February 10th, 2008
Midway through the third period, the Florida Panthers are trailing the Sabres by one goal. Olli Jokinen nails Clarke MacArthur in Buffalo’s end, but trips over his legs as he falls. As Jokinen’s skates come up off the ice, Richard Zednik skates directly into one of them. With his neck. Hard. Zednik falls to the ice, but the first massive spray of arterial blood hits before he does. He grabs the right side of his neck, and flies toward the bench. He’s met on the ice by Florida trainer Dave Zenobi, who immediately holds pressure on his neck. Teammate Jassen Cullimore skates in to help him off the ice, and one of Buffalo’s training staff runs in with more towels, frantically signaling for help. Buffalo team physician Leslie Bisson meets the panicked group in the tunnel, and as they half-drag/half-carry Zednik to the dressing room, the Florida bench and surrounding fans are yelling for more medical staff.
Leslie Bisson – an orthopedic surgeon at UB orthopedics – holds pressure on Zednik’s neck for the two mile ambulance ride to Buffalo General Hospital. When he arrives at the BGH emergency department, staff note that his blood pressure is low and his heart rate is high – signs that his body is desperately trying to compensate for the blood he’s lost. The swelling around the injury is beginning to threaten Zednik’s airway, so he’s intubated and put on a ventilator. He’s rushed to the OR where vascular surgeons Sonya Noor and Richard Curl spend an hour repairing his external carotid artery. He spends six days in the hospital, and is told his season is likely over – while he’s initially told he’s facing a six to eight week recovery, the truth is it will likely be months before he’s cleared to resume strenuous workouts.
Seven months later Richard Zednik returns to Panthers’ practice, and in his final season in the NHL he tacks up 33 points and a +2 rating, his best season in five years.
The External Carotid Artery: Intact is better.
Your carotid arteries are how blood gets from your heart to your brain (which is super important). There’s one on each side of your neck, and they’re what you’re feeling when you check your pulse. The carotid artery splits into the internal and external carotids at the level of the thyroid cartilage (a fancy term for the Adam’s apple). The internal carotid is the one that supplies the brain, but don’t let that convince you that the external carotid isn’t important. It supplies the thyroid gland, tongue, a large portion of the face and scalp, ear, and teeth. All of those are important, and all of those need blood.
Cutting any blood vessel open is problematic, but cutting an artery is a special kind of screwup. Veins carry blood to the heart, and arteries carry blood away from the heart. The upshot is that arterial blood is under much higher pressure, so when there’s a hole in an artery, the blood is much more eager to find its way out. If you injure a vein, chances are that unless it’s something really, really major (like your IVC) the blood it drains will find another route back to the heart. If you injure an artery there’s not only the problem of interrupting the blood supply to various important areas, but also the problem of high pressure blood that’s now being pushed out of a hole instead of through the vessel.
The difference between veins and arteries is the difference between Richard Zednik and Clint Malarchuk’s injuries. Almost twenty years before Zednik’s injury, Clint Malarchuk suffered a jugular vein injury at the hands (skates?) of St. Louis’ Steve Tuttle. He was also rushed to Buffalo General Hospital, he also had surgery, but he was back on the ice a week later. A massive oversimplification of the reason that’s possible is that if you patch a hole in a low-pressure hose (veins) it’s a lot less likely to leak than a hole in a high-pressure hose (arteries).
What do you do about an arterial injury?
In addition to maintaining one’s sphincter tone and containing one’s panic, the main goal is to stop the bleeding. Of course we all know that the correct order of business in the treatment of traumatic injuries is A-B-C (airway, then bleeding, then circulation), but arterial bleeds are one of the few injuries that are addressed at the same time as an airway compromise. You can stabilize an airway all you want, but unless it’s attached to a body that still has some blood in it, you won’t be doing much good.
Control the bleeding – Apply direct pressure. Don’t lift the dressing up to peek underneath. Just hold it there. Hard. Controlling the bleeding generally doesn’t include fishing around in the wound for the ends of the bleeding blood vessel. That’s a thing they do on TV, and it tends to screw things up worse than it helps. Just about the only person who should explore a wound for vascular stumps is a vascular surgeon in an operating room. Of note, Zednik’s artery was only lacerated, not completely severed. Had it been severed, it would have been unlikely that he’d have survived. Arteries are very muscular (compared to floppy-walled veins) and have a bad habit of retracting back into wounds. That’s the reason amputated limbs don’t always bleed as badly as you might expect (you’ll just have to trust me on this). That’s also why a severed carotid would be a disaster. Artery ends are hard to put pressure on if they’ve retracted up into the neck and down in to the chest.
Get to the hospital – Self explanatory. The good news is BGH is two miles from the HSBC Arena (and the site of the old Buffalo Memorial Auditorium), and ambulances can go very, very fast.
Permissible hypotension – Hypotension is low blood pressure, and normally it’s a bad thing. In the case where you have a hole in an artery, though, it’s not such a terrible idea. As long as you have enough pressure to perfuse your brain, you’re good. If you go adding tonnes of blood or fluid to a system like that and raising the blood pressure, you’re raising the force with which blood is traveling through the arteries, and thus pushing its way out. So you have to wait until you’ve got control of the bleed, then you dump a crapload* of blood and fluid into the patient.
*not an actual medical term
Fix that joker – There are a few ways to fix a lacerated carotid. The external carotid can sometimes actually just be tied off instead of fixing it ( I know, I know, that blew my mind too) because the head is so vascular that the odds are good there are enough vessels originating elsewhere to supply the tongue, teeth, scalp, etc. In Zednik’s case, however, his artery was repaired (not tied off).
The ways to fix a carotid are many and complicated. Sew the cut ends into other nearby vessels to provide bloodflow, patch the vessel with a synthetic material or a piece of cow pericardium (which is the covering over the heart and NO I’m not kidding even a little bit right now), or just sew the hole shut.
Rehab – Zednik missed the remainder of the season because going right back to strenuous physical activity after repairing a hole in a high-pressure blood vessel is a bad idea for reasons that I hope are obvious. Malarchuk was back in a week because he had a repair to a low-pressure vessel. Both injuries looked absolutely atrocious, but they were essentially very different. Both Zednik and Malarchuk are automatically given membership in my Holy Frig He’s A Frigging Badass club, though. Whether they skated off or not (and they did) doesn’t really matter – the fact is both suffered terrifying, potentially career (and life) ending injuries, and both bounced right back and kept playing.
Damn, that’s some fine sewing.
When Richard Zednik gave a press conference a week and a half after his injury his scar was barely noticeable. The horizontal scar was all that was left of the injury, and the vertical scar showed how the vascular surgeons accessed the inside of his neck to make the repair. It doesn’t look like much, but I’m swooning over how beautiful it is. Not to mention the fact that he’s alive, which is pretty damn cool.
A video you may not want to watch:
It bears mentioning that while taking notes during this video I wrote down “ 2:05 in video holy CRAP that’s a lot of blood.” The video is graphic, but it shows how everything came together to save Zednik’s life. Quick responses on the part of Florida and Buffalo staff, and (most importantly) Zednik himself resulted in an outcome that, four years later, is still absolutely amazing.
Special thanks to @billiemeanjean, who is an actual surgeon who actually knows things about actual vascular repairs (unlike myself, because I just stick my finger in bleeding things until they stop). Also to Buffalo General Hospital and all the ER staff whose company I enjoyed for a month in medical school. Great hospital, great staff, and the new ER looks like an Apple store. Plus they save hockey players’ lives there (and other people too).