Here we go again

Another professional athlete makes some irresponsible statements and a major newspaper is more than happy to perpetuate the mistake by publishing his comments.  This time, Brian Urlacher of the Chicago Bears admits that he would hide potential TBI symptoms form the team's medical staff so that he could continue to play.  The comments are incredibly irresponsible and they give kids terrible ideas on how to usurp their medical staffs and stay on the field.  It is because of incidents like this that the education of the public slows to a crawl.  It would be my hope that at some point, the NFL would be able to fine athletes for comments like this, but I don't see that ever happening without risking a lawsuit from the ACLU.

A recent, concerning event

A couple of weeks ago, we hosted our biggest wrestling tournament of the year.  It is a two day event using eight mats in our field house.  The event starts on Friday night with four groups of four round robin that determine the seeding for the two eight man double elimination brackets in each weight class for Saturday.  Needless to say, there is a lot of wrestling and certainly a lot of opportunity for injury to occur.

On Saturday, a young man came limping over to me from a visiting team and asked me to look at his knee.  He was unable to bear full weight on the leg and most of the pain was on the medial side.  It turns out, according to his history, he likely injured his knee early in the fall during his football season.  He was able to "grit it out" and competed through the rest of football and here we are in early January looking at it after his opponent twisted his leg.  As it turns out, when I stressed the knee with a valgus stress, it opened up by about a centimeter compared to his contralateral knee.  Obviously, the concern was very real at that point and I disqualified him from continuing.  According to the coach, he was completely unaware of the prior status of the injury and he agreed with my decision to end the kid's day.

The most concerning part of this injury is the parent involvement. Granted, I have dealt with my fair share of kids that were neglected or ignored by their parents and minor injuries have gone untreated.  This seemed to be of an entirely different level.  The MCL that was injured was not, by any measure, insignificant.  It was only by luck that this young man didn't end up with a far worse injury by continuing to participate in athletics and not get the injury looked at by a medical professional.  I am not sure whether this school employs a certified athletic trainer or not at this time.  However, this situation is demonstrates why there should be an AT employed at every school.  This young man should not have been participating and this should have been caught much sooner.

New tech to detect TBI

Another new piece of technology is being talked about that may help diagnose serious head injuries.  This new device detects hematomas in the skull as a result of a head injury.  Subdural hematomas, by definition, are classified as moderate and severe traumatic brain injuries.  These are not mild TBIs, commonly referred to a s concussions. 

Mild TBIs are more insidious and involve the process of calcium and potassium ions crossing the cell membranes and causing an energy crisis in the brain.  There is no bleeding to speak of in an mTBI.  Therefore, it must be made clear that this new piece of technology, while it may prove useful, will not rule out mTBIs.  This must be very carefully explained each and every time this piece of technology is purchased and used to test for a head injury.  Otherwise, it will have the same problems that CT scans and MRIs do when emergency room staff erroneously tell a victim of an mTBI that they are fine because the test came back negative.

New Years Wish 2012

I  would just like to wish everyone a safe, happy, and healthy new year.  Hopefully this year will bring many more advances that will allow every ATC to care for their athletes better and keep them participating in their chosen sports as much as possible.

NFL athletic trainers in the booth

In light of the incident with the Browns and Colt McCoy's belatedly diagnosed concussion, the NFL has decided to put an independent athletic trainer in the press box of every football game to watch each of the league's 32 teams for proper adherence to TBI assessment protocols.  This can be a unique opportunity to promote the profession of athletic training and to demonstrate that we are capable of performing more than just taping ankles and getting ice.  I hope that this will not only bring more stability to the NFL, but will also promote the safety of the players, and bring some positive publicity our profession.

Upon reading many comments of fans and others interested in the TBI crisis, I found a great many of them had a very negative response to this new rule.  Many of them were asking "Why can't a doctor just be hired to do it and forgo the AT.  To this, I have two answers.  The first is cost.  ATs are far cheaper to hire to watch from the press box than are physicians.  Secondly, according to neuropsychologist Dr. Mickey Collins at the University of Pittsburgh Medical Center, the designers of the ImPACT program, "There is a large number of athletic trainers that are practicing better medicine with regards to this injury than many physicians."  I can't think of a better endorsement than that for allowing ATs to have this chance.

One thing is certain, I will be investigating the position and see if I can get into this for a side job.  After all, it sounds like fun.

The Value of an Education

This post is a significant tangent to the theme of this blog, but I can't help but blow my horn a little.  Yesterday, I walked through my third commencement and received my Masters of Education.  My field of study was educational technologies.  Imagine that, I learned more about using current technologies for instructional purposes.  I think that has something to do with this blog, after all.  So all I really have to say here is "Yay Me!"

Colt McCoy and the Browns TBI

The Cleveland Browns are involved in a controversy.  I should also report that the sky is blue, the grass is green, and water is wet.  This time, the Browns have come under fire for how they treated Colt McCoy after he got hit by James Harrison in the fourth quarter of the football game this past Thursday night.  I was just as shocked as the rest of my colleagues were when Colt reentered the game.  His return is being reported as occurring just 3 minutes and 50 seconds of real time (not game time) after getting hit.  Local radio talk show hosts are using the incident to further their cause for ousting Pat Shurmur as the head coach and people calling in are agreeing with them.  Colt's father even discussed with a local journalist and called the Browns' actions egregious and that his son should not have returned to play. Needless to say, it has caused quite a lot of conversation locally, and a fair amount nationally.


To nobody's surprise, fans' amazing powers of prediction were confirmed when the Browns released the injury report and Colt was listed as suffering "concussion like symptoms."  According to reports, the symptoms started after the game was over.  This is not out of the realm of possibility and symptoms may not have appeared until after the game ended since it was the fourth quarter when the hit occurred.  I have seen many instances where it takes 10, 15, or even 20 minutes before any symptoms appear that would indicate the athlete's cognitive function has been compromised.  A bigger issue arises in the fact that Colt was only on the sidelines for less than four minutes.  There is no way to perform a comprehensive evaluation of a person's cognitive functions in that short amount of time.  Simply getting symptom score from the SCAT2 would be difficult in that short time given the amount of noise that was present around the evaluator and Colt in Heinz Field.  To complicate matters, Colt did complain of some pain in his thumb that the ATCs would also need to examine in that short time and Colt was lying on the field for some time after the hit while the broadcast cut to a commercial.

Granted, there were only a few people on the sideline that would know what the story is and how it unfolded, but it does seem to me that after a particularly hard hit like that, it would behoove the medical staff to at least get a concussion exam performed.  It does seem highly likely that a TBI screening was never performed on the sideline before allowing Colt to reenter the game, which would confirm Mr. Mortensen's assertions on Sunday that the Browns lied about the TBI evaluation and allowed him to return to play.  The critics' arguments are based on the fact that Colt "was suffering from concussion like symptoms" at the time of the hit because he was "obviously knocked out when the hit occurred."  I would love to know what kind of visual aid these critics were using to diagnose this because I cannot possibly confirm or disprove that Colt was indeed, "out cold."  The only person that might know that would have been James Harrison, if he bothered to look at Colt after the hit.  Unfortunately, the replays cut away too quickly to know if Mr. Harrison had looked.  I have seen a lot of athletes simply lie on the ground for a half second after a hit to "catch their breath" before getting up and running off.  This "knocked out cold" diagnosis is impossible to make from the camera angles, the existence if the helmet, and distance.  Therefore, we must rely upon what the medical staff saw at the time of the hit.  Since I wasn't there, I cannot offer an opinion and I believe that nobody else should either, especially non-medically trained radio talk show hosts and callers.

Since the medical staff will not be speaking to the press anytime soon (the federal law, HIPAA, makes it highly improbable that it will ever happen), we have to rely on the official information being released by the Browns.  This information has been tightly controlled and therefore, leads to a lot of speculation.  The problem is that the media needs to realize that they won't always be given all the answers to report and their speculations are not the truth.  This often leads to other issues that make every athletic trainer's job significantly more difficult.  The issue that faces the high school and collegiate AT is that leaves athletes and parents wondering about what the proper protocol is when their son or daughter gets hit in the head.  Why do I take so much longer to evaluate a kid when the Browns can do it in under 4 minutes?  It makes me look like a poor professional and it leaves the high school and collegiate ATs in a pinch when this situation comes up.  It then takes an extraordinary amount of time to explain the difference that I can only hope takes place after I have completed my thorough examination, not during it.

James Harrison Strikes Again

How many times does it have to happen for some fans to get it through their thick heads that the rules have changed from the days when they ran up and down the football field?  Medicine has advanced considerably and has proven that these actions have a high probability of leaving a person with a life altering injury.  The face tackling, butt blocking, and spearing techniques have been illegal at all levels of football for nearly 40 years.  What has changed is the awareness of head injuries associated with these collisions.  The rules have only recently changed to create better rules enforcement because of recent discoveries with head injuries.  I understand that this is a violent game played by consenting adults (in the NFL), but that doesn't mean the players need to be at an unnecessary risk for injury.  This risk is easily minimized by making a solid tackle at the hips using the chest and shoulders.  The headhunting and ESPN highlight reel hits are unnecessary.  This oaf has been been repeatedly fined for these actions and has not learned his lesson.  The slow motion video clearly shows that instead of lowering his level and breaking down to make a tackle, he lowers his head slightly and launches at the QB's head.  Since this is not the first time he has done this, he needs to be suspended without pay for an extended period and warned that expulsion is a consideration.

To all the former high school and college players who want to say "this is just football", think about that when it is your 7-17 year old son imitating these hits in their Pop Warner, middle school or high school games.  When it is your son who gets hit like this and ends up as a special education and special needs child as a result of of the hit.  This IS HAPPENING all over the country.  It is not well reported, but you can find the stories over the internet every year.  I would refer you to websites like http://www.theconcussionblog.com or http://www.sportsconcussions.org where you will find many resources to educate you about what is happening.  It is time for the fans of "traditional" football to wake up and realize that we can significantly decrease the injury rate and maintain the integrity of the game.

 Finally, there may also be some reason to question the Browns' medical staff as to the nature of a head injury to Colt McCoy as a result of this hit.  There have been a few reports including this one that state that McCoy doesn't remember the hit and that the media was requested to not use the intense lights on McCoy after the game.  Both of these are indications that there may have been something wrong and a possible traumatic brain injury.  I hope that there will be more comprehensive updates of Colt's status released in the next few days.

An open question to ATs covering wrestling

History
Several years ago, the NFHS followed the NCAA, NJCAA, and the NAIA in implementing the weight certification process for high school wrestling. I had the unique opportunity to offer input into how the rule was written for Ohio. Before I ask my question, let me explain what we are doing in Ohio high schools. We are using skin fold calipers and urine dipsticks as required by the Ohio High School Athletic Association. Furthermore, the OHSAA has a required parental consent form for the urinalysis. Also, there is a two tiered system of certified assessors. We maintain both master and general assessors. The difference is that general assessors can only perform an initial assessment. The master assessors can perform the initial assessment, the first appeal assessment, and conduct the class required by the OHSAA for new general assessors.  There is also a second step appeal by using a BodPod air displacement test or an underwater weighing, both of which are performed by labs approved by the OHSAA.

My question to my fellow ATs is regarding the urine dipsticks. When the rule was being written, I conducted a pilot of the weight assessments with the cooperation of most of the schools in our conference. At the time, we used refractometry to do the urinalysis. However, a short time later, a coworker from the hospital's lab asked me how we were able to get CLIA certification to perform the refractometry. I was left staring at her with a very dumb look on my face. She referred me to the CMS site to look at the Clinical Laboratory Improvement Amendment. What I found was discouraging. Refractometry, when used to determine a health plan, required an expensive license to perform. There is a waiver that can be obtained, but it required payment for individual tests. That quickly got equally expensive for the number of wrestlers we were looking to test statewide.

When I recognized this issue and brought it to the attention of the OHSAA, they balked at the idea of using refractometry and decided to use the urine dipsticks instead.  The dipsticks required a very small waiver fee and the OHSAA pays that each year for all the assessors in Ohio.  Therefore, for the last six years, we have been using the dipsticks.

By now, my question should be obvious, what is everybody else doing to stay legal while performing the refractometry assessments?  Any information would be helpful since I now have two refractometers sitting in my desk collecting dust.  One brand new and never used and the other is only used the one day of the pilot test.

The following section is included to prevent other questions about why Ohio did what they did in other parts of the assessment.
The OHSAA also decided to the skin fold calipers instead of the BIA because of the cost and questionable accuracy associated with BIA.  I had no issues with this, but this was also why Ohio decided that there would be a class required before being eligible to perform the assessment.  In doing so, the OHSAA could assure better competency with the skin fold calipers by the assessors.  To further ensure competency and credibility, the OHSAA mandated that the minimum requirements for an assessor was a bachelor's degree in a related health field.  That standard includes MD, DO, DC, PT, ATC, RNs, dieticians, and exercise physiologists.  Needless to say, there were some very unhappy health club employees out there (personal trainers, fitness trainers, etc.) because they were excluded from the rule.  Since I am a master assessor, I fielded more than one angry call about why they were excluded when they wanted to become assessors found they weren't eligible to take the class.

Congratulations to Pennsylvania

It is nice to see that state legislatures are taking this issue of TBI in youth athletics seriously even though it bucks the trend of the culture surrounding youth sports.  Pennsylvania became the 32nd state to enact similar legislation to help protect the young athlete.  The interesting part in Pennsylvania is that it requires a suspension of any coach caught breaking this law.  I find that to be a very positive step even though it may be hard to enforce.

Unfortunately, it does appear that certain other uninformed, yet boisterous individuals got their outdated opinions heard and the law reflects that.  While athletic trainers are designated specifically, the physicians are allowed to designate people that they trust to return an athlete to play in a timely manner.  I understand that this individual was nowhere to be seen or heard from when the bill was being signed.  It is truly a shame that he could not be bothered to show after he decided to interject himself and his ridiculous opinions into the conversation.

Finally, I am now wondering where my home state, Ohio is on its bill.  It has been sitting in committee for months now with little to no movement and it seems to have stalled.  There have been no updates released about the legislation in a couple of months now and I am beginning to worry about it.  I trust our state legislature is still working on getting it passed in a timely manner.

Football season reflection

As our football season draws to a close this year, I am reflecting back to how things went and what needs improvement from a sports medicine standpoint.  Certainly, this season was not without its glitches.  The majority of the high school/ middle season went well, but I am I afraid the officials lack of attention towards illegal helmet contact was still a major issue.  There were many times this season that I found myself instructing our players to keep their heads up and avoid head hunting after hitting an opponent in an illegal manner.  Surprisingly, with one varsity game remaining, I have not seen a single illegal helmet contact called against us.

That is not to say that I didn't see it called all year.  In one game, the same kid from the opposing team was called twice in the same drive for illegal helmet contact.  Both calls were warranted and correct, but I wonder if they were penalized appropriately.  Certainly, if the student athlete had hit anybody in the same manner a third time, I would have been screaming for his disqualification.  There is no reason why that should happen repetitively by the same person.  A second identical penalty should carry with it a stiffer penalty for a disregard for safety.

The next issue that I saw with this season involved parent understanding of the rules regarding return to play after a TBI.  The rule was released in Ohio back in January by the Ohio High School Athletic Association, and yet, the majority of the public has no idea it exists.  In Ohio, everybody must agree for a kid to be eligible to return to play.  This includes the physician, parents, athletic director, coach, and the athletic trainer (where applicable).  If one of those parties says no, the student-athlete is not eligible to RTP.  It was a large issue early in the season with one parent that they wanted their son back in the game, but he had skipped many days in the RTP protocol and I was holding him out.  This caused some friction early on, but fortunately, he was able to play in the first game and only missed scrimmages.  However, I am sure the issue will rise again and I have not addressed it for the last time.

Also, there is the issue of the youth leagues.  Fortunately, it appears that in Ohio, the state legislature is moving forward with the law and it will include the protection of kids younger than middle school.  However, there is still a very serious lack of education about what a TBI is in this age group and how it is recognized.  The incident I ran into earlier this year certainly explains a lot about the lack of education at this level.  It needs to be addressed and quickly.  I plan on working more with the hospital that I work for in order to increase our course offerings and try to get the word out to more people.

Finally, the legislation that I referred to looks like it is bound for passage soon.  The latest arguments are over who should be included as a medical provider capable of making RTP decisions for student athletes.  While the bill hasn't been updated online to reflect the changes, it is my understanding the DCs have been added to the list that already includes MD, DO, and ATC.  I have also heard that the PTs and RNs have been told a flat no to this point.  While I am not crazy about the DCs being added, and I admit I am not fully aware of what their qualifications are, I hope that the bill stands the way it is currently written.  I know far too many PTs who want no part in the RTP decision after TBI and question the OPTA for their stance on the bill.  I am forced to agree with the individual PTs.

An interesting partnership reported

One of the recent articles that a Google News search produced for me described an interesting partnership between a highly reputable companies.  The timepiece manufacturer, Timex, and the Korey Stringer Institute (known for researching and education of the athletic population on the dangers of heat illness) recently joined forces.  I was intrigued that Timex would have the inside knowledge of the research that is occurring at KSI and would be able to design products that would aid in the detection of problems while exercising.  It would be my hope that somehow, they would be able to find a way to monitor body core temperature reliably and be able to transmit the data to a watch or even an iPod.  I realize that the only methods of measuring temperature reliably at the moment are with a rectal thermometer or with a disposable, ingestible thermometer.  It would be my hope that with this merger and using some creative engineering, that these two would be able to develop a practical, reliable, and inexpensive method of monitoring body core temperature.  That is something I would pay for VERY quickly.

A great piece of news from the head injury front

Recently, a player was "earholed" (hit in the side of the helmet, forcefully) on a play and pulled himself from the game.  The athlete went to the AT admitting to various TBI related symptoms and was taken into the building for further examination.  This athlete's parents followed the team physician into the office where she performed her evaluation.  By the time the AT got into the office about 10 minutes later when halftime arrived, the father met the AT requested that the AT not put his son back in the game and hide his helmet.  He was very happy to hear that this AT had already taken the helmet from him.

I was pleased to hear that the father was educated enough to know the dangers and not risk further injury.  While there is still a lot of work that needs to be done on the education front (as is demonstrated in my previous post,) It is stories like this that make the efforts encouraging since it is showing some signs of progress.  If I could, I would give a helmet sticker to the parents for their awareness regarding this issue and I applaud them for their efforts and remaining educated in this issue.

Public and Coaching Education Required

Lately, it seems that there is a great lack of respect for the amount of knowledge that an athletic trainer brings to the table when it comes to traumatic brain injuries.  Certainly, I have stated the case may times, including on this blog, that parents of high school athletes don't really understand the lack of current training of emergency room physicians.

However, it has also been demonstrated to me that an insidious idea is more wide spread than I previously thought.  The idea that having the title "doctor" means that they are the authority on ALL things medicine is a fallacy.  The notion that an individual doctor can know every injury and stay current on every topic is flat out absurd.  The latest instance came where a pediatric oncologist (who as I understand is exceptional an oncologist) signed off for a kid to return to play in a youth football game.  I find it difficult to believe that an oncologist has the same kind of updated training that a neurosurgeon or a neuropsychologist does in treating TBIs.  I find that the willingness of physicians who probably have not had any training with TBI since their days of residency to do a quick evaluation on the sidelines and sign a piece of paper to allow a child with a potential TBI to return to play to be appalling.  I don't know of a single physician that would allow anyone else to intrude into their area of specialty and try to make recommendations based on outdated evaluative techniques and theories.  I don't see where this is any different.

The most frustrating part of this is that the parents and coaches that were most closely connected to this situation completely disregarded the opinion of the individual who was identified as an athletic trainer (who also happened to be a referee of the game).  The league administrators even scoffed at the idea that the athletic trainer's experience may have been sufficient to recognize the possible TBI and send the child for further evaluation.  It was plainly obvious that these individuals had absolutely no idea of the background of a certified athletic trainer and need to be enlightened.

Five football players from one team rushed to ED in one game

This was a scary news article that just cam across my twitter feed via our local Fox station.  It appears that in one local game this past weekend, five kids were sent to the emergency room from one team.  That's right, five kids from one team.  Once of the five was even life-flighted to the local level 3 trauma center.

Granted, it was the hottest day of the season by far, including all of our two a day camps.  It was in the low to mid nineties with very high humidity and it pushed the heat index up over 100.  We hadn't seen these kinds of temperatures in northeast Ohio since the third week of July, before football camp started.

We also dealt with our fair share of heat cramps that evening on both of our sidelines that evening.  (Which by the way, we played about 10 miles away from where this terrible situation occurred.)  Because all of the ED trips were for members of the same team, I highly suspect that there was a group of kids drinking the energy drink that were alluded to in the article.  Previous posts on this blog have attempted to demonstrate the dangers of consuming these energy drinks before the intense exercise.  One thing is for sure, I will be using this as a "teachable moment" for our kids to learn from.

The article from local news source is referenced here.

Updated (8:54 p.m. 9/4/2011) After doing a little more digging, I found that according to the Ohio High School Athletic Association, there is no athletic trainer currently serving at Conneaut High School.  Since the OHSAA is usually very good at updating the information on this directory, I assume this to be the case.  If this is true, it would be very hard to blame an athletic trainer if there wasn't one available.  This just goes to reinforce the fact that if you cannot afford an athletic trainer, then you cannot afford an athletic program.  Of course, many poorly educated individuals are still firing off all kinds of inappropriate comments on various outlets including Fox 8's post on Facebook.

The Second Update (9:32 a.m. 9/5/2011) Since the original article was posted from the local Fox station left a lot to the imagination, the school district released a statement that clears up the situation a bit.

    "Five Conneaut athletes and one Warren Champion athlete were transported from Conneaut Stadium via ambulance to neighboring medical facilities during the game on Friday night. All were released on Friday, with the exception of one Conneaut athlete who is expected to be released later this week from a Cleveland hospital. Preliminary findings indicate that two Conneaut athletes and one Warren Champion athlete were suffering from the effects of the oppressive heat and humidity. The remaining athletes, all from Conneaut, incurred injuries as a result of the game itself. These injuries included a bruised rib, a possible concussion, and a knee injury. Shortly into the fourth quarter, after a brief conference between the referees and a mutual agreement between both team's coaches; the game was halted. The decision was made in what was thought to be in the best interests of the athletes. The Conneaut Area City Schools would like to thank all of the emergency responders, the Conneaut and Warren Champion coaching staffs, school administrators, and volunteer parents who aided in the crisis. Cooperation among all involved resulted in a resolution that protected the health and well-being of student-athletes."  (From the Conneaut School District)

The explanation that only three of the athletes were heat related does help, but the explanation does add that there was one additional athlete from the visiting team that was transported bringing the total to six.  However, the young men with the bruised ribs and the knee injuries would possibly have been screened away from EMS if there was any medical staff there available on the school's sideline.  This sounds more like coaches who are trying to be careful in the absence of an athletic trainer on the sidelines.  This story should only reinforce the fact the statement I made earlier about being able to afford an athletic program.