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McKenzie: So many questions, so few answers

Bob McKenzie
10/14/2008 5:48:27 PM
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The truth is we will never know for sure.

Would Alexei Cherepanov be alive today if he had collapsed on the bench of the New York Rangers in the NHL instead of Avangaard Omsk in the KHL?

Some would say it's inappropriate to even ask the question, that we should not lose sight of the tragedy itself and since there's no way to bring the 19-year-old back to life, we should just leave it alone.

For those who are grieving, that's an understandable reaction. On the other hand, as is the case with any tragedy, it is what we learn from it and perhaps what we can apply in the future to possibly prevent it from happening again that is sometimes the only redeeming quality in a story so sad.

Already, authorities in Russia are questioning whether the treatment Cherepanov received after collapsing on the bench on Monday was adequate or suitable under the circumstances. One Russian lawmaker alleged there was ''negligence'' in the treatment of Cherepanov; another Russian official suggested Cherepanov was playing with a heart condition that should have precluded him from playing professional hockey.

The problem for us is that it's been extremely difficult to find out exactly what happened and precisely what action was taken or not taken by the medical authorities and it's equally difficult to gauge whether Cherepanov should have been playing without knowing details of any pre-existing heart condition.

The questions that need to be answered are as follows:

- From the time Cherepanov collapsed on the bench, when did the first medical personnel arrive on the scene?

- What training and/or expertise did the person(s) have?

- Was CPR administered and, if so, for how long?

- Were defibrillators accessible and in good working order and were they used?

- What was the precise nature of Cherepanov's pre-existing heart condition?

Only when those questions are answered with a degree of certainty can anyone start to piece together what could or should have happened differently in a best-case scenario for Cherepanov.

What little we do know, or we think we know, is, however, troubling.

The haunting Youtube video shows the players gathered around the collapsed Cherepanov on the bench, with Jaromir Jagr's familiar figure standing close to him while someone in a red jacket appeared to be working over Cherepanov.

Was this red-jacketed figure a doctor? A paramedic? Was he performing CPR? How long after Cherepanov collapsed did the video start?

So many questions, so few answers.

But for as little as we know, here's what disconcerting: The first order of business should have been to clear the players away from the scene to allow medical personnel to do their jobs; if CPR was being performed on Cherepanov, it's difficult to see it being administered; if working defibrillators were there, they are not in view.

But most troubling of all was seeing the players and others hoisting Cherepanov's body onto their arms and shoulders and carry him off the bench and to the dressing room. It's troubling not just because of the imagery but also because whatever was the problem with Cherepanov's heart, the only two things that can be done on the scene to possibly save him are CPR and defibrillation.

At this point, there's no way to know whether both or either may have revived Cherepanov. The sad fact is that some people drop dead of heart conditions and no amount of modern-day medicine is going to bring them back.

But we also know from the Jiri Fischer episode in Detroit that swift action taken by experienced medical people can also save lives that otherwise would be lost. It's why the NHL mandates that physicians be within 50 feet of the players' bench during games and that defibrillators and other emergency equipment, including ambulances, be readily available.

It was originally reported that the ambulance that staffs games in this Moscow arena had left early. Since then, reports suggest it was never there. If accurate, in a league where millions and millions of dollars are being thrown around, it's unforgivable. But in the harsh reality of the Cherepanov situation, an ambulance was not going to necessarily save his life, unless perhaps the ambulance had working defibrillators. Doctors will tell you the longest the brain can go without blood flow is around six minutes, which is why it's so important to maintain continuous CPR and try to manually ''push'' blood from the heart to the brain or to use defibrillators to try to re-start the heart and get it pumping on its own.

What also clouds the issue is determining exactly what pre-existing condition Cherepanov may have had.

Initial reports out of Russia indicate he may have had ''myocardial ischemia'' or ''heart muscle hypertrophy,'' which are two completely different conditions.

The former is usually what you find in out of shape adults with bad cholesterol although it can afflict healthier, younger people as a hereditary condition, often treated with cholesterol-lowering medications. Myocardial ischemia, is the reduction of blood flow through the arteries that supply the heart muscle. At a critical point, the heart muscle dies from lack of blood and therefore it cannot contract
 
The latter the most common heart condition that can kill seemingly healthy young athletes - it was identified as the cause of death for Windsor Spitfire captain Mickey Renaud  -- and its full name is Hypertrophic CardioMyopathy, or HCM, which in layman's terms is a thickening of the heart wall.
           
''HCM usually kills you by the heart muscle outgrowing its nerve supply,'' says Dr. Tim Rindlisbacher, who heads up sports medicine at the Toronto office of the Cleveland Clinic. ''The muscle stretches wider and the nerves can't so a disturbance in electrical conduction occurs. This arrhythmia causes irregular or absent heart muscle contraction and death.''

Whether Cherepanov had myocardial ischemia - it's highly unusual for elite athletes to have this condition and even more unusual for it to go undetected -- or HCM remains to be seen and perhaps we'll never know for sure, but screening for the latter can be extremely difficult.

Dr. Rindlisbacher said elite athletes tend to have thicker heart walls to begin with so if they do not exhibit any symptoms per se, detection of HCM can be difficult if not impossible in many cases.
Which is why there is a premium placed in the NHL on being ready for medical emergencies of this nature, of having a doctor nearby, of having defibrillators handy to say nothing of additional medical support in the form of EMS personnel, ambulances and a stretcher.

None of this guarantees the avoidance of tragedy, and we should not be so presumptuous as to think Cherepanov would be alive today if this had happened at Madison Square Garden…but it also seems apparent that more could have been done in Moscow and if there's any hope of making any sense of this tragedy, and that's difficult, then perhaps the Russian authorities will put in place higher medical standards to give their athletes the best possible care.

Bob McKenzie

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