Team Approach Critical in Buffalo Bills’ Kevin Everett’s Care
The inspiring story of Buffalo Bills tight end Kevin Everett has raised critical care awareness within the sports world and the general population. His recovery from a severe spinal cord injury has caught the attention of national media. While the decision to induce moderate systemic hypothermia to treat Everett and its effect on his outcome will be debated in the medical community for years, another important decision in his treatment deserves recognition and requires no debate – the timely care provided by a multiprofessional team of dedicated critical care experts played a vital role in the recovery of this fortunate football player.
In September 2007, during the Buffalo Bills’ season opener, Everett sustained a severely dislocated cervical spine. The scene by now is familiar to most: Everett lay on the field completely still as his medical team gathered to execute an emergency plan of action. Among those included in that huddle of medical professionals was Andrew Cappuccino, MD, the team’s assistant orthopedic surgeon.
It was Cappuccino who would make a key decision about Everett’s treatment. He directed Everett’s ambulance to Millard Fillmore Gates Circle Hospital, even though players usually were taken to the closest facility, Buffalo General Hospital. But Cappuccino, an orthopedic surgeon with specialty training in spinal disorders, knew Gates Circle had a team of specialists able to treat Everett right away. He knew the hospital had magnetic resonance imaging (MRI) and computed tomography technicians on duty at all times. “It allowed me to have immediate imaging of the cervical spine,” he said. “Within two hours of Kevin’s injury, we had all of the diagnostic imaging we could possibly want. Those modalities and staff were available at Gates Circle and not available anywhere else in Buffalo.”
Additionally, Gates Circle has a neurological intensive care unit (ICU), providing Cappuccino with the most options in terms of neurosurgical consultants and neurological ICU management. Everett would spend the next 12 days in the neurological ICU, but it was those first hours that proved crucial to his speedy recovery.
Multiprofessional Approach
“In the field of highly subspecialized medicine, which is what we were dealing with in this situation, I wanted to have the full battery of subspecialists available around the clock,” said Cappuccino. “I knew the subspecialists in the areas of neurosurgery, critical care medicine, cardiology, pulmonology, and general surgery. I had worked with them before and we had a good collegial team approach to treating such injuries.”
Society of Critical Care Medicine member Kevin Gibbons, MD, director of the neurosurgical ICU at Gates Circle, concurs. “Any patient with acute serious injury requires specialized care. It’s important to get individuals involved who have both an interest in, and significant experience taking care of, the patient’s problem, as well as the staff available to do it routinely.” As an example, the neurological ICU at Gates Circle has critical care-trained neurosurgeons and neurologists, and even a dedicated pharmacologist who rounds with the neurosurgery team. “It’s a specialty focus with multiple disciplines involved,” he said. Members of the critical care team treating Everett included a pharmacologist, a stroke neurologist who is also an expert in hypothermia, the chief resident of neurosurgery and Gibbons, the attending neurosurgeon who helped care for the patient in the intensive care unit.
That care involved many significant ICU management issues that were triggered when hypothermia was induced for 24 hours using an intravenous catheter the morning after Everett’s surgery. Among them were a fluctuation in his electrolytes, blood gas abnormalities, and issues related to ventilator management as well as the need to keep Everett heavily sedated to mitigate the discomfort associated with shivering during hypothermic therapy. “These are issues we deal with all the time for individuals in the neurological ICU,” said Gibbons. What is often overlooked, however, is that critically ill patients, such as those with spinal cord injuries, head injuries or acute stroke, require a great deal of nursing care, he added. “Whether it’s the use of hypothermia, intracranial pressure monitors, oscillating ventilators, or prone ventilation, these therapies are incredibly nursing intensive,” noted Gibbons. “The majority of critical care is provided by nurses and therapists in the ICU, not the doctors.”
Hypothermia Controversy
Inducing hypothermia in this case was a controversial decision because the practice is still considered experimental for patients with spinal cord injury. However, Cappuccino noted several studies documenting its efficacy in experimental and animal models. Proponents say that it appears to work by slowing the body’s metabolic rate, thus reducing damage caused by inflammatory processes, as well as facilitating the healing of damaged tissue. Other experts cite a lack of human research to support its effectiveness in treating spinal cord injuries.
Cappuccino acknowledges the controversy surrounding the use of moderate systemic hypothermia. However, he says there is a sufficient body of literature, including that from The Miami Project to Cure Paralysis, to suggest that cooling the whole body has a protective effect on the spinal cord. The Miami Project to Cure Paralysis is a leading paralysis and spinal cord injury research center dedicated to finding a timely cure for both conditions. Based at the Leonard M. Miller School of Medicine of the University of Miami in Florida, it is considered a world leader in neurological injury research.
“Whether or not we thought for sure it was going to make Kevin’s spinal cord injury better, from a critical care approach, maintaining and monitoring his temperature and keeping him relatively hypothermic was better overall than allowing him to spike fevers and trying to treat him with other methods. The cooling catheter facilitated doing this in a controlled fashion," Cappuccino said. "During his transfer from the stadium and prior to the cooling catheter use in the hospital, simpler methods such as iced saline infusion, ice packs and cooling blankets were effective in reducing the patient's temperature. Everett’s temperature was reduced from about 101 degrees – the normal temperature of a football player during activity – to just below normal by the time he arrived in the emergency room. It was worth taking the risks, which we felt could be minimized, because of this particular patient’s high level of conditioning.”
While Cappuccino would not yet recommend moderate systemic hypothermia as a standard of care for spinal cord injury patients, he did reinforce the need for further research. “I encourage my colleagues to keep an open mind until the studies are complete,” he said. “Let’s let the science determine whether we’ve barked up the right or wrong tree.”
Gibbons, however, believes that inducing hypothermia was not a factor in Everett’s recovery as he had already shown signs of improvement before the cooling catheter was used. “The morning after surgery, after the anesthesia wore off, Kevin demonstrated definitive and clear-cut neurological improvement in his legs in multiple muscle groups. Around the same time, when he was developing a fever, he had an MRI that basically showed a normal-appearing spinal cord. It was after that he had a cooling catheter placed, but his recovery clearly had begun.” Inundated with requests for a treatment protocol following the Everett case, The Miami Project to Cure Paralysis has issued the following statement on its Web site: “At this time, since the use of hypothermia in spinal cord injury is not an established standard and is still very much experimental, we cannot recommend its widespread use. If cooling is taken to a temperature below 92˚ F, it may cause severe side effects including cardiac arrhythmias, blood clotting disorders and increased infection. Procedures still need to be established for when, how and to whom hypothermia should be administered so as to provide the best benefit while minimizing the risks.”
Meanwhile, Cappuccino continues to see Everett on a semi-monthly basis for routine follow-up visits. “Kevin has done extremely well postoperatively and continues to progress toward complete independence,” he said. The care provided by the multiprofessional team certainly played a major role in this extraordinary story.
