have your familiarity and preparation. Attempt to have everyone present, including team medical staff, your trainers, your therapists, your physicians, your ER physicians, your EMTs, your building security, and just keep practicing. You have new additions to staff each year, I'm sure, and so just making sure everyone's comfortable and familiar with your protocol. Have an open discussion regarding medical devices and the emergency bag and new additions, such as the Lucas chest compression device, and then discussion of logistics regarding resuscitation and when you're wanting to transport. You really want to run through your EAP from beginning to end, because with this athlete, the resuscitation didn't just end, and our EAP didn't end once we were able to resuscitate him. So, the end isn't just when the athlete leaves the ice, and the end is not when the athlete is in the ambulance. It's important to talk through the full scenario leading up to their arrival at the hospital. Where is the ambulance going to be parked? Who has keys to the ambulance? Simple things that you wouldn't necessarily think can be important. Maybe the person that has the keys to the ambulance thinks he's going to be helpful by doing another task, and meanwhile, you get this athlete to the ambulance and there's no keys. Who's going to go in the ambulance? You have to talk through these. The game can't proceed at the NHL level without having your ER physician or your orthopedist or medical doctor there. Who's going to be able to open the building exit for the ambulance, your building security? This is really important. Who's going to be able to unlock any gates to exit the parking lot? Who's going to be in charge of notifying the building security to ensure all necessary gates are open and locked? And then again, there may be different people there at different dates, so who's going to be backup or alternate for some of these key roles? Again, as we talked about the importance of speed, and so because of all the practice and all the teamwork, I'm proud to say that we were able to defibrillate Jay under two minutes from the time of collapse. I just want to just show this. I'm sure a lot of you are already familiar with this device, but this is one that we always have with us. We didn't use it that night, but you can see it right there by us in case we needed it. The Lucas chest compression system allows you to deliver uninterrupted chest compressions at a consistent rate and depth. It can be used in the field, during transport, and throughout the hospital. It's important to continue quality CPR as this athlete is being transported from a plane surface onto a gurney and into the ambulance during transport. This was a study that just confirmed what I think everyone who's familiar with these situations would say, that transport chest compressions are significantly worse than on-scene chest compressions. And so again, when you're trying to get an athlete onto a gurney and then moving the gurney to do quality CPR is extremely hard. And so this device, I think, has a role when, one, you have a prolonged resuscitation measure, where maybe you don't have enough people available to do really good quality chest compressions. It can be valuable, and then also during transport. One experience or one thing that we learned after we sat down afterwards and everyone talked through the resuscitation measure is that it's helpful to have more than one gurney. With hockey, these gurneys actually, although they enter from the Zamboni tunnel onto the ice, they do not fit through the bench doors. And so we now have a gurney that's on the other side behind where the tunnels would be for the opposing bench and our bench, as well as a gurney on the Zamboni entrance where we've typically had it. But this, again, saves time of having to move that gurney all the way around and can allow you to transport athletes, whether it happens in the locker room or the bench versus on the ice. Lastly, I just want to recognize the emotional impact these events have. Obviously, your goal is the athlete who's suffering the cardiac event, but it's really important just to recognize the emotional impact that it has for the athletes, the coaches, the fans, everyone who's there. And so I do recommend afterwards, which is what I did, to really address the team, the staff in an appropriate setting, and then offering any services if people are struggling with anything that they might have been part of or seen. And some of these athletes are extremely close with each other, as you know, and many of the families are close with each other. So it's just really important to recognize this aspect. Lastly, I'll conclude with EAP. There's some key points. EAP requires teamwork. It requires dedication. I appreciate the dedication from all of our staff, including those who weren't present that night, as they all deserve credit for the success. And it requires practice. Only practice can help reduce anxiety and allow for an efficient employee response in these emergency scenarios. EAP requires composure and maintained humility. Sometimes you can't control the outcomes and you can only critically evaluate the response, control what you can, and strive to improve. This is the staff that was with me that night. And just to again thank the St. Joseph's ER physicians and the UCI medical team and our whole organization and building staff, as well as St. Louis Blues staff and all the people that really were helpful in integral parts of that night. Thank you. Thanks, Dr. Feibel. We'll just take a minute for any questions from the audience for Dr. Feibel. Well, this is Tony Colucci, Kenton. How you doing? Good. How are you? Good. So, yeah, I think a couple of points. I mean, we discovered the same thing you did when Phish went down in 05 was the gurney. We had to have two totally equipped gurneys, because on this side, on the locker room side of the benches, that gurney doesn't go through. So what's hard is the financial, again, NHL-wise, it's a struggle even to battle with the providers or the EMS system and say, I need a full equipped gurney for both between the locker rooms for the inside of the bench. And then for the ice, there's a whole other gurney totally equipped with monitor. That's a challenge, I think, with people that don't have the revenue or the income to finance that. The other thing was one of the beginning slides that you showed, very revealing about the importance of adequate quality CPR and the ability to sustain viability and CPR cardiac arrest. Yeah, absolutely. I mean, there's always going to be those challenges, you know, at different levels. But thankfully, we were fortunate to be able to install some of these things. But I agree with you that that certainly is a challenge of what you have available. And same thing with the Lucas device. I mean, that's not a cheap device. And so having this stuff available as much as you can, at least talking through some of the ability to make this maybe part of the team's budget in future seasons might be just helpful. Thanks for the comments. And Dr. Harmon. I don't think the online community could hear that. The question for Dr. Harmon was if Kenton if you know the underlying pathology that caused his cardiac arrest in this case. Yeah, I mean, there was, I can't share the full details is probably for for privacy reasons but but nothing that I mean in general really nothing that that we have a great idea of an exact ideology or cause he was feeling well in the timeframe before that there was nothing that the athlete and the training staff that had any, any concerns or thoughts or any prior history or for reasons for it to happen. So I mean I think that's the case for a lot of these I think you know is as healthy as all these athletes are and and big and strong you never know and these events can happen with people that it's not always, you know, there's an underlying issue that you're aware of. So, I think it just highlights the importance of just being always prepared and aware that this can really happen at any time. Okay, thanks Dr. Fidel. Okay, so our next talk gets introduced Dr. Dr. Duran they do and TD force that medical director and head athletic trainer for the Edmonton Oilers talk about vascular emergencies, who unfortunately have some experience of their own. Thanks Ryan, appreciate that. So far we've talked about the airway, the cardiac, and now we're going to do some vascular. So it's going to be a little bit of a combination here, myself, TD Force, Head Athletic Therapist, Athletic Trainer for the U.S. folks out there with the Edmonton Oilers, Dr. Duran Naidoo and Dr. Ed Bedushko. Duran, that's his funding, he's the CMO of the Canadian Football League, he's also team position of the Edmonton Oilers and the Edmonton Elks. Myself, I have nothing to disclose and Ed Bedushko has nothing but Ed said that if anyone wants to sponsor him, he'll see him afterwards outside, so you can talk to Ed then. Alright, we're going to run a video here of unfortunately one of our athletes, so go ahead and if you can run that. This is a player, if you could pause it there, made contact, fell to the ice and everyone's going to think it's his right wrist, but that's not what we're going to be looking at, we're going to be looking at his left wrist. There's going to be a player that comes in on the left hand side of the screen, an opposing player. His left skate actually goes into the torso area of our player, number 91, and then as it comes back out, you can see right there, he'll blow it up, keep it going. You can pause it when it's that time where he has his laceration. Just hold it there for a second. So you can see that player is slightly exposed, he doesn't wear wrist guards at the time, he didn't wear wrist guards, but now he does, thankfully, but that's quite a bit of a gap. You'll see players will pull up their jerseys up on their elbow pads so that it doesn't dangle down, but it just exposed it there. You can let it run through, you can see the blood that was on the ice, and then take a look at our player's face. All right, some initial thoughts as a therapist, so I'm going to speak as a therapist. As you can see in the video, player panic, something like this that happens, they look down and they see their flesh and a bunch of blood, they are going to panic, and that's what he did. The good thing is that he did go to our bench, that's where, as someone's mentioned earlier, the players will tend to go is right to the bench. Our player, actually, I jumped down from behind the bench to go see our player, and he ran right, or skated right by me, into the bench and down the hallway. It was in Tampa Bay, and my third point there is the unpredictability of this, is that he ran down the hallway, and he's been there many times, a veteran, 14, 15 years, he knows where the training room is, he got to the end of the hallway and didn't know where to go. Luckily, I caught up to him, on the left-hand side was the player change room, where they get out of their suits and stuff, but on the right is the locker room, and in the back of the locker room is the training room, so I actually had to tell him, turn right, turn right, turn right. He ended up going through into the locker room, into the training room, and that's where our team physician and our assistant was, and then where the paramedics ended up coming. So let's just talk, again, I'm going to be talking from a therapist's perspective. I like this diagram on the right, it was shown to me at one of our NHL meetings, it kind of gives an idea of what to do for certain areas of the body. The red is areas to pack, chest seal is the blue area, and then the tourniquets are what you consider if you needed them on those extremities. Many of our speakers have talked about that emergency action plan, so I'm going to talk about preparation. Number one I have there is the emergency action plan. If you're someone that doesn't have all the qualified people that we do have available, if you have your emergency action plan, you're going to be able to help that athlete. One of the things that you have to have to be prepared is gauze, so your abdominal pads, your roller gauze, and your combat gauze. A tourniquet, have that with you as a therapist, have it accessible and open. What I mean by open is that most of these tourniquets come wrapped in some type of cellophane or tight wrap, and you have to have that open and ready to go. If you don't have that open and ready, it's like trying to take off the little top of the plastic of those Heinz bottles that when you get to the restaurant and it takes you like three minutes to get it off, well imagine doing that when you're in an emergency. So have that off, and then in the back of your mind just think about what would you do if your player goes into panic and eventually shock is a possibility. So this is just sort of repeating, what are we going to be using, are we going to be using towels or the abdominal pad and the gauze, obviously we're doing the two on the right. So just walking through when we have a vascular emergency, specifically on an extremity, first thing you want to do is apply direct pressure with your abdominal pad. Get that athlete to a place that they'll be calm and that you can take a look at it, that you've got good lighting. Determine the source of the bleed in the wound. So in our case the wound was almost four or five inches long, and so where is that bleed coming from? Is it coming from proximal, is it coming from distal? You got to find out where that is, and what you might actually have to do is remove that abdominal pad to see where the bleed is coming from. But it's important to know where that is. Then when you get your combat gauze out, you want to start to put direct pressure with the combat gauze where that source is, and you want to keep that pressure. Keep it the whole time while you put short lengths of the combat gauze into the wound. Now you can do it alternating hands by keeping pressure on the area where the source is, or you can just keep the pressure with one hand and feed it with the other. Completely fill that wound with the combat gauze, and once it's completely filled then put an abdominal pad or other gauze on top of it. Hold it. Hold it for three minutes. And the reason we're holding it for three minutes is so we can let all the chemicals in that gauze activate and do their job. Then you apply a pressure dressing over top, and then secure that with roller gauze or whatever other product that you have. So talking a little bit more about the tourniquet, you want to keep them accessible. I got the number two there. You want to always have two at least. We'll talk about that in a minute. But you may want to have more depending on your situation. As a therapist, you want to have one on you for sure, and then you want one likely in your medical bag with your assistant if you're fortunate enough to have one, and also one if you have a medical room and you want at least one in there. As I mentioned, be familiar with it and ensure it's open and ready to go. So when should I go for a tourniquet? Well, these are the guidelines that we'd recommend. With major blood loss, whether it's expected or it's occurring, for example, if your direct pressure on it is not controlling that bleed. If you're in doubt, if you're, as a therapist, you're thinking, hey, should I possibly put on a tourniquet to this person? You probably should have done that already. So make sure you go ahead and do that. Once your tourniquet is on, it stays on. And a question we often get is that, you know, can I put it over clothing or padding? The preferred and the recommended is to put it directly on the skin, and you definitely wouldn't want to put it over any padding. Case dependent, of course, with the clothing. Another question, if the bleeding isn't controlled with the tourniquet, you have to make sure that you put your tourniquet on properly. Obviously if this is the first time that you had an emergency, maybe you haven't put it on properly. Or the second thing you could do is put on an additional tourniquet. And another question we get is how high and how tight? Well, you want it all the way up and as snug as you can. It should hurt the athlete once you get that thing tightened and snugged on. Obviously you can check to see if the blood flow has been reduced or stopped. So just a couple reminders, again, from the therapist's perspective. Have your abdominal pads and your combat gauze available. Make sure you know where your tourniquet is and know how to use it. In our case, our player did start developing shock. So we were able to get the oxygen on him and curb that. But be aware that your athlete may develop shock, whether that's from actual blood loss or just from the shock of actually having the injury. And get them to advanced medical care. My last slide is just talking about some protection, things that you can use for your athletes if they have places exposed. You could use tape. Obviously that's not the preferred, but it is something that can help minimize it. You want the cut-resistant materials. You can see some of the ones on the top of that picture, the sock, the wrist guard and the undergarment. There's more and more coming out every day. More and more athletes are using it. And the last thing is you can put a hard guard over it. This picture on the bottom is a picture post-injury. When our player was back, he had a little bit of neural sensitivity in the area. So we actually put a little hard guard over that area. And he did, thankfully, wear wrist guard protections from that. Duran, I think you're next. Sure. I just had a couple slides. I just wanted to say in this case, as a team physician, we do travel with a physician in Edmonton. So there's many different specialties. And really, your job is to round the troops. We've got a well-organized system in the NHL. We have, obviously, have you heard, ER physicians. There's EMS that's activated and hospitals that are ready. And basically, to reinforce the basic principles of controlling bleeding while trying to safely identify the structure that's bleeding. And really, in this case, we had nerve, tendon, muscle, and bone all kind of as areas that were injured. So really, the role was really to make sure our eMERGE docs were coming from a TAMPA perspective. And with the well-organized NHL system, we did have that. So just next slide, TD. And then really, also in the post-operative communication, obviously, the surgeons in TAMPA took care of our player. And then we had local medical experts in Edmonton. So really trying to facilitate them to chat and using this information to help guide the player. And then as a team physician, the player usually knows you as the most familiar face. So you really have to synthesize that information. And fortunately, this player was able to return amazingly 10 weeks after the injury and didn't really complain a whole lot after and nothing until last season. So the next thing we're going to do is, for the next slide, is have Dr. Berdusco come up and just chat about vascular injury to the neck for about five minutes. Hello again. I'm still looking for disclosures, if anyone has any. So I'd like to talk a little bit about some vascular injuries here. And as we know, there's been some significant injuries in the past and then, of course, the recent tragic Adam Johnson injury. The carotid artery and jugular vein from a neck perspective, relatively superficial vessels and they're in close proximity to each other. The vein is over top of the artery. And the cerebral blood flow is about 750 mils per minute and approximately 15% of the cardiac output. In a usual human, most of you out here probably have a cardiac outputs right now of around 5 to 6 litres per minute. But in an athlete that's exercising, that can go up to as high as 35 litres a minute of cardiac output. So for my American friends, the 35 litres is a lot. So what I've done there is put a jug and that jug is a 5-litre jug. So that's kind of what our blood volumes are. And that jug is 7 inches wide by 14 inches high. So that's not that much blood that's in there. And when you think that an athlete's got 35 litres going around, if you think that 15% of that is going up to the head, that's about 5 litres or that thing that is going to the head every minute. It's a very large amount of blood. So you realize that you really don't have much time when you're talking about vascular injuries to the neck. They can bleed out in a couple of minutes. So the jugular vein, low pressure but high flow, okay, deoxygenated blood. So it's got that dark red blood corpuscle. On the artery side, high flow, high pressure, oxygenated blood, bright red. So those are going to be our delineating characteristics. So a cut has happened. You got to get to the player. So this is the important thing. You've got to get them either to you, as again, player gets injured, they skate off, okay, or you've got to get the athletic therapist to them. You're going to get them, you're going to have to get that player down because you have to look at that wound and you have to be able to apply pressure and you can't apply pressure to somebody that's standing up, not enough that you'll need. And then you want to get that exam to decide if it's venous or if it's venous and arterial bleeding. If it's just venous, you want to start packing that. So you're going to look, you're going to see that it's dark red blood and it's not really coming out under pressure. So it's not spurting past your shoulder, okay. So you're going to take your gauze and you're going to put gauze in to the bottom. You're going to take gauze in the other hand, you're going to put it over top and you're just going to keep doing that until you get that wound packed. And then you're going to keep pressure on that. So the person that starts packing is the person that keeps pressure on that wound, that you don't hand it off to somebody else. So and that's, they go with the player to the hospital. In a carotid artery, so again, high flow, high pressure, this is where you take a look, you've got bright red blood, you've got it spurting over your shoulder. You say, okay, we've got to get this under control. This is with one gauze and pinpoint pressure. And as soon as you put your finger into that laceration, you start going by tactile sense then. So you're going to feel for where it's spurting out of the artery and you're going to put your finger with the gauze over top of that area. And then you're going to have somebody handing you packing and you're going to pack all around your finger. Then you're going to let your finger off a little bit to allow flow to go back through that blood vessel so that you don't have anything distal to there with no blood flow. We don't like strokes. We want to minimize them. And then again, travel to the hospital with the player. So if this is happening in our arena, I've already discussed with TD that I would like him to be the one that is doing with his finger or has pressure on there. And the reason I say that is because as soon as we've got control of the vascular, I'm going to start thinking about airway and we're going to think that I'm probably the one that's going to be doing the intubation. If it needs to occur. And I don't want to take me out of the equation for that. So I've let TD know that the therapist is going to be the one doing the pressure. And then of course we would talk to the hospital, the sending hospital. So from a wrap-up, be prepared. Get help. These are going to be something that you're going to need lots of people in on, teamwork. And these are things you really need to practice. Again, as we've said time and time again, practice, practice, practice. Thank you. That was awesome. So our next talk is Dr. Guy Lanzi from the Philadelphia Flyers, who is the team physician and oral maxillofacial surgeon is going to be joining us online. So thanks for joining us, Dr. Lanzi, the floor is yours. Can you hear us? I can. Can you hear me? Loud and clear. That's perfect. Great. Terrific. Terrific. So like Kenton, I wish I was out there with you guys, couldn't make it, but really look forward to presenting this material. After airway and cardiac and vascular, this may be a little bit mundane, but important nonetheless. I'd like to talk to you about on ice emergencies, facial and dental injuries. Can everybody see that? Yes, we can. Absolutely. Why don't we just get started? Maybe. Go to the middle one, the slideshow right there, I think might do it for us. Are we good? No. All right. Can you advance it to the next one? I cannot apologize, guys. You go right there to slideshow in the top, the sixth one over? Yeah. Does that work for you? No, it's not working. Screen sharing. How about if you just click on your second slide over there at the left? Go to the bottom and that little screen, the slideshow bottom at the bottom by the volume, all the way down to the bottom. How about now? Can you guys see it now? We're still seeing its title slide. We see the title slide. I'm seeing my advance. Okay. How about now? You guys good? Double click on that one. Yeah, we're good now. We can see the second one. Okay, I apologize for the technical snafus. Um, again, I'm going to talk to you about facial and dental injuries. I'm a private practice oral and maxillofacial surgeon in Haddonfield, New Jersey. But I've had the great pleasure of being the team physician for the Philadelphia Flyers hockey team since 1993. Aside from that, I have no financial disclosures. This is a very broad based topic. So I've included with your packets, a PowerPoint presentation with a lot of treatment options, return to play issues and a little bit more detail. So this is basically a concise overview of that. I sort of divided the face into three sections, the upper face, the middle face, and the lower face. In the upper face, I want to talk to you a little bit about eye trauma. Fortunately, or maybe unfortunately, because a couple of eyeballs had to be lost for this to happen. But fortunately, now we've gone to face shields and cages in the other legs. And that's done a lot to significantly reduce eye trauma. But we can still see some of the simpler injuries that you may see, including corneal abrasions and hyphemas. Corneal abrasions are just a damage superficially to the cornea. They're very painful. They're pretty unmistakable when a player gets one. It's severe irritation and discomfort. Hyphema is a little bit more serious. It's a rupture with blood in the anterior chamber of the eye. Corneal abrasions can be taken care of pretty simply, but both of these injuries are referred out for treatment. Orbital fractures, such as orbital rim or blowout fractures, are rare with shields, and especially with cages. But you can see orbital fractures in our game with zygoma fractures and with direct cheek trauma. Usually, the etiology is a puck or a fist. Diplopia and limited eye movements may tip you off to a fracture, and you need to hold a player out and refer all of these for immediate evaluation. Ear lacerations are most commonly these days from direct trauma to the ear flap area of the helmet. Usually a puck, could be a fist. Superficial skin lax can be glued or sutured. Deep lacerations involving the cartilage or partial avulsions of the ear usually need to be transported for layer closure and pressure bolster. Hematoma needs to be avoided in ear lacerations to avoid cauliflower ear deformity ultimately. And ear contusions can also lead to hematoma. So even if there's no laceration, if there's significant ear trauma, the player needs to be observed for a few days. In the middle face, lacerations these days I find are from the shields to the nasal bridge, the most simple lacerations. And they occur pretty commonly. So it speaks to keeping the helmet on nice and tight. Simple lacerations are easy to take care of. They can be glued. They can be steri-stripped with skin adhesive like benzoin or mastisol. Or if they need be, they can be sutured. Deeper lacerations, we need to think about hemostasis with Surgicel or some similar hemostatic packing and then definitive treatment. Deeper lacerations may need to be held out of play and sent out. The NHL typically would do them right in the arena. But in non-professional scenario, they probably need to be sent out. Layered closures for deep laceration is very important. Deep sutures are very important to decrease dead space and approximate the wound. If you look at the nastiest lacerations, if deep sutures are put in, it almost looks like the skin is closed already. And so that the skin sutures are just for approximation, not so much for the wound strength. With deep lacerations to any part of the face, you have to keep in mind injuries to deeper anatomic structures, depending upon the location and the depth of the wound. This could include canthal ligaments of the eye and the upper face. It can include nerve structures, large vessels, and can include salivary gland ducts as well. So keep in mind your anatomy. And if there's any doubt, refer it out. In the case of lip lacerations, layered closure is important if the laceration is deep or if it's through-through. By through-through, I mean from the skin into the intraoral area. From my point of view, closure of the intraoral laceration is very important, and antibiotics should be considered for through-and-through lacerations. And basically the way those lacerations are closed is the intraoral mucosa is closed first in a watertight fashion. The outside is then prepped sterilely, and then a layered closure is done, as you would any layered closure. Nasal trauma has been reduced with shields as well, but we still see nasal trauma. Obviously, we see nosebleeds and nasal fractures. We all know how to take care of nosebleeds. The best way to start is with dental rolls, pressure, ice, and the head postured forward, mainly because you don't want your player to swallow a lot of blood. If you're unable to stop the bleed, obviously you've got to refer. And a lot of times this may be a more serious bleed, a fracture. Posterior bleeds are notorious to not be able to stop. We don't generally see those in hockey, though. Most of the bleeds that we see are anterior. But if you have evidence of nasal bone or nasal septal fractures, those players need to be referred out. Nasal bone and septal fractures can occur with shields. Sticks can get under the shields, so you have to be aware of that. Obvious suspicion of fractures include nosebleeds, pain, obvious displacement, and crepitus when you palpate the nasal bones. If the fracture is minimal, non-displaced, you can protect the fracture and continue to play with a cage or a bubble if the player can tolerate it and if there's no epistaxis, if you've been able to control the nasal bleeding. Tooth trauma is a very diverse thing. I'm going to start off by giving my stump of mouthguards. They're key, even with shields and with cages. Mouthguards prevent jarring trauma of the upper versus the lower teeth, so they can obviously decrease teeth injuries. But they also prevent bite injuries to the soft tissue, especially the tongue. So even with a cage or a shield, I think mouthguards are key. I think they can also reduce concussions, especially with direct blows to the lower jaw. But they also help players brace themselves. And all of us have seen those players that don't see the hit coming and the head and neck are not braced. And those seem to be some of the more serious concussions that we see. Tooth trauma is very variable. You can have a minor chip that the player won't even tell you about, a minor enamel, or even a dentin chip. They can go all the way to the exposure of the nerve, which is painful, to complete separation of the crown from the root, to partial or total avulsion of teeth. Obviously, simple chips don't hold a player out. Nerve exposure is very painful and very cold sensitive, but can be easily anesthetized with local anesthesia into the gums adjacent to the tooth for player comfort. You can even inject a little local anesthesia or put topical anesthesia on an exposed nerve pulp and get the player comfortable. Tooth mobility is something that we worry about. We see it all the time. Sometimes it's not a big deal. Dental people grade it as 1+, 2+, or 3-plus mobility, and it has to do with how many millimeters the tooth moves. 1-plus mobility is not a big issue, and if the player has a mouth guard, the mouth guard's going to stabilize the tooth. It's not even really an issue. Most of these injuries, the tooth will tighten up on its own. 2-plus mobility means the tooth is moving 2 millimeters side to side. It's a player and trainer choice to continue, but there is a danger of further loosening, so I would protect the player, at least with a mouth guard, maybe even a cage or a bubble. 3-plus mobility, or a partial or total avulsion of a tooth, generally the player's out and to the dentist, certainly in the non-professional arena. In the professional arena, I would just be suspicious that the tooth is not somewhere you don't want it to be, like in the mouth, or somewhere in the oro or nasopharynx, or even worse, aspirated. Otherwise, I think if you have hemostasis and the player's comfortable with returning, obviously they can return and they go to the dentist the next day. If you aspirate a tooth, you're going to pretty much know it because it's going to cause significant airway irritation, but I like always accounting for those teeth. Always be suspicious of alveolar bone fracture or jaw fracture if you have loose or avulsed teeth. The alveolar bone is that part of the upper and lower jaws that actually house the teeth. So you can have an alveolar fracture without a jaw bone fracture, and if a tooth is 3-plus mobile, 3 millimeters mobility either way, there's almost always an alveolar bone fracture, so keep that in mind. But be suspicious if there's tooth mobility or alveolar bone mobility that there may be a jaw fracture as well. Cheekbone fractures are part of the midface. They're more common in our game than maxillary fractures. They still require a fair amount of impact, but a puck or a fist or a collision can cause a zygoma fracture. Players will have pain. They'll have facial asymmetry. You'll know about this injury. It won't be a cult. There may be an indentation of the face. There may be a step discrepancy that you can palpate in the cheekbone area or in the infraorbital rim. Some players may report a malocclusion or a difficulty getting their teeth together and almost always difficulty opening. And there are usually ocular signs, mainly diplopia. With a zygoma fracture, you can have associated orbital fractures as I talked about before, and these can include rim fractures or blowout fractures. Players out with this kind of injury. You can start with plain films in your arena or locally, but almost always you need a CT scan for diagnosis and for treatment. Fractures of the maxilla or Lefort 1, 2, or 3 fractures are very, very rare in our game, especially with shields or cages. I spent a lot of time in a level one trauma center in training and in my practice. These injuries are very high impact injuries, mainly motor vehicle. They're associated with significant pain, with swelling, with a change in the occlusion, and with mobility of the upper jaw relative to the face. So if you have one hand on a player's nose, another hand on his upper teeth, and you can move that upper jaw relative to the nose, you've got a maxillary fracture. Now a lot of times your players will come back from the x-ray with a report of a maxillary sinus fracture, or it may just say a maxillary fracture. The maxillary sinus bone is eggshell thin so that you can have maxillary sinus wall fractures. These are rare too with shields and cages, but these are not true maxillary fractures, not true Lefort type fractures. And sinus wall fractures generally do not require any treatment. If there's any doubt with any teeth, alveolar, or jaw injuries, need prompt x-ray and evaluation. Moving on to the lower face, lacerations are treated similarly. Glue, strips, or sutures for simple lax, layered closures for deep lax, or through and through lip lacerations. You will notice suturing a wound that even one deep suture is better than none, how it approximates the wound, how it decreases dead space, and how it decreases hemorrhage. Infection in these wounds a lot of times comes from a hematoma from dead space that wasn't closed. So it's important to put those deep sutures in. Even one is better than none. And again, with a through and through lip laceration, close the inside first and then work your way out. Tongue lacerations can bleed significantly, particularly if it's a subtotal through and through tongue laceration from a tooth bite. Definitely deep stitches are indicated in tongue lacs that are deep. The airway can be compromised with these kind of injuries. So careful observation for floor of the mouth, expanding hematoma, and elevated tongue has to be looked for. And it's a danger sign. Tongue lacerations and anterior mandibular fractures are especially airway culprits and especially a flail mandible. If you get a mandible that's fractured on both sides and at the corner of the mouth area, because of muscle pull of the jaw, that can significantly impact the airway. And these patients need to be transported acutely if there's any doubt, and certainly a same-day evaluation. Mandibular fractures are not uncommon in our game. The etiology is a stick, a puck, a fist, or even a collision. Susceptible areas are the jaw joint areas, the mandibular condyles, the lower canine tooth areas, because the canine teeth are so big they weaken the mandible. And in our group of players, especially the third molar areas, it is not uncommon at all for players to have jaw fractures through impacted wisdom teeth. So we talk to our players all the time about removal of impacted third molars early on in the offseason to lessen the chance of fractures. Suspicion for a mandible fracture, pain, alteration of the occlusion, difficulty opening and difficulty getting the teeth together properly, mobility segmentally of the jaw, and there can be open fractures in the tooth-bearing areas that bleed significantly. With these kind of injuries, the player obviously is out. Local anesthesia can help. You can basically put an oral surgical version of an X-fix on the mandible with wire or even floss, lasso ligation of the stable teeth on either side of the fracture. Put a wire or floss around teeth on either side of the fracture, tighten it up. It can greatly help with pain and with bleeding. So Dr. Lanzi, just not to rush you, we just have a minute or two left, just in the interest of time for the sessions. Great, next to the last slide. Clinical diagnosis for lower jaw fracture, inspection, palpation, crepitus, mobility, step discrepancy. By manual palpation, grab the jaw with both your hands and just wiggle around the teeth and look for mobility. Send them to the ER with all potentially problematic fracture. Arrest the bleeding and watch the airway. Fractures are out for four to six weeks and imaging is key. As the previous speakers have talked about, it's the brain and the airway and the face is close by. Thanks everybody. Thanks Dr. Lanzi for joining us and thanks to all of our speakers in the session. All right, so we're gonna do something a little different. I'm gonna call up our expert panel here. So Ed and Neil, Tom, Tony, Darren. T.D., why don't you come up too? You guys can have a seat. We're going to do, these are my disclosures. They're not relevant. So here we go. Maybe this will play again. This is probably kind of a familiar injury for all of us in hockey. And, you know, you can see this player down and you kind of go out to evaluate for a potential C-spine injury. I'm going to try to play this. This is what P-hats put together during the COVID year about spine boarding. So we'll go ahead and go through this. So why don't we stop the video right there. And Tommy, why don't you just tell me, first thing you're thinking when you go on the ice, down to athlete, not moving, where do you go first? Well, first of all, most times you're going to see the incident. You know, if it looks like there's some type of C-spine injury, obviously that's the first thought you're thinking. You know, otherwise, if you don't see it and you're, obviously your thoughts are, you know, your first thought as a player, conscious, unconscious, you're going to proceed from there, assuming that there could be some type of C-spine injury. If we do get to our player, and I know it was mentioned earlier, but our, you know, universal sign in the league that we use across the league is fist in the air. Fist in the air will, you know, bring everybody out there, your medics, your ER physicians, ortho and gen med. Or the other thing that we do is if we get to a player, we know there's a C-spine before we even get our chance, we get our hands and we take C-spine. Once we get our hands, that's kind of a signal as well for a full complement of staff to come out. So Tony, what are you doing? Your next guy out. As I'm sliding out on the ice to the player, I'm hoping that there's not an airway issue. Already coming with my A, B, and C plan as far as, or 1, 2, and 3 for an airway, seeing that the trainer most likely has stabilization of the C-spine. As I approach, that's one of my first things. Once he's got C-spine stabilization, my main concern is do we have an airway? Do we need to protect an airway? Is he breathing? So kind of go through that algorithm first. Once we've established that the player is protecting his own airway, breathing on his own, then we go right to the C-spine. And we start, paramedics, if I'm coming out, paramedics are coming out with that gurney that Kendall was talking about regarding all the equipment on it. And then we start preparing for spine board stabilization. Roll the video. We'll just walk through this, and I'll let it run a little bit. You leaving that helmet on, Petey? I would say, you know, in Canada, we would go the standard line, depends. But our, in Edmonton, our train of thought is usually if we remove the helmet, we're going to remove the shoulder pads as well. So that's what we would typically do. If we think it's safe enough, we will do that, remove the helmet, and then remove the shoulder pads as well. I like what TD said too, as far as it depends. You know, in our case, what we kind of practice in Tampa and in rehearsals, if it's a tight fit in the helmet, we'll leave it on. Obviously, the less movement, the better. But if the helmet is loose and the head could potentially move inside the helmet, then we are going to remove it as they did in the video here with the assistance of a second person coming in from the inferior angle to kind of take the head while you remove the helmet and then put your hands back on. So what, if I may jump in, so what we do in the ER, we have motorcycle accidents. Sometimes football players come in, and we have a motorcycle accident, and we have a motorcycle accident, and football players come in. If we're, we need to make sure we are able to have quick access to the airway, so we'll remove the helmet if there's, if it's pretty, again, that's our main priority, and we can always pad underneath the head if they have shoulder pads on to make sure we keep that in-line stabilization with the C-spine. But the one thing I would just say in terms of that, as you said, it depends, because the standard of care for the NFL athlete is to take the face mask off, and they, you know, different helmet, tight-fitting helmet, just an example of, you know, you don't want to be struggling with that, so that it's, I think it's, some of these helmets are not even on their heads. If I could add on to what Tony was saying there, once we come out and see that the airway breathing and circulation, or airway is good anyway, then I think that it's a good time for us to slow down. I think we're always in a really big hurry to try to get them off the ice, and I think that one of the things we've done in Edmonton is to make sure that we we slow it down at that point and make sure everybody is up to speed with what's going on. I just stopped to hear, like, if you've done this, if you've been around hockey, you gotta have skate guards on, or you're gonna end up, everyone's gonna get a little bit beat up, right? Yeah, it's probably one of the things we stress the most during our pre-season rehearsal with our medics, who typically aren't involved with hockey players and their daily course of work, but we, you know, stress the importance of covering those skate blades. The last thing we want is a secondary injury to someone that's actually assisting and providing care, so we keep the skate guards in our cart that we have on our bench, the bag that we bring onto the ice, and we also have a backup pair that our medics will transport with them on their cart as well. All right, we can roll the video. So here we go, and skate guards are going on. And we're going to stop it right here. I just, real quick, want to get the opinion of the panel, you know, because this is always a little bit of a debate. Do you guys roll the player and then put him back on the board, or do the straight lift and slide the board underneath? We do. Depends. Depends. The one thing I want to talk about is that since the league's instituted the pre-game, which we have not talked about yet, meet and greet, you know, except for the playoffs, but that's something that we always talk about, and we always decide that from the get-go with the visiting team. They have their doc there, too, and we say six-man lift. So last thing I think you want to have is a discussion with two training staffs, two medical staffs on the ice. So that's one thing we always decide beforehand. I'm not saying one's better than the other. I'm just saying we decide that beforehand. Yeah, I mean, I would say from my opinion doing this a few times, rolling the player and then back onto the board is, I think, harder. I mean, we've just figured we always have about a million people out on the ice, so doing a six-man lift is pretty easy. We can run the video. Who's putting a collar on him here, or just the pads? Well, that would depend on, you know, depend. Actually, who's in that situation? Typically, in our case, it would be one of the medics who's grabbing that collar from their kit and getting it prepared. So you're probably having EMS do that. But the collar can be really hard to put on with their chest protectors on, right? So that's, to me, I think that's your Venn diagram. So if your chest protector, I don't, a collar can't fit. And then we actually, we were testing it out, and it was just like, oh, wow, how do you make a neck move as much as you can put a collar on with, you know, a chest protector on? Let this. I believe in this one they have those lateral pads on for c-spine stabilization. And then off we go here. Unfortunately, I can't speed it up. I think the next part of this video, and maybe we can speed it up a little bit off. So yeah, keep going. Keep going. All right, so this is the hard one, right, I think. So any tips here, TD or Tom, on prone athlete? We can stop the video. Well, yeah, there are a few things that we were taught and we like to do is that, you know, we're lucky that our ice surface is slippery. So it is something that we can either roll the player right onto the board, which would probably be preferred. Or we could slide them over, slide them out of the way if they're on their back, and then just do the six-man lift. So those would be my two thoughts when looking at this. The thought that I'll jump in with here, too, is I know sometimes when you're putting yourself in that situation, you come out to the player, and you're not sure which way to put your hands. We were always taught, and I'm sure most people in this room have been taught to start with where your hands are going to finish, reverse it, and then take C-spine. So if I can give a real-life situation. So a couple years ago, my mom actually fell out of her bed. She lived with me for two and a half years, fell prone, had a C6 cord compression fracture with a central cord syndrome. Couldn't move her arms or legs at the time. My son, who's an ER doc with me, happened to be living with us at the time. But it's kind of what the textbook, I mean, as far as bringing one arm to the side, getting stabilization with the neck, doing the roll on the side that the arm is down, rolling her over. She got complete C-spine stabilization. She's moving all her arms and legs now. But it looks very cumbersome, but it actually works in theory and in reality. We can roll the video. So I think in this video, they're going to actually roll onto the board. And I think that's fine. We usually practice it. We'll actually roll them all the way supine and then do the six-man lift. And again, I think the concern is to get them face-up so you know what their airway is doing as quickly as possible. Just for, we can stop the video. You know, I think all of us are privileged here because we're working with a big crew of highly trained ER docs and EMS. Like for the people who are taking care of a high school team, I mean, how many people do you think you need to board somebody? Well, if you, you know, I mean the six-man lift, I think, you know, to Anil's point, you know, you got to make sure you don't drop them. So you're going to have to have enough personnel, but any slim crew or limited crew that you have, let's say you have three people would be, I'd say the minimum amount, one on the C-spine, two to help do a proper log roll. So three at the minimum. So you can grab any three people to get that person stabilized. I just encourage, like if you're taking care of a high school team and you're by yourself, you just hold the head until EMS comes. I mean, you don't have to be a hero and, you know, try to get somebody off the ice with two or three people. We can roll the video. Any hints here? So try not to let them slide back. All right. So just to, I'm going to advance this thing. A couple of quick things. I know this is a little bit of a religion thing, but board versus scoop, what do you think? I would just suggest, if you can, to train on both. And, you know, we are prepared to do both in Edmonton. We would lean towards the scoop, but yeah, train to do both. I think actually, even in Michigan and Southeast Michigan, I mean, most of the pre-hospital agencies are going to the scoop. All right. So we talked about helmet on and off. I mean, this isn't an issue for you guys, but you take care of high school or college players, you got to figure out what you're going to do with that cage. I mean, these helmets don't come off as easy. You know, they're usually still on. So, you know, I don't know if you have any advice. Usually we will flip them up and leave the helmet on. One of the hints is that thing then falls right back down. So it's kind of nice to tape it or, because you got to control that shield from coming back down. You know, you guys. Well, you're saying, what about goalies? Just because to Anthony's point, my son playing goalie, slap shot to his face. I was talking, I wasn't even, you know, watching, which is terrible as a goalie dad. And then game, he's head down, blood's all on the floor. So, you know, it's, you have to always worry about the ABCs. I hadn't, you know, so I mean, next important, but still to stress Ed's point. So, yeah, I mean, I had one other dad, you know, flipping out with the blood and I'm like, just don't worry about the blood. And I took the helmet off and I had to roll them over. That's, I mean, I had to just see where it turns out it was oral blood and it was just, you know, teeth and shit like that. But have you guys boarded a goalie? I mean, do they even fit on our boards? I mean, we all hope, have you even tried it? I was just going to say, if you use the scope or the scoop, they have a adapter that widens it out for goalies. So, and we can put a, make it longer, of course. So we have ordered a goalie and it's not an easy fit. The pads are probably twice as wide as the actual board. Yeah. Yeah. It's a, it's a challenge that we all kind of talk about and then just shrug our shoulders and hope it doesn't happen, but that is a hard, a hard thing to do. And just, just to add to that in Edmonton, as long as it's safe to do so, we'll remove those pads because we found when we put them in the ambulance, it really restricted, you know, where the people in the ambulance could go and what they could do. And so, kind of off their direction, they said, if it's possible to get those off, that's what we did. I think that's actually a critical point because we've, we talk everything in our EAP about what we do. And then when you talk to the EMS guys, what they do in the ambulance, some of the things are like, okay. And some are like, oh no. Well, if you're going to take the pads off as soon as he's in the ambulance, then we should be taking the pads off because we know much more about the pads. So that's something, it's another discussion that you should have. Obviously you'll have one person in the ambulance, but they're going to, you know, they're kind of running the show at that point. So that's a great point. And this is all discussions that happen in your practice during your preseason EAP practice that you go through these discussions, have that plan ahead of time. That way, when it really comes down to it, not to mention pregame, you know, where you go and introduce yourself and say, this is the plan, you reiterate it. So you may have a different ambulance crew who wasn't there, so. I think, and Ryan may know better, but I think it's New York state law that they have to put a collar on in the ambulance. So they're taking that chest protector off. So it's eventually going to have to happen on transport. Right, Ryan? Yeah. Right. So there's the, yeah. So we were like, oh, why would you want to get the board? I mean, but get them to their proper, to their, so there's a lot of state specific EMS transfer law or country specific. I mean, I think this is one of those things that especially, I think if you're going to take care of high school, college, where you don't have the entire army of well-trained staff, you really have to practice it a few times because it, once you're on the ice and figuring out how to do things, I mean, Aaron and Jeff are here, you know, we actually still drag our board across the ice with a rope. I mean, that's how we have to get our athletes off, you know? So, I mean, you got to practice it or you really look dumb trying to do it. So we'll go on to our next case, I think for this video play. Oh, maybe I got to advance the slide, did I? So this is just knee into the boards in one of our preseason games this year. The video is not that important, but, you know, I think what I wanted to talk about is guy goes, you know, feet first or knee first into the boards, you run out there, T.D. or Tommy. I mean, has it been a challenge? Oh, yeah. Yeah, it's okay. Has it been a challenge to kind of figure out what the diagnosis is? I mean, you know, whether it's hip, whether it's femur, whether it's knee? I'm just screaming on the ice, right? Yeah, fortunately, unfortunately, we've had this situation on the road. And, you know, the player was in a lot of pain, but he wasn't screaming, but he was telling me he's in a lot of pain. And I did ask him, and it's my typical question, did you feel a pop or crack? And he said, Oh, yeah, I felt a lot of pops. And then in his case, I just went straight to palpation. And he let me know where it was sore. You know, I couldn't feel any deformity, but just a minimal amount of pressure, you know, he and he was like saying, Yes, that was that's exactly it. That's where it was. So then we just deferred. And we just said, Okay, well, we're going to treat this like a fracture. And it turned out that that's what it was. So yeah, it's it. That's, that's sort of the way I would explain it. So specifically for femur, not in and you can talk about tibia or ankle, but but for the femur fracture, you guys even trying to do anything with a splint. In our case, we splinted him in the position which he was sort of sidelined with his knees and hips, you know, slightly flexed, we just put a pad in between it was the bottom leg, we raised the top one, and then we splinted him in that position. And then we we moved him on to the to the gurney backward picture here is is that guy coming off and that I think our EMS crew did a great job. I mean, they just basically, you know, put him on where he was most comfortable and and got him on the gurney and got off. I'm not sure I've had any luck with hair traction or any splint in the field for a femur fracture. Any comments on that? The one thing in terms of diagnosis, I would look at the resting leg and if there's asymmetry of the resting leg. If one leg is kind of pointing forward and one leg is abnormally externally rotated, then you're thinking of a long bone fracture. And I would still, I would be the guy holding the leg and pulling gentle traction to get him on the gurney. Because it's easy to watch him on the gurney, it's transferring to, you know, he's going to say ow, or she. Why don't we, oh, so there he goes right there. You can see him go. Like I said, I always think the hard thing is when you get out there and they're, you know, it's not entirely clear what's, you know, going on with a femur fracture. So do we want to pull up Dr. Anawat's slides? Yeah, come on up. So thanks, thanks everyone for coming. It's a great meeting. Really I love the multidisciplinary kind of approach. So this is a much less crazy environment because we're talking about femurs, knees, ankles, not, you know, surgically putting a pen in someone's neck, which, you know, I watched MacGyver once and I never want to, I wish, I hope, I wish Ed worked with us because, you know, but we've had our fair share of disaster. So this is, this is a, I do have a lot of disclosures, Ed, so if you want some I can give you some. How much do they worth? Well, you know, I'll tell you that later. So let's see if this vehicle, this is a play that happened this year. Player goes to the wall. So we were home and immediately couldn't get up, had serious pain. So I'll start with the person who knows this case the best. So tell me what happened. What do you think? And walk us through it. Well, from the bench, I saw the hit happen. Saw the hit, so it looked obviously unusual the way he went down. As I was going out there, I couldn't tell if it was knee, ankle, or lower leg. Could hear him yelling as I was going out there. So typically, you know, that's a little bit more serious. And once I got to him, all he was saying were some choice words and some in English, some in Russian. I saw where he was grabbing and my first thought was, let's stabilize that lower leg. Fist went in the air and, you know, your staff came out, New York, the medics, and Dr. Lengor and yourself. And from there, I was just trying to stabilize him, try to get him comfortable, try to calm him down and, you know, get him transported. Brad, any pearls? So it seemed like it was, you know, once we got there, you know, it was knee or below. You know, any pearls here? Did you guys vacuum splint him or just? We did not. Not on the ice. I think, you know, things that sometimes get done on the football field are a little bit harder to do on a sheet of ice. And we've kind of done that, too, where we've just basically got them off and then dealt with them in the runway in the back and, you know, put a splint on there and then put them in the rig. Ironically, this was the second tip fracture I had had in Tampa and, you know, similar situation. The first one was a collision with a goalpost and we, you know, we didn't splint that case either. Stabilized him, actually used the splint bag propped up on the gurney to stabilize him. I think we didn't use the blow up splint, but the little orange splints that, you know, the EMS guys, we used that to kind of stabilize, just traction, get him on the bed. TD, any pearls that you've had with the? Well, just to add about the splinting, I mean, you have a very stiff boot on, you have a very, you know, splinted lower leg from the shin guard up to the knee, and then you have the pads up there. So the point taken about the football, you know, often they're just, just their sock where we actually have a hard piece of plastic that we can splint with. So how about pearls? So now we're in the training room, we got an x-ray, I think the x-ray, you know, this is, you know, x-ray looks something like this. So this is actually, x-rays, the one in the middle is actually from the training room, the other one's when he was in the ER. What do you do about the pads? That was actually the most challenging thing, was to get the skates and the pads off while still applying traction. Any tips from the trainers? I'm going to turn that one over to yourself because I was still on the bench at that time. I heard every Russian curse word I've ever heard in my life. I know, I know that our, you know, our two assistants that were with us were back there with him and, you know, obviously you're going to work as a team to try to continue to stabilize, but, you know, cut the sock if you need to, cut through the tape, but to try to expose that to see if there is any secondary injury. I mean, the thing that we, Ron, did you want to add something? If I could just interject, as T.D. mentioned, you know, the boot and the shin guard really kind of stabilized him as we put manual traction to get him off the ice. But at that time, you know, to get the x-ray, as Anil mentioned, we need to remove the shin guard to make sure it's not an open fracture, so that was critical. But that was when the pain really kind of intensified. Yeah, so right, obviously we took him from stability to instability back to stability when we put in the boot. Did you tie the legs together when you were bringing him off or did you sort of hold them together? When we got him off, that was easy because he was with his skate and his boot and we put those orange pylons, so he was pretty stable getting off. The hardest part was getting his pads off in the x-ray room and that's where, you know, before we could then re-stabilize him when we got him into a cam boot. Did you consider any analgesia? Yeah, that's what I was just going to say, nowadays, what do you have? Great point. That's going to go to the next case. So after he's yelling and screaming at me, I'm like, somebody give him some pain medicine. So, you know, because it was just, we did, but it was probably too late. The reality is, unless you're giving him IM medicine, which we don't have, you know, you know, readily available, that pain, you've got to just stabilize it. I mean, I don't think, we did give him some oral narcotics, but once you got him in the boot, then he was fine. So I have a question that, sorry, do you want to say? No, just maybe talk about where EMS carries the lozenges. Yeah, we have fentanyl lozenges that are 400 micrograms of fentanyl that the player or the athlete can just suck on for pain control. So we can give them that while we're waiting. In our rink, we would probably put an IV in and give them some IV meds as well. Okay, that's a good point. We've used IM Toradol, which has also been, you know, helpful, not as helpful as fentanyl. So I guess from going from the stable, the shin guards, the skate as a splinting mechanism, so to speak, now you have to identify where the break is at. So do you go with the boot, because you could use actually the boot on and use it a little bit like a buck's traction, pulling on it while you're taking the shin guards off, and then do your stabilization. But did you identify first where it's at, applying traction on the skate first, or you took the skate off first? In his pads for the x-ray, totally comfortable, because he wasn't moving. It's just motion, right? And then once we got a mid-shaft tibia, we then pulled traction. We're always holding traction with the skate, then took the leg pad and, you know, cutting everything off. One thing we did learn that, you know, everybody had all the lace cutters, but it wasn't right there, like, you know, so then we got a lace cutter, got the skate off, and then we put him in a boot, and it was, you know. The reality is, I think there's no real great, I mean, unless you have IV or, you know, sublingual fentanyl, you know, once you put him in the boot, he's like, he's fine. Yeah, it just, you got to get him into that boot as quickly as you can. So he was then transferred, and then had this, and I don't know how Tom can say it, but he came back real fast. So here's another case, only like a month later, this was kind of like a curse for us. Player goes down, in this case, he grabbed his ankle, but he could get off the ice, and then pretty easily, just with one skate. My question is to Brad, or I'm sorry, to the trainers, what do you, how do you approach a single limb, you know, ankle, distal tibia foot, something bad, do you want another player to come with you? Do you want two people holding him? How do you, you know, or do you do it yourself, or is it just too fast, and you just get him off the ice? What's that approach? You're using one man, two men to get him off the ice? Well, if they're weight bearing, I would. On one leg, they're weight bearing. Yeah, I would typically tell them not, obviously, not to put down the other foot. I would just say, whatever you do, don't put that, don't put any weight on that, we'll get you across. I would definitely like to have someone else help me. I would like one of us on either side. You know, I have spikes on my shoes, but I always like to have another player with me to take the player off, and then once I usually get to the bench, then my assistant would take over. So, as long as they don't put a weight on it, on the lower limb, I'm okay taking them off if, you know, half the time they're getting up already, so it's almost like you're just trying to get them to the bench. Anything else? Do you want two people? Do you want one? I mean, I guess the question is, how much do you want the other players involved? Sometimes they can be helpful, sometimes they can be too many guys, you've got ten guys now, like, guys, just get out of the way, like, give them some air. Sure, in a situation like this, TD hit it right, and you know, obviously, it's easier to have a player escort them off, same height, they're more stable on the ice with their skates than we may be, even with spikes on our traction, or extra traction on our shoes, so you know, as long as they understand that we're right there with them for the most part, we're not letting them go off on their own, you know, we'll be talking to them throughout that process as far as, you know, maintaining non-weight bearing and, you know, providing any other assistance that they may need or support. So, this is an interesting x-ray. If you look at the AP, maybe the deltoid's a little widened, but the fibula looks completely pretty good, and then you look at the lateral, you see a long spiral fibula, so, you know, so this was at first, we were like, oh, this is, you know, this is a tough guy, why is he in so much pain, but then, so he actually had a, he ended up with this, you know, he had a synesthematic injury, pretty high grade, he had to fix his deltoid, sculpt his ankle, but he actually came back pretty early, too. What's your experience, Brad, with synesthematic injuries, and when do you, when do you guys pull the trigger, or when do you, you know, this is, to me, very variable, this was a no-brainer because his deltoid was blown out on a weight bearing CT, what's your approach with synesthetic injuries? Yeah, I think if they're statically unstable, then it's an easy decision, they're going to get surgery. I think the ones that are a little bit harder are the ones that may have subtle dynamic instability, and if you talk to Bob Anderson, really the only way to make that diagnosis is probably arthroscopically, so you have to kind of make the decision, who are you going to take to the OR, and so what we've done at Minnesota is we kind of give them about five days, or seven days, if they can't get up on their toe in five or seven days, we're probably thinking that they're going to need their ankle scoped, and then they get a dynamic test with the scope in, and we've never had any that didn't come out of surgery without that, so, you know, they're going to, if they go to the OR, they're getting that. It's not that much of a test, then. Yeah, I mean, Marty O'Malley does a lot, and Mark Dracos, and Holly Johnson, you know, they're big in weight bearing CTs, and that's their version of their dynamic scope, but yeah, the threshold now, I think, is getting lower and lower in foot and ankle surgery to be more and more aggressive with this injury, with this new minimal fixation, versus big screws that we used to put in. All right, one last one. Here's a player, jammed to the ice. The one thing I wanted to point out, in all three of these examples, what's the most consistent thing? It's always a, all four, leg to the boards, and it's always a wedging of a skate in the boards, because you make, for my, the reason why this, you know, this sport doesn't have a lot of knee injuries is the dynamic nature of a blade on ice, versus the non-dynamic nature of a foot on turf, or a foot on a hardwood floor. The one time it's not dynamic is when you wedge it into a board. So this is a guy, again, knee injury, presumed knee injury, off the ice, positive Lockman exam, just walking through the whole panel. This kid, you know, young kid, you know, five years in the league, trying to get a new contract, you know his ACL's out. Anthony, you tell him, the kid right there, that his ACL's out, and he's out nine months, or what's? Oh, God, no. No, I mean, I, one of the big things, and I think it's important in delivering the message to people that are just starting off in sports medicine, stay in your lane, and you don't ever give them, if you don't know the answer, and you don't have the exact information, you got to, you have to have a conference with my orthopedist, myself, the GM, the coach, and the trainer, and say, all right, this is what we have, and then you present it to the player. You don't ever give the player a bit of information that's not the most accurate, because they usually hang on the wrong answer, and then you have to spend a whole lot of time undoing it. So make sure you go through the, get all the information, get all the data, just like we should do in medicine, have your conference with the medical team, and the decision makers, and then you present the options to the player. You know, Joel Boyd once told me, you know, it's better to be right than fast, but you also have to be fast. But I mean, these are the situations where I think it's really good to say, look, you're not going back in the game, I'm worried about your knee, we're going to get some additional tests, and then we'll talk about it after those additional tests. And that way, you're not telling somebody they tore their ACL, and it's not, and you're, you know, looking silly. But I do think it's okay to share with the player your level of concern. Yeah. I agree. I mean, I think, Dr. Boyd? Yeah. Since you were quoted. Yeah, I know. I know. I know. Yeah. The other term that we've now used, and we use it very often is, and it applies to most of these, is we're going to know more about this injury tomorrow than we know right now. Because you're going to get our studies, you're going to have everything in line, and then you can have a rational conversation. You know, you've had a chance to talk to your colleagues, you've had a chance to sort of frame it, because you've got to know what you're going to say to the coach, what you're going to say to the GM. So it gives you a chance to gather and collect your thoughts, and it calms the athlete, just to say, hey, look, we don't have all the information now. I mean, Brad's right. We need, you know, we're concerned about your knee. We just need more information, and we'll get that information over here within the next 24 hours. Yeah, I mean, I think, I've had this conversation a lot with all different levels of athletes, and I think you can't, they're all smart enough now that they know it, you know. So you can't completely, I don't want to say lie to them, you know, you've got to show that there's a level of concern here. You're not playing today, we've got to get a bunch of, you know. But obviously, I don't think you can, you know, you don't say, well, you know, it's a high-grade ACL off your femur, and you have a bone bruise in your lateral condyle, and you have an infusion, and you know, it's going to take six, you know, so it's information overload. But I think also, athletes usually relate to the truth, and giving them some level of the truth is important, especially to gain that, what we heard this morning, trust, how critical trust is. And I think that's really critical. I would say not just in orthopedic, but probably even more so on medical issues, is try to advise them to stay away from Dr. Google, because that next morning, they are coming in a blazing with questions of everything that they read the night before on Google or their wife or girlfriend discovered about their injury. All right, well, this guy had an ACL and did well, and subsequently came back nine months. Brad, how many ACLs have you seen in your experience in hockey? So I think with the Wild, we have had three or four, I would say. And with Gopher Hockey, I don't know, we've probably had about four, but one that happened on a scooter. That was a disaster. It's one of our better players. So it's not the most common injury. I published this paper in AJSM, and if you looked at the numbers of ACL tears in NHL, it's significantly different than the NFL or the NBA. It's not even close. Andy, what about in Detroit? I mean, how often have you guys seen knee ligament injuries in the hockey players in your 30 years? A handful. In the 35 years, there's a handful. And I mean, to your point, I think football and basketball, without question, outnumber the hockey ACLs. Everything happens in Tampa Bay. You've had your fair share, so. No, and when it comes to ACL, I'd say in my 20 plus years, between our team and our AHL team, maybe half a dozen combined. Personally, my daughter's going through an ACL rehab now. She's a lacrosse player, so that's where you see them a lot more commonly. That's a new knee plan. Okay, well, so we're done with the four o'clock session. I think we have now a 15 minute break, and then we're back with Dr. Nadeau, who's going to lead our concussion program. So let's everyone take a quick stretch, thank the panel, and then I guess everyone online can just re-log on. Thank you very much.

Bill Daly

NHL

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