Spleen? Nah. Overrated.

Peter Forsberg finished his NHL career with the Calder, Hart and Ross trophies, two Stanley Cups, three all-star nods (four if you count the rookie team), two well-used feet, and no spleen. While it’s difficult to maintain an NHL career with feet that won’t bear your weight, you can do fine without a spleen, as Forsberg found out halfway through the 2001 playoffs.

It took seven games for the Colorado Avalanche to finally finish off the Los Angeles Kings. As the team was celebrating their win at a local restaurant, a pale and uncomfortable Peter Forsberg told team management that his stomach was hurting. By 3am he’d been CT scanned and the decision was made to remove his spleen. After two hours and almost two liters of blood, Forsberg was minus a fairly important organ and finished for the playoffs, not to mention the next season.

So what’s a spleen anyway?

The spleen is an unassuming little organ that sits in your left upper abdomen, snuggled in behind the stomach. It’s about the size of your fist, and sort of a pretty dark purple-red colour (ask me how I know because I REALLY want to tell you). Its position up underneath the edge of your ribcage affords it some measure of protection, but despite the clever hinding spot it’s the most commonly injured solid organ in blunt trauma. Hockey, of course, is an excellent source of blunt trauma. The exact moment of Forsberg’s injury was never made clear, but at some point in game 7 something hit Forsberg in just the right way and with just the right force to rupture his spleen.

See if you can spot the spleen in this picture. A hint has been provided.

 

Okay, it’s in the gut. But what does it DO?

The spleen is small and pretty, but it has a some fairly big jobs. It filters the blood, removing old or damaged red blood cells (those are the ones that haul the oxygen around your body), and recycles or disposes of what’s left of them. It also acts like a giant lymph node, in that it filters nasty crud (bacteria) out of the blood and produces antibodies to fight them off. Obviously this is a giant oversimplification (stand down, spleen fan club), but it’s enough to explain why a screwed-up spleen is a problem both in terms of massive bleeding and in terms of infections. Anything that filters all of your blood obviously has an impressive blood supply, and can therefore bleed like crazy. Anything that produces antibodies obviously can’t produce antibodies if it’s missing.

A happy spleen in its natural environment.

 

How would you even know if your spleen was ruptured?

The easy answer is that it would hurt. Your body likes to keep its blood where it belongs, so when it seeps out into strange places, it can be very irritating. The spleen sits under the diaphragm, and the nerves of the diaphragm originate in the same place as some of the nerves in the shoulder. So if your diaphragm is pissed off because it’s being forced to sit next to a ruptured spleen, it may actually be your left shoulder that’s sore. Or maybe not. Like any intraabdominal injury, different people can have very different symptoms.

In Forsberg’s case, he started to have abdominal pain at some point after the game, and was said to be very pale when he finally admitted to team staff that he wasn’t feeling well. This isn’t by any means exact science, but consider the fact that Peter Forsberg is a big healthy guy. Big healthy guys tend to compensate for blood loss pretty well. By the time a big healthy guy has gotten pale enough that a look at him scares his team into taking him right to the hospital, he’s lost a lot of blood. A lot could mean as much as 30% of his total blood volume (seriously, that’s a lot).

But how did they know it was his spleen?

There’s a few ways to figure out if something in your abdomen is bleeding. These days it’s a quick scan with an ultrasound, and that may or may not be followed up with a CT scan. If there’s obvious blood in the abdomen and you’re starting to get shocky, you’re probably going right to the OR and losing that speen. If you’re stable and it’s not obvious what’s going on in there, you may get a CT scan first. Something that’s not done a whole lot any more (mostly because it’s awful and not that accurate) is diagnostic peritoneal lavage – simply put, someone cuts a small hole between your umbilicus and your junk, sticks a tube in there, runs a bunch of saline in, then sucks it back out to see if there’s any blood in it. So basically, hooray for ultrasound and CT.

It doesn't take a radiologist to tell this isn't normal.

 

Let’s talk splenectomy!

One of the first things you’re taught on any surgery rotation is that you don’t f@*k with the pancreas. In contrast, it’s completely okay to f@*k with the spleen because it can kill you in a hurry, and you can live just fine without it. Sort of. Because of its role in fighting infection the trend has turned towards saving the spleen whenever possible. A patient with a splenic injury that’s not actively bleeding and who is hemodynamically stable – meaning they’re not dumping their blood pressure – can usually keep their spleen. Not hemodynamically stable? That spleen is either getting repaired, taken out, or embolized. Embolization involves sticking a catheter into the splenic artery and injecting material to block the blood flow and thus the bleeding.

While it’s possible to get a spleen out laprascopically (with little holes and little cameras), a patient in shock with a trashed spleen needs it out NOW. And that means a big abdominal incision. Big abdominal incisions go through big abdominal muscles, so recovering from that sort of surgery isn’t so much about adapting to life without a spleen as it is about hurting like stink until your muscles heal. A week or two in the hospital, and one to four months of additional recovery time is what a normal person could expect. After a non-operative splenic laceration, it would be more like four to six months before you could even think about getting back to any kind of contact sports.

It doesn't take a surgeon to tell this isn't normal.

 

Peter Forsberg is far from normal, because he spent four days in the hospital and was making noises in the final round about wanting to come back. He didn’t. He actually didn’t come back until the playoffs of the next season. He took advantage of his spleen-healing time to have surgery on both ankles, then again on just the left ankle. A decision to take the start of the 2001-02 season to heal turned into the entirety of the regular season when tendon damage in his foot led to more surgery in January of 2002.

The glamourous post-splenectomy lifestyle

Because the spleen is a major player in fighting off certain bacterial infections, splenectomy patients have to have vaccines that the rest of us may not need – vaccines for Streptococcus pneumoniae (the pneumonia shot – usually just for old folks), Neisseria meningitidis (the meningitis shot – given to little kids and usually required for college), and Haemophilus influenzae type B (another vaccine that little kids get). They may also require prophylactic antibiotics before having any dental work or surgery done.

Life without a spleen is much like life with a spleen for people who were healthy at their baseline. The recent NHL spleen club includes more than just Forsberg:

- Sean Avery: Lacerated his spleen in 2008, was treated non-operatively.

- Matt Hunwick: Lacerated his spleen in 2009. Initially treated non-operatively, but had continued pain and bleeding and had his spleen removed a few days after the injury.

So while lacerating your spleen is a scary injury that can involve significant blood loss and a major surgery, for Peter Forsberg it didn’t affect his ability to play hockey at the pro level. His feet and ankles are what ultimately took care of that for him.

Don’t like gross stuff? Stop reading here.

When you’re a med student, you spend a lot of time on surgery standing around trying not to fall asleep, telling yourself you really don’t have to pee and that eating is a highly overrated activity reserved for the weak-willed. One night on the trauma service as the team prepped for an emergency splenectomy, I prepped to stand in the corner and count ceiling tiles. They opened the patient’s abdomen in less time than it took me to piss off the scrub nurse by standing too close to her table. They scooped handfuls of congealed blood (which has the consistency of squishy jello) out of the abdominal cavity, tossing it into a basin where it landed with a wet plop. They loosened the spleen from its cozy home behind the stomach, tied off the vessels supplying it, and then I heard the four most beautiful words I could have possibly hoped for: “Here, hold this spleen.

It was warm, it was a pretty shade of purplish-red, and it blew my mind how sick its former owner was – almost no visible trauma to the abdomen, and yet an almost non-existent blood pressure and skin that wasn’t pale so much as it was sickly grey. My personal list of organs not to be f@*ked with definitely includes the spleen.

Afterword: The patient did fine, and I eventually got to take a pee break and get something to eat. Also, OR #12 has 64 ceiling tiles.

Comments (12)

  1. Very nice read, thank you!

  2. I know we haven’t met, and I know this sounds crazy, but:

    I love your articles, I love your sense of humor and personality, and if things don’t last between my wife and I, I think I’d enjoy sharing a hockey game and a cheeseburger with you.

    Since my wife and I are not currently planning to divorce anytime soon, I’d figure you’d be just as happy to know that you are firmly in my “Top 5 People to Invite to a Dinner Party” list.

    Your articles are that awesome.

    • I suck at checking comments. This made me blush, and now my ego is completely out of control. Thank you!!!

  3. For the surgeons, rule #2 is “Don’t mess with the pancreas.”

    Rule #1 is “Don’t piss off the scrub nurses.” Or at least, it should be.

    An excellent read, as always. Hope all is going well w/ your residency, Dr. Innes!

    • I <3 nurses. Scrub nurses have saved me from many near-death experiences at the hands of my own stupidity.

  4. I love these articles! I hope we get to read many more in the future! Although, I dont want players getting strange injuries for you to write about… CONUNDRUM!

  5. I think that “Don’t like gross stuff?” warning came a little late in the article.

    Great piece. Hoping one day to read about an injury I’ve gotten – broken fib, fixed with ORIF. Fun way to spend the holidays!

  6. Another member of the NHL ‘he didn’t lose his spleen club’ is Quintin Laing, Washington Capitals, March 2009.

    Even crazier that only weeks later Sami Lepisto suffered a spleen injury while playing for the Hershey Bears, the Caps AHL affiliate.

    Tried to provide links to the stories, but the site thought they were spam so wouldn’t publish.

  7. I always love your articles, Jo, but I simply HAD to ask: How do you know what pretty colors the spleen is?

  8. Love the article – helpfully informative! Actually — the same thing happened to me two years ago. I took a hit mid-ice, dropped like a sack of bricks and thought I’d broken a rib. In the OR next morning they found a real mess: pulpy spleen and 46% (yep, that’s right) blood loss. The doctor said if he didn’t order the blood when he saw the CT scan it would have been a very different story. I’m with Foppa on this: nah, ya don’t need a spleen!

  9. The most common symptoms of meningitis are headache and neck stiffness associated with fever, confusion or altered consciousness, vomiting, and an inability to tolerate light (photophobia) or loud noises (phonophobia). Children often exhibit only nonspecific symptoms, such as irritability and drowsiness.”‘,.

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