If you recall, back in mid-September, Kim Quinter crafted a comprehensive look at the challenges facing an athlete who had been diagnosed with multiple blood clots.
Now that Kimmo Timonen is closer than ever to returning to the ice, here is an updated piece, in easier layman's terms, explaining what might lie ahead for a blood-clot patient once physical activity resumes.
Further disclaimer: this article is released without any prior knowledge of treatment plans between Timonen, the Flyers' front office and the doctors involved.
Once again, a reminder: Kim is graduate of James Madison University and currently works as a Physician Assistant at James River Family Practice in Newport News, VA.
Can Kimmo Timonen safely return to play this season? As Timonen continues to skate on his own and has finally begun practicing with the team, beginning Tuesday in hopes of a return this season, this question is left hanging in everyone's head.
Let's start with the issue of the chronic blood clots in Kimmo's legs. A chronic clot is one that has been present for greater than 1-2 months. Typically, an acute clot or deep vein thrombosis (DVT) will typically heal and dissolve with treatment from blood thinners over several weeks or months. When the DVT does not completely dissolve, the area where the clot settles forms scar tissue over the clot. This "chronic clot" is stable and there is little risk of a piece or thrombus breaking off and traveling to the heart, lungs or brain.
Just because a chronic clot is stable doesn't mean it can't exist without complications. Just like having a cholesterol plaque in an artery, the scar tissue over the clot can hinder blood flow and cause long term problems.
Post-thrombotic syndrome can cause long term swelling and pain in the extremity where the clot is located. Because blood flow may be hindered by the scar tissue there is always a risk for recurrent DVT, especially in someone that is more likely to form clots. Chronic clots can also occur in the lungs and cause residual pain and shortness of breath as well as a serious complication of pulmonary hypertension. Thankfully, the clots in Timonen's lungs have dissolved.
Typically a patient like Timonen would be on life-long blood thinners or anti-coagulants. Flyers GM Ron Hextall has said that Timonen will not be cleared to play while on blood thinners (ed. note: previous reports did mention Xarelto at one point and Timonen himself noted he won't take blood thinners when playing) so I'm not completely sure how they are going to go about guarding against future clots. If we assume he will be on some type of anti-coagulant, then we can assume an increased risk of bleeding.
There are a few different types of blood thinners that could be used. Heparin and warfarin are the "old stand-bys" and up until a few years ago were the only option for treatment of DVT, pulmonary embolism (PE) and thrombophilia or increased tendency to form clots. Heparin is given injection and is usually not used for long term treatment. Its dose is based on weight and it does have an antidote, protamine sulfate, that can be given if heparin levels become too high.
Warfarin comes in pill form and can be quite tricky to manage because it's efficacy can be affected by a wide variety of foods. Vitamin K is the antidote for warfarin, so patients are generally told to avoid eating greens or green vegetables that contain vitamin K, though patients can also be instructed to eat a consistent diet of the same amounts of food everyday. Eating the same thing every day usually does not work for a majority of people.
Patients also have to avoid vitamin K in supplements and multivitamins. Warfarin also has to be monitored carefully and frequently due to all of the factors that can potentially make it work too well or not well enough. This is generally accomplished with weekly blood testing, however there is a narrow window of efficacy and warfarin can be extremely frustrating to manage.
There are new anti-coagulant medications that require no monitoring and have little to no diet restrictions. These medications are usually taken once or twice a day. The big risk for these medications is that there is no antidote for them, so if someone is bleeding, management of the bleeding can be quite difficult.
Obviously because hockey is a full contact sport we can assume there will be bleeding, bumps and bruises involved. Something as simple as a bruised rib can be a serious issue if bleeding cannot be easily controlled. A broken bone could be catastrophic.
If Timonen is not going to be on blood thinners while playing his risk for recurrent clots are very high due to travel and long flights, possibility of dehydration, trauma, and his existing protein C deficiency. (Ed. note: the Flyers final 25 games this season feature just one long road trip, to Ottawa, Vancouver, Calgary and Edmonton from Mar. 15-21. Timonen may be held out based upon a previously agreed-upon number of games he'd play once up to speed).
I hope that all necessary precautions are in place if Timonen does return to play this season, but some of the variables of travel and depending on facilities and medical treatment away from home can make it difficult to be completely prepared for all scenarios.
Building a Memory
On a night when one of the three finest defensemen ever to dress in Orange and Black was honored
Eric Desjardins, looking fit at age 45, had a lovely, classy pre-game ceremony honoring the distinguished Philadelphia portion of his career, but he nonetheless had to sit through the Sabres' 3-2 shootout win on Thursday night along with 19,471 other disappointed souls.
That makes the Flyers 0-for-2 this year, after dropping a 3-2 regulation decision to the Minnesota Wild back on Nov. 20 when two-thirds of the Legion of Doom finally saw their names added to the ledger in the rafters. The following are brief recaps of games where the Flyers decided to honor distinguished members of the organization both on and off the ice with a spot on the team honor roll.
March 22, 1988: Bruins 3, Flyers 0: Andy Moog pitched a 20-save shutout on the night the Flyers officially welcomed their first two HOF members, Bernie Parent and Bob Clarke.
March 17, 1989: Blues 4, Flyers 3 (OT): The combined power of Keith Allen, Bill Barber and Ed Snider wasn't enough to spur the hosts to victory. Brett Hull's goal 3:21 into the extra session against Mark Laforest sent a sellout crowd home stone-faced. St. Louis completed a three-game season sweep (with two wins in Philly) thanks to the marker.
March 22, 1990: Flyers 5, Penguins 3: Months before his death from cancer, Fred Shero, along with Rick MacLeish were honored as Paul Holmgren's club, desperate to snag a playoff berth, turned it on against the fading Pens. Derrick Smith, Keith Acton and Jeff Chychrun scored in the 3rd period to turn a 2-2 tie into a win.
March 21, 1991: Blues 4, Flyers 1: The end of a season-crushing 2-10-2 spurt included this loss when Barry Ashbee and Gary Dornhoefer were enshrined. Ken Wregget stopped only 13 shots in all, and only four of seven in the first period.
February 13, 1992: Flyers 3, Nordiques 2: Gene Hart and Reggie Leach were feted and the hosts slipped out of the Spectrum with a win against a weak Quebec club. Mark Freer netted the winner at 2:27 of the third period.
April 8, 1993: Flyers 4, Washington 3: Andrei Lomakin, Garry Galley and Rod Brind'Amour (GWG 15:08 of 3rd period) all scored to snap a 1-1 tie and give Bill Dineen's team the fourth in their season-ending blitz of eight consecutive wins in a vain attempt at reaching the playoffs. Still, it gave Joe Scott and Ed Van Impe something to remember beyond the pregame ceremony.
March 8, 1994: Stars 4, Flyers 3 (OT): Tim Kerr would have been right at home in the slot, giving his former team a boost it needed. Dallas' Neal Broten ended things at 2:43 of overtime, after Brind'Amour helped send the game beyond regulation with a power-play goal 9 1/2 minutes into the third.
February 22, 1996: Flyers 5, Capitals 3: "Thundermouth" Joe Watson was rewarded with this victory in the final HOF ceremony conducted in the Spectrum. Shawn Antoski fought twice -- against Kevin Kaminski in the first and Craig Berube in the third -- while Craig MacTavish was tossed for his late-game tussle with Keith Jones. Oh yeah, Dan Quinn picked up three assists.
March 4, 1999: Senators 5, Flyers 0: Brian Propp took his rightful place in the gallery, then saw Roger Neilson's club put forth one of the worst efforts on home ice. The professional debut of Jean-Marc Pelletier didn't go as planned, Alexei Yashin recorded a hat trick and Damian Rhodes stopped all 24 shots he faced. A franchise-record winless streak reached five games.
March 15, 2001: Flyers 3, Wild 0: The first of two nights in Mark Howe's honor saw Roman Cechmanek blank the expansion Minnesotans on just 15 saves with Rick Tocchet, Michal Sykora and Dean McAmmond providing suitable offense.
March 3, 2004: Flyers 5, Predators 2: The game before the game which set an NHL record for penalty minutes honored the club's second-best captain in Dave Poulin. New acquisition Alexei Zhamnov posted a goal and two assists while Kim Johnsson collected two goals and one helper.
February 6, 2008: Capitals 4, Flyers 3: Ron Hextall didn't even get the right bust and John Stevens' team defense went bust in the 3rd, allowing goals from Matt Bradley, Viktor Kozlov and Alex Ovechkin in a span of 5:44 to break open a tie game. Late goals from Sami Kapanen and Randy Jones made for a better end result.
November 16, 2009: Flyers 3, Devils 2: Dave "The Hammer" Schultz finally received his due from the franchise but a game which featured 18 penalty minutes and no scraps was taken by the home team thanks to a James van Riemsdyk goal midway through the final stanza.
Last night's 3-2 shootout loss occurred against a team which had posted almost one-third of their total wins this season (6-2) in the game's final segment. It also came against a team which had won only twice in their previous 21 contests. Yet, there was a distinct air of calmness and rationalization amongst the Flyers leadership.
“They’ve been playing pretty good hockey. If you look all of their games were lost by one goal, they play a pretty tight game. But that isn’t an excuse we need to find a way to get the two points," noted captain Claude Giroux.
Yes, the last six games Buffalo has played have been one-goal contests -- and the Sabres have now won two of those -- and their three wins since late December have all been by one goal so we know they're practiced at playing things close to the vest. Nonetheless, ANY team with playoff aspirations knows that the mode this late in the year is to stomp on the weak on the way to facing tougher opponents.
Last year's Flyers knew this with their backs pinned against the wall in the final one-third of the schedule, taking down the likes of Los Angeles, San Jose, Pittsburgh, Chicago, Washington and the Rangers while also taking care of necessary business against Toronto, Florida while going 15-7-4 down the stretch. They've got a string of 7-in-9 at home before a run where 7-of-9 is on the road and good luck trying to figure if they'll do better here than abroad.
New blood can't quite do the trick if it's Ryan White on the fourth line, and new lines like the ones trotted out in Voorhees today (12-28-17, 24-14-93 et al.) are the age-old fall back when a head coach can't come up with a modification in his system. And when a suspended player who has been a healthy scratch after serving his time somehow is a candidate for lineup re-insertion based on a misguided notion that the club needs some kind of spark, you know this can't end well.
“Unacceptable? No they beat Detroit the other day didn’t they? We fired a lot of shots we had a lot of chances. Like I said we didn’t get the next goal. But unacceptable? I think our team competed," was head coach Craig Berube's sentiment in the postgame.
Sure, you can do a lot in a watered down league just on compete level alone, but those precious Ws aren't measured by how hard a particular team works. And by the way, Chief, that Detroit game you spoke of happened on Jan. 18 and they were down 4-1 before rallying to tie and allowing the Wings to win it late.
Removing the idea that Berube has no clue what he's doing, and in light of the revelation that roster moves are approved by committee, it only reinforces the idea that the front office condones the experimental nature of Berube's coaching because this season is a total wash and no drastic actions are coming.
If Ron Hextall publicly states he likes the resiliency of this group, he at least has something upon which to base it: a stretch where they won 6 of 8 after starting the year 1-3-2; another 6-1-2 spurt after going 1-8-1 and this 6-1-4 run following a 4-8-1 dip. But consistency has been elusive for the better part of three years now and a club not too long ago more than 10 points out of a playoff race can't expect the other side to tank it and bank on another decent winning spurt to make it interesting when a half-dozen other clubs league wide are in the same predicament.
That said, I predicted and fully expect the Orange and Black to be on their best behavior with the gauntlet of Central Division leading Nashville and old rival Washington coming to Philly tomorrow and Sunday afternoon. I expect both games to be victories and at least three points to come about. You can't figure this team out, so might as well just ride the waves and don't ask where they go.