This is one of my more outspoken and shared opinion pieces about concussions, it originally was penned in August of 2013.
==========
There is a lot of belief and trust each and every one of us has in those that are medical professionals. The further you go up the chain in those professionals our trust is greater and our belief is stronger that they know more. The sad fact that in some instances those near or at the top of the chain don’t know enough and are putting people, in this case a kid, in danger; not only in the near future but the long-term.
Compared to a physician (MD/DO) I would say my medical skills are pale in comparison, and rightfully so; their schooling and experience far outpace what I have learned in the medical field. Because of this the athletic trainer (I) am not held as in high regard when it comes to decisions about the care of an athlete; which I am fine with… 97.43% of the time (I just made up that number, ha). However there are times when a MD/DO – those making the final and binding (in parents and patients minds) decisions – make a mistake. This is not just some Monday morning quarterbacking either, its FACT.
Just recently I had an athlete take a blow to the body and head in a practice, and they immediately came to me distressed. How distressed? Well that is one advantage I have over a MD/DO, especially the ER doc, I know the kids and have the resources of his/her peers as well as coaches who have known the kid for many years. In this case the athlete was way out of their sorts;
- stumbling
- grabbing eyes
- rubbing head
- slow speech
Upon asking questions to this athlete they expressed their history with head injuries and told me their head felt like the three previous concussions they had experienced, except that they had never been this “‘wobbly'” in before.
After letting the player calm down and get a drink a quick sideline examination/test confirmed what I suspected; possible concussion. Unfortunately the family has dealt with this situation many times, so the “drill” was known and the information I was passing along was nothing new.
Upon arrival of the athletes caregiver we decided the state of the individual along with the history warranted a visit to the ER to calm any concerns of more extensive damage. So off they went, with the hopes of nothing more than a concussion; while I was pleased that the caregivers “got it”.
Later in the evening I received a phone call from the parent and was told this; “The doctor says they don’t have a concussion, a strained neck, and they can return to play and follow-up with their PCP.” I asked why they thought it was not a concussion and they were told “there was nothing on imaging that would indicate a concussion.”
OMG, SMH, AYFKM, WTH, insert your own acronym.
This exact situation is the bane of our existence as athletic trainers when it comes to concussions – a close second is the ER doc telling an athlete they are out for 2 weeks with a sprained ankle – people who are seeking medical care listen most importantly to the doctors in this situation. Not only does it make me look bad and uninformed, but that information is taken gospel, regardless of my well thought out dissertation/presentation about the suspected injury.
I get it, that I cannot diagnose and I’m not a doctor, but as we have educated hundred of thousands of people it doesn’t take a doctor to identify a concussion – it takes common sense and understanding the evolution of this injury. When it comes to concussions I will put up my knowledge against 99% of MD’s and in this case my knowledge trumps what the ER doc has said; and I will not apologize for saying this.
I was told that the athlete told the doc the same stuff he told me about the mechanism of injury, to the immediate symptoms, their history and the symptoms at the hospital. Yet, to my disdain all of this was ignored for imaging? When was the last time the attending read any material on closed head injuries or mTBI, let alone concussions. I would hazard a guess its been since medical school and its @$^&ing ridiculous.
This cannot happen. This should not happen. This is borderline negligence on the part of the doctor.
What happens if this athlete did not have an athletic trainer and goes right back to action and sustains another blow? How would a coach look if he sent this player to the ER only to be undercut by the attending? Does the coach begin to second guess themselves and not send these type of injuries to the ER? In all those questions it’s a catastrophic outcome, regardless if the worst were to happen, its catastrophic for the long-term brain health of the individual.
Needless to say I placed a phone call to the physician with concussion experience at that hospital and reported it to him. He was very unhappy, he has spent time trying to educate the emergency department on such cases, but apparently this has fallen on deaf ears.
It. Has. To. Stop.
I am not done with this by a long shot, as soon as this is posted the ED will be getting a phone call from “some athletic trainer” who in their initial estimation will believe I am playing outside my realm of knowledge. When, not if, I get the chance to talk to the person in charge they will find out I am about the furthest from that when it comes to concussions.
The Concussion Blog 
It’s a crying shame Dustin. But the fact of the matter (as you well know) is that this sort of thing happens daily. I, like yourself, received a phone call just earlier this morning with a similar situation. I have two physicians I trust and they happen to be the medical directors for our concussion program. They speak the language and understand the drill. Outside of those two I feel the same way you do. Let’s stop the BS with parents trying to circumvent the qualified professionals (AT’s and physicians with specific knowledge of concussions and their appropriate management) and other physicians trying to play that they get it.
Like I tell folks all of the time: There is no “quick” fix. It’s unfortunate that you have sustained a concussion, but it’s part of the game and you have to go through the process (no matter how mild it may seem) and let the “system” run it’s course. Until then, you should follow directions and just be patient. Like one of my physicians told a patient yesterday: “It’s like a FRAM oil filter…you pay now to protect it later” and you’re done with it.
Hang in there brother! Continue to share your stories and educate on this topic.
Tommy
Dustin don’t sell ATCs short. A central fallacy in medicine is that it is a science; it is more akin to a trade. ATCs know the patients and have seen hundreds if not thousands of similar injuries. If the ATC is well trained and up-to-date, he/she is far more capable of making a Dx than most ER docs. Most ER docs are in meat moving business.
If you want to find a good clinician, see how many cases of a similar type he or she handles and look at the outcomes. Interestingly the best of best tend to have slightly less than top outcomes because these docs take challenging cases that go beyond plain vanilla work. For example, a doc that does 4 hip replacements a day is going to be on average a much better orthopedic surgeon than one that does 4 per month.
ATCs are dealing with doctors often poorly trained in brain injury (this guy probably did his residency at UPMC), mislead by phony research (see Mark Lovell’s admission during OTL story from Sunday) and subject to chorus of idiocy orchestrated by Roger Goodell and Greg Aiello to conflate the brain injury issue.
Given Roger’s latest wave off propaganda, you should expect it get worse before it gets better.
I understand your frustration. I finally got tired of the ER docs and put in a concussion policy at my HS. It expressly states that only two MDs that I trust with a possible concussion can clear one of my athletes and that no other clearances are acceptable. But if you believe that your athlete still has a concussion it’s well within your job duty to hold him or express to the parents that you need a second opinion.
First of all let me, as an ER doc, apologize for my brethren. It is very true that the level of sports medicine knowledge among us is variable at best. Truth be told, only a handful of us are up to date with regard to current concussion management (and obviously diagnosis for that matter). I work for a large group and am continuously trying to update my partners on these things. Here is what you can expect when you go to an emergency department, if you have an acute life threating illness or injury your care will likely be very good and standardized. Anything else is going to be a crap shoot based on that provider’s interests and backgrounds. Here is my advice for all athletic trainers 1) have a physician or group that work closely and trust, 2) if you have to send an athlete to the ED, explain what your working diagnosis is, tell them and their parents why they are going to the ED (we need to make sure you do not have bleeding around your brain, or to make sure you do not have a fracture), tell them they may get told something else by the ED if the tests are normal, but that they will need to see X doctor (in your trusted group)before they can come back to practice. In this way you set the expectations of why they are going to the ED, that they may get conflicting information, and you can let Dr. X set everything straight (those dam ED doc’s don’t know anything!).
Dr. Benford,
Sounds like you should be offering a CME, CNE and the equivalent for an ATC. Life would be much easier.
Cheers.
I have done several at the local level but it has been difficult getting the larger group interested.
As previously discussed in this blog…there has been a significant attempt by apparent anti- social and narcissistic individuals to disseminate concussion / brain injury misinformation to both health care professionals and the general public.
Based on ongoing comments re this pattern of misinformation…it appears that nothing changes if nothing changes applies to this situation…
Below is an excerpt from my 2004 Dissertation research re NFL Players’ knowledge of concussions that remains pertinent to this discussion:
———————————————
A Preliminary Investigation of Active and Retired NFL Players’ Knowledge of Concussions (2004)
Not only is there a need for better and more accurate concussion education, it also seems appropriate that professional, collegiate and amateur organizations, along with secondary educational institutions, be held accountable for providing essential knowledge to the athletes, coaches, trainers, health care professionals, and students enrolled in their medical and health care educational programs.
In addition, since much concussion information filters down from health care institutions, curriculum changes seem to be needed to significantly better educate medical students and physicians-in-training pertaining to concussions (Alexander, 1995; Kelly, 1999; Sweeney, Davidson, Melgar, Patel, & Cucos, 2002). Alexander (1995) pointed out that the lack of available research funding for TBI had also adversely impacted this topic being adequately discussed with students enrolled in medical school. (page 91)
Sweeney et al. (2002) not only specifically cited studies reflecting “suboptimal sports medicine educational experience for residents” (p. 219), but also concluded that sports medicine received minimal focus in the US when curricula were formulated.
The authors also found that a survey of recently graduated chief residents revealed that approximately 68% of 233 survey participants reported being less than comfortable managing a concussion sustained by an athlete.
.
PS….
And supporting recent research: 2013
Pediatr Emerg Care. 2013 Aug;29(8):884-7. doi: 10.1097/PEC.0b013e31829ec0d9.
Evaluation of emergency medicine discharge instructions in pediatric head injury.
Sarsfield MJ, Morley EJ, Callahan JM, Grant WD, Wojcik SM.
Conclusions:
Children sustaining head injury were inadequately instructed to restrict athletic activities upon discharge. This is particularly true for patients who sustain an mTBI from non-sports-related activity
PPS…and coincidently I was conversing with a person yesterday whose 7 year old daughter went to a local the ER several days ago after falling and apparently experiencing a seizure.
Child was Dx with a mild closed head injury (mCHI)…and given poorly written instructions re monitoring, etc.
After informing the parent that a mCHI was a concussion / brain injury she was stunned…
and stated “since the ER Dr. said the injury was mild I didn’t think the injury was a big deal “. I had planned on having my daughter participate in her weekly gymnastics…
Frustrating as it is, this still happens on a monthly basis – some hospitals are much better than others. Although, there has been significant improvement in the last few years & I notice it happening less and less in my practice.
I always call the ED physician and explain what I heard via my history and saw on exam – and therefore why this is a concussion. Most of them want to get it right. I also often question exactly what the family told the ED physician – histories can change, especially in the multiple concussion kids, in order to keep that athlete playing. Yes — parents lie and facilitate on a weekly basis for their “star athlete” child. It’s usually one of them saying that he/she had concussions when I was younger and it’s not that big of a deal – “I never had treatment”.
But in the end, in my opinion, it comes down to having a good concussion action plan – well known to parents/athletes/coaches in the preseason, so that there are no excuses during the season. This is includes: management and return to play issues, like who has final say (or can the ATC/LAT overrule a non-team physician MD)? Can an athlete return to play if not fully caught up in school after a concussion? And what communication needs to happen between the school ATC/LAT – school administrators – treating physician to ensure appropriate clearance.
Hopefully, your phone call went well and the conversation did not get too inflammatory.
It was a good phone call…
I’m wondering if there isn’t a way to effect change at the organizational level. ER docs are hired and paid by someone, and those “someones” can set policy. I’m not saying that they should tell docs how to practice medicine, simply that they are in compliance with some set of standards, such as having proof of adequate concussion training. Professionals are required to do some sort of ongoing education to stay “in play”, why not make accurate and up-to-date concussion diagnosis and treatment training a part of that?
Of course, then we get into the question of who sets the standards, but it would be a start.
Considering how prevalent concussions / mild TBIs are and how disruptive they can be, I would think the community would have a huge investment in ensuring their local care providers were up to snuff. In the area where I live, a local hospital was getting horrible reviews, not performing well at all, and earning the sustained ire of the community… and the administration turned it around. Better medicine is now available, thanks to changes driven from the top.
Why not apply that same to concussion care? Reach the people with the purse strings who set policies, and there might be a chance for change.
Here is the very sad truth. Until someone is going to make some money on this (read drug company), no one will be willing to spend the money that is required to lobby (pay for) an agency (such as AHA) to set a universal standard with continuing education requirements. Money talks.
This type of sh** happens more often than we think, and not just in the field. The
truth is that many physicians or docs just don’t know about concussions and physical injuries like PTs and athletic trainers. I remember 6 months back, when one of the boys in our team took a hit to the knee. Looked pretty bad, and we sent him to ‘the’ physician. They sent him back saying there weren’t any fractures or sprains, and that nothing had come up in the imaging. The pain persisted, and so I personally took him to AESM, which an athletic sports injury clinic here in Toronto. Turned out that he needed a month of PT and physical conditioning before returning to the field. If I hadn’t gone ahead and gotten his knee problem diagnosed, he wouldn’t have been able to play for over 6 months. You’re right. It has to stop.