Fighting in professional ice hockey: it's time for a change.

Ice hockey has long been defined by a level of violence not seen in other sports. The rough-and-tough vigilante nature of the game was often employed as a method of enticing fans. Play in the National Hockey League (NHL) evolved throughout the 20th century as the rules governing it did. The nuances of what was allowed on the ice was slowly defined, but the league always fell short of an outright ban on fighting. Notably, the NHL allows fighting while international and Olympic leagues do not. Proponents of fighting's continued presence in the NHL argue that it can attract fans, facilitate momentum changes, help win games, and allows for social regulation on the ice. However, analyses of these theories have found little definitive evidence, calling the utility of fighting into question. The economics of fighting in hockey reveal high salary payouts, increased cost of injury, and a lack of correlation with ticket sales. Additionally, there is a concern for concussions sustained during fighting which has the potential for long term, detrimental mental health effects for athletes. In this analysis, we explore the history and evolution of fighting in the NHL, as well as the reasons behind its continued presence in the game, the risks associated with fighting, and the economics behind it all. Based upon these bodies of evidence, we make a proposal regarding the future of fighting in the NHL.

Using Emergency Department Data to Inform Specialty Strategy: Analyzing the Distribution of 13,777 Consecutive Immediate Orthopaedic Consults in an Urban Community Emergency Department.

Although an estimated 20% of emergency department (ED) visits are musculoskeletal in nature, it is unclear which of these require urgent orthopaedic consultation and which orthopaedic subspecialties are best suited for these consults. When an ED's internal staff does not have necessary orthopaedic coverage, transfer to other facilities is required. However, transfers pose major inconveniences and financial burdens to patients and can lead to long ED wait times, hospital financial loss from walk outs, decreased patient safety, and decreased staff morale. Therefore, it is beneficial for a hospital to have the appropriate staff readily available for consults. Data can be used to assess the orthopaedic needs of an ED. We evaluated the nature of urgent ED consults requesting the timely presence of an orthopaedic provider. Methods: Between the years 2008 and 2017, the Orthopaedics Department of this Health System saw 13,777 patients from the ED requesting immediate consult from an orthopaedic provider. We retrospectively analyzed the distribution of anatomic areas and nature of these injuries for these visits. Results: Hand, foot, and ankle consults comprised 75% of the volume. Knee, hip, and spine accounted for 15% of consults. Most injuries were fractures. Infections and sprains were also common. Discussion: By determining and understanding this distribution, orthopaedic departments can improve their organization to better respond to urgent ED consults, allowing for the proper delivery of orthopaedic point-of-care service to patients, increased revenue for the hospital, proper availability of core competencies, and increased value to the healthcare delivery system as a whole. We also believe that the trends observed in our data are largely generalizable to EDs serving urban communities similar to ours. Thus, these results can help inform a synergistic strategy for the system comprising EDs, urgent care clinics, and orthopaedic surgeons servicing them.