On February 10th hockey fans got a jolt when stalwart St. Louis Blues defenseman Jay Bouwmeester collapsed on the bench following what appeared to be a normal shift. We now know that Bouwmeester suffered a cardiac arrest, and had CPR performed on him until medical staff were able to revive him using a portable defibrillator. Video of the event, below, is a little scary…
Bouwmeester was awake, alert, and moving all extremities when he was transported from the arena to the hospital for treatment. He remained there for several days, during which he underwent surgery to implant an ICD — an Implantable Cardioverter Defibrillator. Try saying that five times fast.
Several days after the surgery the man his teammates call “Bo” was flown back to St. Louis, where he will be under the care of surgical and cardiology experts in two hospitals. In his first statement following the event Bouwmeester thanked medical staff from both the Blues and the Ducks, as well as the hospital personnel, and said he is “on the road to recovery.”
I thought we should look at what that will mean.
What Is An ICD?
An ICD is an electrical/computer device implanted inside your body. It has a tiny computer that monitors your heart’s activity, coupled with a miniature defibrillator capable of administering small electric shocks.
There are two kinds: one is implanted directly next to your heart; the other is implanted beneath your arm, with small wires extending into your chest cavity. The under-arm one is rather new, but preferable from a surgical perspective because it creates less disturbance in the chest cavity, and is easier to reach should maintenance or replacement be required.
The question I had was, since they’re battery powered, how do you replace the batteries? Can it recharge like those watches that wind when you move your arm? Is this an “Iron Man” kinda thing, where Pepper has to keep some wires from touching the housing while you swap out the power source in a hole in your chest?
It turns out, there is no Tony Stark option: replacing the battery requires more surgery. They haven’t yet figured out the wireless charging thing like you can do with your Galaxy S10.
So, guys, I have a weak stomach. Medical stuff gives me the heebie-jeebies. So you damn well better appreciate the torture I’m going through doing the research and typing this up…
Is An ICD a Pacemaker?
No. A pacemaker, in simple terms, releases a constant electric pulse that acts as a guide for your heart to follow every minute of the day. An ICD actually just sits there most of the time, monitoring your heart rhythm, determining your heart’s normal patterns and habits, and waiting for something odd to happen. When it detects something has gone awry — deviating from the established norms to a prescribed degree for a time extending beyond a given parameter — it releases an electric shock to try to “zap” the heart back into its normal patterns.
They program these things for two different types of shocks. You either have one or the other, it doesn’t decide which to do under what circumstances. If what you are experiencing is mild but relatively frequent heart arrhythmia, they program the ICD for low-energy pacing. This is mild shocks that may feel like a flutter in your chest, or being momentarily out of breath.
The more likely programming schema for Bouwmeester’s ICD is the high-energy shock. This has a much stronger electrical output; it feels like somebody kicking you in the chest. It’s for patients that have only occasional, but severe, heart arrhythmia issues. It is, as the name implies, a defibrillator that you carry around inside of you.
(*Whew*) Deep breath, walk around, splash your face, shake out your hands…
So, you have a cardiac arrest, you survive, you have surgery to get an ICD implanted: what happens next?
First thing is, right after surgery you need to treat yourself very gingerly. This implant is adjusting to being inside your body, and your body is adjusting to the implant. Gradually the ICD will come to an agreement with the body as to where it is supposed to “live” for the rest of its life. Once that has been established, your body then has to adjust to resuming normal activity with this weird plastic-wire thingy that has just arrived. This process takes weeks, and needs to take place with minimal disruption.
So: absolutely no vigorous physical activity, though they do recommend gentle walks or just moving your arms and legs to improve circulation. In particular, you need to limit or fully restrict any activity that causes your arm to jerk away from your body. You also cannot allow any impacts to your torso or upper arms, regardless of severity.
Then there are the usual post-surgery instructions: no heavy lifting, no pressure on the incision, change the dressing as instructed, etc. You also have to take your medicine. Religiously. And keep track of what medications you take at what time. This you do, every day, for the rest of your life.
And before we get to The Question, we need to look at what constitutes “the rest of your life” for Jay Bouwmeester. As you would expect, there’s good news, and there’s bad news.
Skewing The Average
When you do research on any condition or disease or affliction, you are necessarily looking at averages. In the case of things like heart attacks, in particular when discussing survival rates and quality of life, the variance in patient outcomes based on factors like age and physical condition prior to the event do render the “average” somewhat meaningless. But an average is all we have; and Jay Bouwmeester is going to skew the average in the right direction, there’s very little question about that.
First, the obvious. The man was in arguably superior physical condition when compared to any 36-year-old male who has walked the earth. Beyond being a starting defenseman for an NHL team, the guy was a friggin’ machine. He had a consecutive game streak at one point in his career that lasted 737 games spanning 12 years — the most by any NHL defenseman, full stop. So if you’re looking for somebody who has the best chance of a normal life after an early heart attack, somebody like Bouwmeester is the example you would point to.
Secondly, and its hard to overstate this: with the possible exception of a hospital emergency room, there was probably no better place for Jay Bouwmeester to have gone into cardiac arrest. There were 3 medical teams including 2 physicians on top of him within 30 seconds. All of the equipment they needed to apply acute critical care was available to them immediately. There was an ambulance waiting, and UC Irvine Medical Center was 9 minutes away by car in normal traffic — I expect that’s more like 4 minutes by an ambulance in get-out-of-the-way mode.
In these situations, seconds and inches count. What if he had collapsed on the ice? Then it’s 3 seconds for the ref to notice and blow the whistle; another 5 seconds for any medical personnel to reach him, assisted by players as they stumble across the ice in street shoes; and equipment has to be carted out to where he was on the rink. How could that have changed the outcome here? And we can only assume what would have happened if he collapsed in the locker room, or on the bus back to the hotel, or in his hotel room that night. In a lot of ways, Jay Bouwmeester was the luckiest guy in the building that night.
But there are not enough words to express the unbelievable preparation, training, and dedication of the trainers for the Ducks and Blues, the EMT’s and doctors on the scene, the rink facilities staff, the teams, and the league. A minimum of two doctors are in attendance at every game — both within 50 feet of their assigned bench and having a clear path to reach it. There are hand signals medical staff use to communicate patient status across large distances regardless of noise levels. Identical medical equipment and supply bags are placed within reach of both benches in all 31 NHL arenas, so medical staff know exactly what they have and where they can get to it. Each bench has a portable defibrillator charged and ready.
But to top it all off, moments like Bouwmeester’s collapse on the bench are rehearsed — literally, player-trauma practice — every year before the season starts. Everyone has an assigned role and position, they run through scenarios of differing severity, and they practice for accuracy and for time.
Now, Google this information online 100 times, you’ll literally get 10,000 different answers from 1,000,000 different web sites. But what I have assembled in the subsequent sentences represents what I feel are the most current statistics on the matter from the most reputable sources given the nature of the subject. So if you disagree with the statistics below, write your Congressman — I’m not interested.
The survival rate for persons experiencing a heart attack outside of a hospital setting is in the neighborhood of 6 percent. And remember, that includes absolutely everybody — from the guy standing on the front steps of the ER, to the jogger in the park downtown, to the recluse who goes into cardiac arrest while watching Jeopardy and the landlord finds him 4 months later still sitting up in his La-Z-Boy.
If there is a trained bystander who administers CPR, the patient’s chances of living increase by more than double. Now, we can debate if the personnel and equipment available to the staff at the rink that night constitutes the functional equivalent of a “hospital setting” — I would argue that it does. But even if you use that standard, the survival rate is still a paltry 24%.
Like I said, the luckiest man in the building.
One last thought regarding the league and its dedication to precision and preparedness during player trauma. There is video of the event from the bench/access tunnel area (NHL proprietary, will not be released). That video will be reviewed by the league and medical personnel. They’ll be looking for any possible way that their equipment, equipment placement, personnel, or training can be improved.
The existence of that video and the review conducted following the event is not merely a lucky happenstance; the cameras are placed strategically for this specific purpose, and the review of the video is standard procedure.
Now The Bad News
So a few paragraphs back we mentioned the concept of a normal life. Plainly traveling around the continent playing 82 games of a rigorous professional sport is not what anybody would consider “normal”. So what’s the standard?
When assessing this, the standard that is used can be simplified to the following: five years after the event, setting aside things like medication and physical therapy, is the patient still alive, and are they living their life the same way that they were before the event? The numbers are not encouraging.
First of all, the most recent data taken from a pool of living, breathing subjects shows 10% had a second cardiac arrest occurring within 15 years. That’s the most current, but it’s also the most optimistic. The American Heart Association’s numbers are more like 25%. And remember that you’re looking at that survival rate between 6% and 24% again with the second cardiac arrest.
Then the “normal life” calculation. For patients who were revived by the administration of CPR alone, the numbers are pretty good — over 40%. For patients that have been revived by defibrillator, which was required for Jay Bouwmeester, those who were alive and lived to resume normal life activities at the 5-year mark was under 10 percent. That’s it.
The ICD provides us with an additional set of data. Once that’s involved in the equation, we’re no longer talking about a normal life, we’re talking about life expectancy. Those numbers vary widely depending on the cause of the cardiac arrest.
If the problems are due to hereditary or chronic causes, those ICD patients can live for decades, provided they adhere to proper self-care guidelines, diet, exercise, etc. For patients with acute conditions, the life expectancy number is now in the neighborhood of 7 years, and the medical community touts that number as a substantial improvement.
Now, was Bouwmeester’s cardiac arrest caused by a chronic or acute condition? We don’t know. But we do know the following.
NHL players go through rigorous physical examination and fitness assessment every year at training camp. Part of this involves the team physician clearing everyone for participation and contact. This isn’t just the once-over by your family doctor ending with “turn your head and cough.” This is the team and the league placing the possibility of a negligence lawsuit against a multi-billion-dollar organization in the hands of a group of doctors. Those doctors are instructed to make sure the guys who are allowed on the ice actually belong there — that during the normal physical stresses of an NHL season, they’re not going to sustain or aggravate an injury, or run the risk of a potentially life-threatening medical event.
There’s obviously no guarantee, but if this was a genetic or emerging chronic condition, there is a strong probability that it would have been caught and addressed by team doctors over the 17 years of Bouwmeester’s career.
So I do not know whether the actual cause of Jay Bouwmeester’s cardiac arrest is chronic or acute. But I have a fairly high degree of confidence in my guess, and it’s not the pleasant answer.
Beating The Odds
I actually have a real-world example for you of the ICD and life expectancy. It involves my Uncle Mike, who smoked heavily from age 18 (or younger) until age 58. It was at that point when, attempting to shovel foot-deep wet snow off the porch, he suffered a heart attack. Well, duh.
This was at a remote cabin, and the roads were impassible. So his wife got on the phone, and in a few minutes the guys in the local snowmobile club strapped him to a toboggan and sped him up to the head of the lake and the awaiting ambulance. Then came the 40 minute drive to the nearest hospital; then the 3 hour drive to the nearest cardiac unit; somehow the old coot survived.
An ICD was implanted, and you need to realize that at the time this was a very new technology. Battery life was limited, it required constant monitoring, and they hadn’t quite worked out the settings on the voltage for the shocks yet.
Uncle Mike continued smoking, though he did curtail his previous activity level somewhat. After about 5 or 6 years he got his antique unit swapped out for a more “modern” one — still, this is before the turn of the century — and continued teaching, tinkering with his computer, and monkeying with his Oldsmobile.
The ICD, primitive as it was, gave my Uncle Mike 20 (that’s twenty) years that he likely would never have had. To my knowledge he never had another heart attack, and finally passed away approaching 80 years old.
We talked before about skewing the average; beating the odds. My Uncle Mike was most likely the worst ICD recipient since the invention of the device: continuing to smoke, eating whatever he damned well pleased, and never doing so much as one minute of exercise. Still, for somebody who, even by today’s standards, should only have lived 7 years, he was most certainly an outlier.
But his lengthy survival span also speaks to the scattershot patient sampling that contributed to the 7 years average. What’s the sample size, what’s the standard deviation, and what are the upper and lower limits, and what is the unweighted median? Unfortunately I could not find that information, so as I mentioned earlier, the average is what we’re stuck with.
Jay Bouwmeester is young. He was in top physical shape when his cardiac arrest occurred. He had immediate, expert medical care. He has access to the best doctors and facilities, and the benefits of the lessons those doctors learned from early ICD
lab rats patients like my Uncle Mike. And he has a state-of-the-art medical device that will help to extend his life should additional cardiac complications arise.
Is Bouwmeester going to beat the odds? I think it would be foolish to bet against him.
On February 27th St. Louis was hosting the Islanders, and the Blues had a special guest in the owners’ box. A deserving salute was given to the returning hero.
The previous day Bouwmeester had been part of a press conference, in which he announced that he was out for the remainder of the current season and playoffs. He was non-committal about what the future holds for him beyond that.
Bouwmeester is currently on a one-year “35+” contract extension; he is an unrestricted free agent at the end of the current season. That means he is free to sign with any team once free agency opens this summer. Will we ever see Bouwmeester play another NHL game, with St. Louis or another team? And so, we come to The Question.
Beyond the normal post-surgical recovery period, there are limits to what you can do as a patient with an ICD. Rigorous physical activity that pushes your heart rate to extended limits is strongly discouraged, as are contact or high-intensity sports.
But let’s say that Bouwmeester says, “Screw you,” and wants to play again. Given the severity of the incident on February 10th, the resulting surgery, the insertion of the ICD, and the potential liability associated with him returning to action, I can’t imagine any scenario in which a team doctor lets Bouwmeester back on the ice. There isn’t a liability waiver broad enough to cover that kind of risk. For all of these reasons, I expect the phone will not be ringing in Bouwmeester’s agent’s office come July 1.
Jay Bouwmeester’s NHL career spans 1,240 games with 3 teams over 17 seasons. During his time on skates he won a gold medal at the World Championships, an Olympic gold medal, and his name is engraved on the Stanley Cup as a member of the St. Louis Blues. At this point, there’s not much left to do.
Bouwmeester, his wife, and three children live in St. Louis. His career earnings is listed on CapFriendly at over $73 million dollars. He is just 36 years old. Now is the time to take a look at what I assume is a decent-sized nest egg, look at his family, look at what has just happened, what his life looks like going forward, and what the future could be for him and those he loves.
So the answer to The Question is, assuming that he does not represent a special case with medical circumstances that fall outside the parameters of what we’ve discussed here: no, you will not see Jay Bouwmeester playing NHL hockey ever again.