I have been asked to write about concussions from time to time. I attempted a chapter on concussions for a book at some point, over the next few weeks I will post this chapter, as I wrote it, no matter how horrible it is. After all I am not an author, but at least you can take a look. This particular chapter deals with concussions in the sport of football. We all should know this injury can be sustained in any sport. Because football is the biggest draw of sporting eyes I felt it was best to present it in this way. (Part I, Part II & III, Part IV, Part V & VI, Part VII & VIII) *All sources will be posted after last portion is up.
Concussion Chain of Command
As with most everything on a sporting field there is a “chain of command” for procedures and decisions. This is also very true for injuries; concussions are a hot topic for this schematic because we are basically still feeling out the process.
Generally speaking with all other injuries on a football field as the player is removed from the game for evaluation the athletic trainer will initially asses and make a real-time decision about contingencies for return or to remove the player. In most division-I and II programs there is a supervising physician on at least the home team sideline. At the upper levels team doctors will also travel with teams, more as a trust factor for the coaches and medical staff.
After the assessment by the athletic trainer the physician will perform a cursory evaluation as well and the two medical professionals will “compare notes” to make a more sound decision. It should be noted that an athletic trainer will perform the same exact testing that the doctor will; skills in the orthopedic evaluation realm are equal between these health care providers. Moreover, if the supervising physician is a general practitioner then the skill set of the athletic trainer for orthopedic evaluation will be far superior in almost all cases.
After the physician makes a determination for further diagnostics (x-ray), and feels the athlete will be safe to return the athletic trainer will use his knowledge to tape, brace or render the athlete ready for play. It is then the job of the athletic trainer to communicate to the coach the player is set to return, after that it becomes a coaches discretion.
With schools that have more than one athletic trainer, there will be a designated individual who is the “head” for that sport or competition and the others will defer up to him/her. If students are involved then each student(s) have a set chain of command in relaying information to those in charge. You can basically think of it as a quarterback (head athletic trainer) in a huddle, where the doctor (if available) is the head coach of the medical team.
In terms of concussions this example of protocol is an absolute must as the physician is the “buck stops here” individual. That is said with extreme conviction, because that is how it should be. Coaches should never be making decisions without proper advice and medical direction from the medical team. Coaches call the plays and make personnel decisions and the medical team handles the injuries and determines return to play decisions.
There are a myriad of “protocols” that exist with this particular injury, states are even passing legislation to define a minimum standard for youth sports participants. The general aspect of all concussion protocols, from youth leagues to the professional ranks, is that the lead health care professional (as defined by each institution) will be the only one allowed to return an athlete back to competition that same day. The other common thread with protocols below the professional level based on the Zurich recommendations, is that no athlete shall return to action in the same day after sustaining a concussion. Noted is that coaches do not, nor will not ever be allowed to return an athlete from a concussion, during the game or after care.
Professional football has a deeper level when returning from a concussion (not during the game); if a player has been diagnosed with a concussion they must not only be cleared by their team’s medical staff, they must also be cleared by an independent neurologist. College football relies upon the school medical doctor and/or team designated neuro-pathological specialist. In the prep level it all depends on which state you are playing in, most however require a physician’s clearance to return to sport. Unfortunately all of these guidelines have not tricked down to the youth ages, as very few states have a mechanism for that age group, it is hopeful that those leagues will follow the lead from above.
Consistency is the key with this injury, as we have noted with orthopedic injuries, fractures or ruined ligaments have a standard “protocol” for safe return. It is hopeful that those involved with decision-making will solve this pressing issue, and standardize concussion assessment, management and return to play.
My Scariest Moment
As an athletic trainer I see every injury that you have heard of and some that you may not have. Seeing legs broken and facing the wrong direction, shoulders out-of-place, and fingers pointing in unnatural positions are occurrences that are “easy” to handle. Although disturbing to see and painful for the individual, those tend not to be life threatening and are rather simple to manage and get help for. Not so “easy” is the injury to the head, particularly closed head injuries or concussions as you have come to know them.
Unlike the other “gross” injuries with a concussion you cannot see a whole lot and you rely upon what the person is telling you. Concussions are an “invisible” injury, one that up until now most people either did not fully understand or refused to understand. Being the health care provider on scene and the one who sees the injury occur puts the profession of athletic training in a unique position. As we have discussed previously the detection of a concussion is not unlike being a CSI.
On Friday October 22, 2010 I posted about what was and still is the most scared I have been doing my job as an athletic trainer.
The most recent concussion I handled was my worst nightmare right before my eyes. Some of the scariest moments in athletic training are those when kids are returning from an injury. On the inside, you are scared that they will re-injure, that what you have provided was not enough, that you could have done something more to protect them. All of that is amplified by about ten-fold with a player returning from a concussion.
This player was one of our first concussions of the season. He sustained it September 13th and was not allowed to return with MD clearance until September 27th. He went through the graded return to play. He passed that, and then passed his (neurocognitive) test with flying colors. He participated in lower level games and one varsity game prior to last week. Each game he was debriefed by one of us in the athletic training room.
However, this past Friday he sustained another hard shot to the head. I saw it, and cringed a bit as he was on the ground, but he popped right back up. As he began his way to the bench from across the field, he grabbed his head and I knew something was wrong.
I let my student perform the evaluation on him. He wanted back in the game, saying he was fine. Although, you could tell that the weeks of drilling him about the symptoms and dangers of concussions were beginning to seep through. He was more truthful and compliant with us, so I focused my attention to the game on the field, while my student watched over him. As I was trying to find a ride for him (other than the bus) to get home, I was beckoned by my student. She reported to me that his condition was deteriorating, as she was telling me this he started to close his eyes and sway badly.
Without thought I bolted across the field, while teams were in the huddle, to inform the home athletic trainer I need the ambulance, “NOW”. I sprinted back across the field, this time the officials blow the whistle, and our coach asked what was going on, I told him to clear the field and let the ambulance on our sidelines.
Keeping him coherent was a task, all I could think was “Second Impact Syndrome“…All I could think was “let this not happen”… All I could think was “stay calm”… All I could think was “do your job”… All I could think was “he is going to be OK”. As the ambulance arrived the crew deferred to me and immediately placed him on the stretcher, got him in the ambulance, and they left with lights and sirens to the local hospital. His parents were not there, so I sent my student in the ambulance with him so I could still perform the role as athletic trainer for the remainder of the game. Thankfully, the only injury was a rolled ankle in the waning minutes.
After the final horn, I took care of all the post-game stuff and checked my phone for an update. It had been about 25 minutes since the player was transported. I received a text from a student that read, “just arrived at hospital, they were having a difficult time keeping him aroused.” I debriefed the head coach and he sent the team off on the bus home, and stayed with me as we headed to the hospital. The administration had contacted parents, who were 1.5 hours out, but on the way.
At the hospital, only his aunt, uncle, the coach, my student, and myself there for him, but we were not allowed in the room, per HIPAA rules. In fact, the only update we received was watching him roll by on a stretcher from CT scan, and he was not looking good. He was pale, being administered oxygen, strapped to a spine board, with his eyes closed. For the first time I allowed myself to be worried. Not knowing his prognosis was the worst. After retrieving my student’s car from the school, the hospital staff informed us they were transferring him to a bigger hospital, as his condition was not improving.
Thankfully the bigger facility was the hospital I work at, so I could get access to him until his parents arrived. I think I needed to see him more than he needed to see me. As we arrived I used my badge to get in the ER and find him, eyes open and a huge smile greets me. All I could think was “PHEW.” He just wanted off the board, he just wanted to hear he was going to be OK. He wanted to know if he was going to be like the kid I had posted on my blog (video was removed), that had permanent damage. I could not give those answers, all I could tell him is that I was there and that he was in GREAT care and hold his hand, which he squeezed hard as tears streamed down his face.
After some comforting I found the attending physician, a friend of mine, who filled me in. His CT was clear, but the doctor was concerned about his reaction, and his previous concussion. Since he was stable, I asked that we remove him from the board and we could talk more. By this time, his family had arrived and were told he was going to be OK. The efforts had not been for naught…what we did was right. Immediate care, immediate transport and immediate imaging of the brain to rule out Second Impact Syndrome.
In our conversation, the doctor was given the history from someone who knew exactly what has happened to the player. We discussed possible interventions to concussions in the emergency room. We talked about the increase of concussions recently. We talked about a presentation to the medical staff of the ER about concussions. A very enlightening conversation for both parties, one of which we will deal with at a future date. Although this athlete was concussed for the second time, it was as if it was his first in terms of the body’s reaction. This was only due to the fact that he was allowed to “heal” over the time he was previously out. Had that not occurred there is a great possibility that we would be looking a different end to this story. I felt relief in the fact that all the preparation and education had worked and worked well. And this relief that I felt dwarfed the feeling of panic I had about two hours prior.
He was OK! Shaken up, scared, and worried about his athletic future, but he was going to be fine.
And so was I.
As you can see even with all the precautions, education and experience there are circumstances where nothing more could have been done. The underlying concept of this story is that, thankfully, he was not hurt worse and he should be able to continue playing the sport he loves very much.