A renewed, valuable perspective

There has been a lot of attention paid to professional athletes who sacrifice so much of themselcpves for our entertainment recently. This includes a major lawsuit brought by former NFL players that suggests that these players were doing so blindly because the NFL "told them it was safe to play." They claim the NFL minimized the risk of concussion injuries while making a lot money. However, the validity of this argue net is not the point of this post. Whether the players are right or if it is the NFL owners that have the high ground inps a debate for another time.

This brings me to my point. These athletes are crying foul while most of the youngest retirees (and some of which were a part of the lawsuit) made a lot of money playing a game. Let me say that again. They made a lot of money playing a game. And yes, I understand that the medical costs and the squandered fortunes that are often associated with these ex-players is also devastating. However, I met somebody this weekend that gave me a whole new perspective on this discussion.

This weekend, the high school that I work with hosted an alumni football game as a fundraiser that helped the athletic departments of the my school and that of our next door neighbor. During the pre-game, I met a father who is an alum of the high school where I am employed. (He also has at least two sons that we talked about that evening who are students in the same district.) This gentleman came in to get his ankles taped before the game.

I asked for a brief history of his injuries so I could give him the best treatment I could. After a remarkably long list of injuries, I had to ask how a person who appeared to be in his mid 30s ended up with such a dubious collection. He explained that he has been a military man for his entire career of 16 years if my memory is correct. He then offered that he is soon expecting to reenlist for another 6 years and hoped that it would be his last enlistment.

What struck me the most is that he was not looking for anything except the taping for his ankles. I regret that I did not have the time to talk to him more about his experiences and his injuries. I look forward to talking to him again and I hope he will be willing to share more about his experiences.

Here is thing that has really bugged me; prompting me to write this post. Here is a hero, a real hero, that is sacrificing as much and risking so much more than the professional athletes that we give so much attention to. He isn't asking for fame, isn't expecting a fortune for doing what he does, and yet, is doing much more. Most people will agree that it is always appropriate to always thank our members of armed services, but the irony of this conversation just heavily reinforced for me the need to follow though on it.

In short, I am thankful (and regretful) that God introduced me to this person and I look forward to our next conversation so that I can correct my oversight. God bless the men and women who do such tremendous service to our country and keep them safe.

The Sound of Ideas

Dear Diary,

Today I appeared as a guest panelist on our local PBS radio station, 90.3 WCPN in Cleveland, Ohio. I  participated in a call in show titled "The Sound of Ideas." Our topic was concussions in youth football. I was able to offer some ideas on the problem and have some fun in the process. The show also featured Dr. Joseph Congeni of Akron Children's Hospital, the president of a local youth football league (John Prochaska, his son Sam, and one other player on his son's team, Dylan Himmal.  Many issues were discussed and I thoroughly enjoyed my time. Below is the embedded link to the episode that I appeared on from their podcast feed.

(Click on the logo to go to website and download the episode or subscribe to their RSS/podcast feed)

Many thanks to Ida Lieszkovszky (producer) and to Mike McIntyre (host) for their generous invitation and hospitality today.

Lightning strike at high school football halftime show

This video is offered here without comment. If this was as random a lightning strike as is being reported, that is scary. If, however, the strike could have been foreseen coming with a smartphone app, then there is no excuse for it.
Video as reported by WTAM in Cleveland, Ohio

Another big hit in HS ball.

I struggle with this many times and continue to try to preach the dangers of hits like this one.

This occurred in a recent game that I was working and you can see the defensive end get ear holed by the pulling guard. I am not sure if the officials saw this hit, but if they had (they did not penalize it,) then I need to seriously step up my educational efforts. These kinds of hits need to end.

Falling behind again

We are now back into fall season with everybody underway in their preseason practices as of yesterday. This year, we had a different wrinkle since the football team didn't start until four days after everybody else did. It is unusual because in most years past, the other teams either started after football or on the same day.

The worst of these arrangements is having everybody starting the same day, bar none. It makes it very difficult to spend time with each team when they all start at the same time and I find myself being pulled to football more often than not for many minor details. (Usually a helmet needs some air added or removed.  Ironically that just happened as I was typing this too.) If I had one wish for the OHSAA during this time of the year, it would be to make sure that we keep some sort of staggered start to the fall seasons.  It doesn't matter to me who goes first, (although I like the later start to football) since it is a lot easier for many of us who deal with every sport.

Beyond that, we seem to be having a very cool and dry summer in northeast Ohio this year. Despite the lower risk of heat illness, it is still vitally important to maintain hydration levels since the temperatures are expected to climb somewhat over the next couple of weeks. It is my hope that the temperatures do not spike on one day (like opening night) and have all the kids wilting on the field since they were unprepared for the heat.

Finally, I am also heading back to school for a second Masters degree in applied exercise science so that I can sit for the corrective exercise specialist exam and add that those credentials after my name as well. At the pace that I am going on that, I may have multiple alphabets after my name by the time I am done.

Hopefully, in all of this and my family life, I will still find the time to be more active on this blog.  It may even become more important for me to do so just to maintain my sanity at times. Here is to hoping that everything goes well!

Seminar Season

It has been too long again since my last post. I am finding myself busy doing many other projects and this blog has suffered as a result.

Anyway, welcome to summer! 

As we get ready for the heat and begin preparations for the return of fall seasons, this is my chance as a high school athletic trainer to go out and continue to learn. I had the opportunity a couple of weeks ago to attend a conference in PIttsburgh, Pa. that was presented my the UPMC staff on concussions. 

The course was an update as to what has changed in the last few years and a glimpse of some of the more promising research for the future. I was particularly excited to see a demonstration of a new MRI technique that showed an extremely high definition picture of the the brain being scanned. The potential for this technology os extremely promising and it would be a welcome addition to the arsenal of diagnostic tools.

The most exciting thing that I heard that weekend is that there will be an iOS and android version of the new SCAT3 test available this fall.  I am hoping that the test will be released in the iTunes Store before August 1st, which is our start date.  However, there was no definite date given and it could be released much later in the season.  I guess I'll have to stick to the paper and pencil version for now.

The conference also pointed out that the SCAT3 does not include any testing for the vestibular system and it was the strong opinion of the UPMC crowd that this oversight needs to be corrected. Visual tracking and looking for nystagmus is one thing, but testing the cicadic movements of the eyes and other forms of visual tracking are also important. These additional tests don't require much more time or training to perform and should be included in an evaluation.

There was also some discussion about the upcoming and long promised pediatric version of ImPACT. A preview of the format was given and, as expected, it is more game like than the original adult version. There was a focus given to avoid reading as much as possible especially since this is designed to be taken by 5 year old children.

The thing that surprised more than anything with ImPACT is that they talked about being able to take the adult version of the test as early as age 10. Previously, I had heard that the minimum age was 13. However, the UMPC group did recognize that the normative data for this 10-12 year olds needs to be separated out from the adult scores since there is a large difference in the scores.  Needless to say, I am happy that I will be able to offer the test to my middle school children now, but that does involve a lot more work too.

Now I did say in my opening paragraph that this was about summer seminars. The other big seminar I am attending this year is in Las Vegas for the National Athletic Trainers Association convention. In fact, I am writing this blog post while en route. I hope to have more to share after what should be a fun week in sin city.

Unsung Heroes at the Boston Marathon

On Monday, April 15th, 2013, we were given another reminder about how the dangerous the world in which live is. The bombing of innocent victims at a marathon of all places is disgusting and inexcusable. While authorities struggle to find who was responsible for the horrific attacks, the media has been busy bringing attention to the heroic acts of the doctors, nurses, EMTs, police, military, and firefighters. These people demonstrated extreme heroism since it is fairly well known that these kinds of attacks often involve multiple explosions designed to injure the first responders. These people scoffed at that danger and rushed in to help. Congratulations and thank you to each and every one of you.

Secondly, and no less important than my first point, my prayers go out to the victims and their families. I hope that they are all able to move past this horrible event and find peace.

Now for my small rant against the media. It has been very disappointing to me to see how these well known and celebrated professionals are the only ones who get the recognition that they deserve. This may come as a surprise to many in the public, but these people were not the only ones responding. Within that group of "other healthcare providers" were athletic trainers, physical therapists, and likely a few others. It sickens me that these these other professionals get less recognition for their efforts in this tragedy. I wish I had the resources available that the media does to be able to get a list from race organizers of all of those who were there that day and responded. I don't think that it would be any great effort on the media's part to publish a full list of the professionals that responded. I guess the recognition will only come after many more long and arduous years of public education.

A Prime Example of Why We Need More ATs

Yesterday, in the first half of the Duke vs. Louisville elite eight men's basketball game, Kevin Ware of Louisville attempted to block a long shot in front of his bench and landed awkwardly.  The landing resulted in an open compound fracture of the tibia and fibula (both lower leg bones) and you can see in the video where the tibia was protruding from the leg at the point of the break.  (As coach Pitino said after the game, "It was protruding by about six inches from his leg.") The injury was horrifying and my prayers will meet with yours that this young man will make a full and speedy recovery and I hope that this will not affect his future to too great of a degree.

http://youtu.be/onTWl_eXOM8

Warning: This video is considered by some to be graphic.

The highlight of this terrible situation has to be the quick and appropriate response of the Certified Athletic Trainers, physicians and EMTs that were present.  Their quick and practiced response helped to make this young man as comfortable as possible in a quick fashion.  The rapid response played a large part in getting this young to the hospital quickly where he underwent successful surgery that evening and has a bright outlook.  I commend the medical staff for their efforts and we should all be thankful that this high quality service was available yesterday.

The centerpiece of this response team was surprisingly not the physician.  The people that were doing the splinting and such were the teams' Certified Athletic Trainers.  These were the people that were making the decisions on the best splint to use and how best to transfer the patient to the gurney.  These were the people who were practiced in the emergency responses that they designed and executed flawlessly yesterday when is was needed.  These are the people who are at their best when you are at your worst.

Unfortunately, this is not always the case.  According to statistics from the National Athletic Trainers Association, only 42% of high schools in the United States have access to an athletic trainer.  This is an appalling statistic in and of itself.  When you examine it even further, you will find that this means that only 42% of high schools have ANY access to an athletic trainer.  This does not mean that there is a full time athletic trainer available for all events that a high school and covering both games and practices.  No, this statistic includes all the part time athletic trainers at schools that might "drop by" once a week for an hour to examine injuries that have occurred in the last week. This is obviously far from ideal, but is still included in this statistic. 

It has been estimated that only a third of these 42% of schools have a full time athletic trainer. (I am looking for the article to cite it.) If you work that out, only 14% of schools in the United States have full time access to an athletic trainer. That is embarrassing! The other point that isn't covered in these stats is that of those 14%, many of those ATs are working 60-70 hour weeks.  They often report that they are not able to keep up with the demand at the schools they work for because of the numbers of athletes and contests that are scheduled concurrently. They are not able to fully implement rehabilitation protocols, preventative measures, or spend the appropriate amount of time that is needed for each athlete because of time constraints.

I can sympathize with this since that is my current situation.  Often, I have to make decisions on which sport to sit and watch depending on the likelihood of an injury occurring.  One prime example that happens a lot is deciding between a varsity soccer game and a freshman football game.  It is tough to have to decide between them since both have a similar high risk.  Often, when the injury occurs where I am not, this causes tension amongst the parents and school.

Finally, this statistic talks to high school athletics only.  It does not discuss the need for athletic trainers to be available for middle school and youth and even recreational adult events where injuries also occur.  In these instances, when there is no athletic trainer who has the training to respond appropriately, you are often left the best of what's available. Sometimes, that option is far less than what is needed and emergencies become tragedies. This is why athletic trainers are so badly needed.  And don't fool yourself, injuries like this happen across the country at every level of play.

It has been an amazing experience for me to see first hand the number of unqualified people who are always too willing to jump in and try to help in an emergency situation.  In conversations last night on Twitter with fellow athletic trainers, we discussed some of our nightmares where well-intentioned, but unqualified people were way too quick to insert themselves into an emergency situation.  I have been verbally accosted by many people in the past because they didn't appreciate my qualifications.  Having a nurse standing over me as I am trying to work and shouting instructions to the group or the EMT handing me his cellphone that he used to call a local physician for a kid that needed EMS transport were the worst examples parents that didn't understand their limits.  I understand that this is a burden that reinforces my drive to educate the public about what it is that I am qualified to do.  However, some of my colleagues have had instances of lab techs, and other lay persons who had NO business on the field, yet felt the need to do something to help.

The ironic part of Kevin Ware's injury is that it occurred on the last day of March, which is National Athletic Trainers Month.  The injury helped to underscore the need for athletic trainers at every level of play.  The number one excuse for not hiring athletic trainers is, and likely always will be, cost.  The Mom's team article that is link here even reflects that 9% of people think a volunteer health care professional is appropriate for this job.  If you plan on hiring the lab tech or the medical secretary to cover the next football game, I will probably hold my child out.  That is unacceptable.

There is a growing mantra from athletic trainers that helps to underscore this idea that is captured in this article.  It states that "If you cannot afford an athletic trainer, then you can't afford football."  I have agreed with others that this should be taken this one step further to include hockey, lacrosse, and other collision sports into this mantra.  Yesterday's injury only underscored this belief and it should probably include contact sports like baseball, softball, basketball, soccer, and other sports like it.

However you approach it, there is an obvious need to change things in our athletic society today. We need to increase the number of athletic trainers in the United States that can be these first responders to injuries like this. I would implore anyone reading this that agrees and would like to see changes made in their local community to perform their own research and discover for themselves what an athletic trainer can provide for their athletic program(s). Listed below are a few more articles that I found very quickly that help to support this argument and can offer direction to anyone doing their own research.

https://www.oata.org/documents/resources/HS_Sport_Safety_6BA94A22DE261.pdf
http://www.tulsaworld.com/sportsextra/article.aspx?subjectid=227&articleid=20120915_29_B13_Itsint238054
http://www.athleticbusiness.com/articles/article.aspx?articleid=269&zoneid=35

Also, over the last couple of years, I have been saving links to various articles on my social bookmarking (Delicious) account.  There are hundreds of articles linked here: www.delicious.com/pirateatc/

Youth Coaches and Their Reactions to HB 143 in Ohio

So far, the responses that I have received regarding the implementation of HB 143 (Ohio's Zachary Lystedt law for youth concussions) have been greatly mixed. The responses have ranged from mildly excited, completely apathetic, and more than a few people were reluctantly accepting of it. It has been greatly humbling, and at times, depressing to see these mixed reactions. While this is a topic that I care so deeply about, most people I have met with are simply trying to shrug it off and move on.

The situations that I worry about most are the parents that will fight and argue to their dying breath that their kid is not concussed despite obvious signs and symptoms that the child displays. I have heard far too many times from parents that "They care most about player safety." and "Safety always comes first." That is, until the score appears to dictate different priorities and that same parent denies that an injury could ever happen to their child or their teammates.

Please forgive me if I hold judgement on how effective this law is until I see how parents will react when it is their child that I am holding out of a game because they have some symptoms that generate concern. I have a feeling that more often than not, this will lead to much more confrontation between the parents, coaches, and myself from those individuals that still fail to understand the potential severity of concussions and second impact syndrome.

Certainly, our educational efforts need to continue if we are to have any hope of alleviating these confrontations as much as possible. However, my experiences tell me that this new law will not change the attitudes of far too many people who will still allow themselves to be too caught up in the score of the game when it matters the most.

I guess all I can do is hope that I am wrong about these assumptions. I will also hold out hope that this new law starts to open some eyes to the potential disasters that concussions can make of promising young lives.

New consensus statement on the treatment of concussions

Earlier this week, a new consensus statement was released by the powers that be that discusses the recognition and treatment of concussions in sports. Along with this statement came a revised version of the SCAT test, the SCAT3.

The first important part of this statement for the layperson is that it reinforces the standard of practice that requires coaches and medical staff to hold a person out of play on the same day of a suspected concussion. I agree with this statement completely since I have found several instances where symptoms of concussion have not been apparent until several hours after the time of injury.

We need to take every concussion seriously and stop ignoring the signs just to win a game. This is a very poor priority and is not in the spirit of a quality athletics program for youth. Unfortunately, this is has not always been the case in my experience, even recently.

The other significant point is that the statement reinforces a need for a gradual return to play by which the patient slowly increases their activity. This is meant to take at least six days, but it may take much longer if symptoms persist. This could be weeks, months, or even years.



For those that are interested in seeing the statement, it can be found at:
http://bjsm.bmj.com/content/47/5/250.full.pdf

The new SCAT3 adult version (ages 13 and up) is here:
http://bjsm.bmj.com/content/47/5/259.full.pdf

The new SCAT3 pediatric version (5-12 yo) is here:
http://bjsm.bmj.com/content/47/5/263.full.pdf

And finally the new Concussion Recognition Tool (for laypersons to identify a potential concussion) is located here:
http://bjsm.bmj.com/content/47/5/267.full.pdf

NFHS rules changes for football in 2013 are welcome.

Mom's Team website found at www.momsteam.com was the first place that I saw the new rules changes for the upcoming high school football season. When I saw these changes, I was extremely pleased. This finally addresses at the high school level, a problem that is growing at all levels of football. Seeing players losing their helmets while playing is getting downright scary, and it is getting worse.

I first witnessed the problem a couple of years ago and have only seen the number of helmets popping off increase since then. I have also found that there are two common reasons for it. Most if the time, the helmet is a poor fit for the player and either needs to be reinflated or replaced with a more appropriate size. This can be easily fixed and needs to be done so as quickly as possible. A poor fitting helmet exposes the player to only losing his helmet, but also a greater chance of injury. Obviously, the best way to prevent this is to have the kids report back that their helmet needs some more air in it as soon as they notice it.

The other reason that I have found for this to occur is that the snapping hardware on the helmets has been a lot easier to unsnap in recent years. Several time over the last few years, I have been forced to dive into our supply of old chinstraps and procure older snaps that hold to the helmet much more strongly. I am not sure wether this was a manufacturing error or not, but I would be interested to know from other ATs and equipment managers if they have had the same problem in recent years.

Regardless of the cause of the helmet coming off, it was welcome to see the NFHS address this issue in the rules. I am glad to see there is now a 15 yard penalty for illegal contact for hitting a helmetless player and illegal participation for continuing to play without a helmet. If the NFHS had not instituted this rule for next year, it was one that I was going to propose to the local youth league that my sons play in. Fortunately, that is one proposal off the list.

This Needs to Be Penalized More!

Being both a high school football official and a certified athletic trainer has often given me a unique perspective that often sets me apart from each group. In the past, it helped me to teach the athletic trainers that I work with what the rules are that govern the sport and how to craft padding so they can remain compliant with the rules. This unique combination has also given me understanding that many ATs didn't have when the rules regarding head injury weren't made clear to them. Before the Zach Lystedt laws, officials had the responsibility to inform a coach that a student athlete needed to be evaluated for a head injury. Many ATs didn't know about this rule and thought the officials were overstepping their authority in the rare event when an official enforced the rule.

However, this dual credential has also had some ill effects. I usually don't complain about the same things that coaches do on the sidelines and I often am able to back my arguments with the rules and proper terminology. This usually doesn't make me many friends from the officials when I have a valid point; creating some tense discussions. However, one of the hottest discussions that I have had with officials has not occurred on the field, but off of it.

With a version of the Zach Lystedt law passing in Ohio, it is now a requirement of all coaches and officials that work with kids under the age of 18 to take an online course covering concussions every three years. This has been a big source of conflict since I have been working with officials who are friends of mine to inform them of their new requirements. the most common reaction I have received is that of resistance. The statement "the officials are not there to make a diagnosis" is very common. While I can't disagree with them on this point, they are missing the bigger picture.

The point that I counter this argument with comes, again, from football. Having the officials take this concussion course will increase the awareness of the issue if nothing else. Its should, therefore, also help the officials realize their importance in the prevention of these injuries.

And as it just so happens, another great example of my argument occurred last night in the AFC Championship game. Last night, Stevan Ridley of the New England Patriots was carrying the ball and was confronted by a defender who was ready to tackle him.

How did he react to this situation? Did he try to juke and run around him? Did he try to stiff arm and push him away? Did he change direction and try to find another open running lane?

No, he chose to lower his head to take the impact to the head first. Immediately after the hit, Ridley fell to the turf and displayed what we call "posturing" or the "fencing response" while the rest of the players fell into a scrum for the fumbled football. As you can see on the video, Stevan Ridley is holding his arms out at unnatural angles in front of him after getting hit. While this response is still somewhat controversial as to the relationship of the severity of the concussion for someone who demonstrates a fencing response, it is widely believed to be "not a good sign" for obvious reasons by many in the medical community. When it was later reported by the announcers that the Patriots were not allowing him to return to the game due to a "head injury," every doctor and athletic trainer watching the game screamed at the television "No kidding!"

Of course, this is one concussion that likely could have been prevented in the first case. There are rules in place that make leading with the head like this an illegal helmet contact at all levels of play. However, this has not been equally enforced, if at all. In the last couple of years, spearing has seen a resurgence and is being called more often. However, it is usually only called against the defense and seldom, if ever, against the ball carrier. This needs to change.

Furthermore, the illegal helmet contact penalty is only being called for spearing. Spearing is defined as the perpetrator lowering his head and hit with the crown of his helmet. This is a nice start and helps prevent the catastrophic neck, or cervical, fractures that plagued the sport in the 1960s-70s, but there is more to the illegal helmet contact rule than spearing.

The problem with this is that leading with the face mask MAY reduce your chances of a fracture, but it does not reduce your chance of sustaining a concussion. Therefore, officials need to recognize and call butt blocking and face tackling as well. These are defined in the rules books as illegal acts that consist of hitting an opponent by leading with the face mask. (The difference between the two techniques is subtle and it depends on who is being tackled.) Unfortunately, these hits are usually celebrated by coaches as the big "ESPN" highlight reel hits that end up on YouTube and are not being called properly. Here is one such example that makes me sick to see no flag and to hear the coaches celebrate this hit. http://youtu.be/-V-TUmknlUY

If the NFL refuses to make this call against the ball carrier, then they are essentially telling the youth that this is how it is supposed to be played. This is what gets celebrated. This illegal hit is what gets you a bigger contract, endorsement deals, and ESPN "Top Ten Plays" appearances. The youth are watching and mimicking the pros. The NFL must understand that. It doesn't matter if the professionals don't want to be seen as role models as Charles Barkley of NBA fame once stated. They are role models to the kids who dream of being a part of that small percent of youth football players that make it onto the same fields, under the same lights, and in front of the same crowds and cameras that their role models are playing for.

Of course, this problem is not exclusive to football either. Hockey has a big problem on their hands too. MMA recently released a statement calling their sport "safe." (Whatever they are smoking, it must be really good.) The point is that officials in all sports have a central responsibility in helping to PREVENT the injuries from occurring. The way they do it is through enforcing the rules and creating the precedent that violations of the rules will be penalized. If it requires the officials to go and take a short course once every three years to help recognize their responsibility, then I am in full support.

Besides, did I mention the classes are free?

Reaching out

Over the next couple of months, we will be trying to reach out and inform a lot of diverse groups about the implications of HB 143 in Ohio. Since this legislation requires everyone who works with active children under the age of 18 to take an online course every three years, this is a monumental task. This means that every person who supervises a martial arts class, ski instructor, PE teacher, summer camp counselor, and you name it, must take this this class. We are working quickly to try and build the network we will need to get the word spread as quickly as possible. Here is some of what we have planned.

A major announcement coming soon from the hospital about a project that a colleague and I have been working on for the last two years. No, I can't say any more than that yet.
A new twitter account for our group within the hospital with some planned tweet chats has been created.
A new lunch time podcast will premier soon on iTunes. (Guess what the first few topics are that we have chosen to cover.)
A new quarterly electronic newsletter to help inform parents and coaches via email.
A significant amount of work to drive more traffic back to the hospital's Facebook page and website, both of which will hold more information about the law.
Educational courses for school administrators and teachers to increase awareness of issues and how they can help victims significantly by identifying issues in the classroom have been constructed.

Needless to say, that with the short window we have to eat this all done by March, we have set a very aggressive timeline for ourselves. This promises to be a very busy month and a half since it also coincides with our preparations for National Athletic Training Month and, oh yes, I think there might be a couple of basketball, wrestling, swimming, and gymnastics tournaments running soon.
Yep, this is going to be a fun time.

And just for reference, here is a link to the new law:
http://bit.ly/UdWArT