As hard questions continue to be asked about the treatment, or lack thereof, Alexei Cherepanov received before dying on Monday in a rink just outside of Moscow, another question is coming to the forefront:
What was the cause of death?
Russian authorities have publicly stated the 19-year-old Cherepanov died of a pre-existing condition known as "chronic ischemia," which in layman's terms is a lack of blood flow to the heart.
Doctors here in North America, though, are skeptical that was the cause of death.
"I would say it's highly unusual, virtually unheard of, for an elite 19-year-old athlete to have chronic ischemia," said Dr. Anthony Colucci, the Detroit Red Wing team physician and emergency room doctor who saved the live of Jiri Fischer when the former Red Wing defenceman, like Cherepanov, collapsed on the bench during a game on Nov. 21, 2005.
"Ischemia is a coronary vessel disease," Dr. Colucci added, "and you can see it on an EKG (electrocardiogram). It's not that hard to detect. And to say a 19 year old has 'chronic' ischemia, I mean he's only 19, how chronic can it be? I am not saying ischemia can't kill a person but if that was the cause of death I can't tell you how unusual or rare that would be in this instance."
In other words, if Cherepanov suffered from ischemia Dr. Colucci and other medical people in North America believe it would have shown up when Cherepanov was medically tested at the NHL Scouting Combine in June of 2007, just before the NHL entry draft, or in the fall of 2007, when he attended the New York Rangers' development camp.
Russian authorities also alluded to Cherepanov having a "hypertrophic" heart, which is a thickening of the heart wall and that, Dr. Colucci, said is more likely what caused Cherepanov to collapse on the bench and ultimately die.
The condition is known as Hypertrophy CardioMyopathy (HCM) and it is a silent killer, often difficult to detect and often lethal when it strikes.
"The first and sometimes only symptom you see from HCM," Dr. Colucci said, "is when the player collapses during activity. The individual goes into sudden cardiac arrest."
Dr. Colucci said that if the Russian authorities are saying Cherepanov had a "thickened" heart wall, "HCM would be No. 1 on my list for what was the cause of death. Until I could find evidence of something else I would be looking at HCM. This is the leading cause of death in elite athletes who exhibit no other symptoms and then collapse during activity."
It was Colucci's quick action on that night in November of 2005 that saved the life of Fischer. It will never be known for sure if similar action taken by medical authorities in Russia could have saved the life of Cherepanov, but what is becoming clear is that Cherepanov's chances of survival diminished greatly because he wasn't treated as efficiently and expertly as Fischer.
Reports from Russia indicate there were no working defibrillators on the scene - they are used to shock the heart back into a normal rhythm - and no ambulance either, although Dr. Colucci suggested an ambulance would not likely have saved Cherepanov's life because the window of opportunity to revive an athlete who has collapsed because of HCM is so small.
"Ambulances should always be there and in the NHL we have rules that there has to be two at every game, one for the players and one for the spectators," Dr. Colucci said. "But the (life-saving) treatment on the player has to happen immediately. There's no time to move him."
In fact, Dr. Colucci said if the proper treatment isn't started within four minutes, it's likely too late to do anything.
"(Four minutes) is the maximum amount of time the brain can go without blood flow from the heart," Dr. Colucci said. "After that, there's irreparable brain damage."
In order to save a life, as Dr. Colucci did with Fischer, a very specific treatment is required.
It starts with chest compression CPR, five cycles of it for two minutes, followed by defibrillation. This process ensures the blood flow from the heart to the brain is continued manually with the CPR and the hope is the defibrillation shocks the heart back into beating normally again. It is repeated until the heart responds. Or doesn't.
With no working defibs on site, Cherepanov's chances of survival dropped drastically.
"There is nothing that guarantees anything 100 per cent," Dr. Colucci said, "but if you do the CPR properly and use defibrillation, your chances (of revival) increase dramatically, they go way, way up. If you only do CPR, they go way, way down. If you only do defibrillation, they go way, way down."
And if you do nothing at all?
"Your chances (of survival) are zero per cent," Dr. Colucci said.
When former Detroit Red Wing Igor Larionov, the classy Russian who will be inducted into the Hockey Hall of Fame next month, heard about what happened to Cherepanov, one of his first calls was to Dr. Colucci.
Larionov has said the Kontinental Hockey League must respond to this crisis and ensure it never happens again, or at least the league should take steps to ensure every arena is better equipped to deal with emergencies of this nature.
Dr. Colucci agrees.
"This is such a horrible tragedy," Dr. Colucci said. "I know this Russian league is trying to make it more attractive to NHL players but this is one huge blemish on this league. Reading what happened, it is pretty clear they were not set up properly to handle this. It's a tragedy."
Authorities in Russia will investigate if there was any criminal negligence in the Cherepanov case.
Dr. Colucci is a strong supporter of the Jiri Fischer Foundation Healthy Hope, which Fischer started after his near-death experience. Amongst other things, Healthy Hope is pushing for people to be trained and certified in CPR and to have AEDs (Automated External Defibrillators) in as many places as possible.
"I really think defibs should be in every home, every vehicle, every workplace, everywhere," Dr. Colucci said. "Lives can be saved."
Sadly, not Alexei Cherepanov's.