Concussion continues to be one of the most difficult conditions I have to deal with as a Team Doctor.
I am sitting on the side-line on match day as Team Doctor. In my head I have run through all the possible medical scenarios that I could encounter. As a back-room team we have discussed these and run through various scenarios. I have checked and double checked all my medical gear. I have spoken to the ambulance crew, know where they are positioned in the ground and how to signal to them if they are needed urgently. I know what facilities are in the medical room and where the closest appropriate hospitals are. I know that my pitch-side trauma training is up to date. I know what medical conditions I can safely manage and which need to be managed in hospital.
One of our players takes a heavy tackle. He hits the ground and doesn’t move. Myself and the physio lift our bags and run towards the player. Our pitch-side trauma training kicks in and as we run we consider possible diagnoses – everything from life-threatening injuries to the player just being tired and needing a few seconds break.
We can quickly rule out most diagnoses but diagnosing concussion on the field remains very challenging.
The obvious concussions are easy to diagnose. A player MUST be diagnosed with concussion immediately if he/she fulfils ANY of the following criteria following an impact on the field:
- The player has lost consciousness
- There has been abnormal posturing
- There has been any seizure activity
- The player appears to be dazed or confused or acting in an inappropriate manner
- The player states he/she has any symptoms that may indicate a concussion (see SCAT3 sheet)
- The player fails the Maddock’s questions If ANY of the criteria exist, the player MUST be diagnosed with concussion immediately, must be immediately removed from the field and not allowed to return to play
So, our player has none of the above. He is on his feet, looks to be his normal self, denies all symptoms, and passes the Maddock’s questions.
He is shouting at me that he is ok and is pulling away from me to play on as he can see his opponent unmarked.
I know my responsibilities as a doctor, where the player’s health and life is my primary concern, not the match, not the result, not the team. I know on occasions I have to make that hard unpopular call to protect the player from himself. I also know I have to be honest with the player and not remove him from the game without good reason. The referee is shouting at me to hurry up and make a decision as he wants to restart the game. The crowd are becoming restless. The match is being televised and I know my every move is being scrutinised. If I get this wrong I will be ridiculed in the studio and in the media tomorrow.
“If you suspect concussion then you must remove the player from the field” my medical colleagues will tell me. Not particularly helpful in this situation and this is the bit Doctors who don’t work as pitch-side Doctors don’t seem to get – of course I “suspect” concussion. As I was running onto the field I suspected everything from life threatening injury at one end of the scale to there being nothing wrong with the player at the other end. Thankfully, due to my medical training, I was able to rule out a life threatening injury quickly then most other conditions in turn – but am I confident he isn’t concussed?
What makes this worse is that I know concussion can be an evolving condition – so the player who seems ok now could be running like Bambi in 5 minutes.
Research from other sports such as rugby1 2 and consensus statements from the likes of the American Medical Society of Sports Medicine3 and the Australian Institute of Sport and The Australian Medical Association4 advise a comprehensive side-line assessment of the player to help determine if concussion is present.
I need to take the player off so I can do a more comprehensive head injury assessment in the calm of the dressing room to check his symptoms, his balance and do a neurological assessment but Gaelic Games don’t allow for a head injury assessment sub. If I take the player off to do this assessment, we will be reduced to 14 players and I could be responsible for losing the game.
So what is a head injury assessment sub if it were to be introduced?
- This is an assessment whereby a qualified Team Doctor can ask the referee to allow a substitution, whilst he/she removes a player to the changing room, for a more detailed assessment for concussion.
- The player will have a more detailed check of his symptoms, a balance examination, a neurological examination.
- The Doctor will be better placed, in the calm of the dressing room, with these extra few extra minutes to make a more informed judgement on whether or not the player has concussion.
- This assessment is only to be used where:
- The player has suffered a significant impact AND
- The player has not lost consciousness AND
- There has been no abnormal posturing AND
- The player does not appear to be dazed or confused or acting in an inappropriate manner AND
- The player states he/she has no symptoms that may indicate a concussion (see SCAT3 sheet) AND
- The player passes the Maddock’s questions
- If the player fulfils ALL of the criteria 1-6 but due to the nature of the impact, the Team Doctor would like a few more minutes to assess the player, off the field, out of the glare of the crowd and media, whilst the game can proceed with introduction of a substitute, the doctor can request use of the head injury assessment sub.
- If following this head injury assessment, the Team Doctor is concerned that the player may have suffered a concussion, the player is not returned to the game. The substitution will remain permanent. The player then will follow a return to play protocol
- If following this head injury assessment, the Team Doctor is content that the player has not suffered a concussion, then the player will be allowed to return to the field of play and the substitute will be removed.
I am well aware that the use of a head injury assessment sub is controversial.
Arguments against the introduction of a head injury assessment sub
- A head injury assessment will not detect all cases of concussion.
- There are no tests that can definitely prove if a player has/has not got concussion
- We run the risk of returning a player to the game who then turns out to have concussion and therefore have put the player at risk
- We will have different protocols for different teams/competitions – where a trained doctor is present, a head injury assessment sub will be allowed but where a trained doctor is not present then a head injury assessment sub cannot be allowed. The vast majority of club players in the country will not have access to an experienced team doctor who can perform this head injury assessment.
- It may be abused by players/coaches to rest a player who is not genuinely injured by putting on a temporary sub
Arguments for the introduction of a head injury assessment sub
- Experienced County GAA Team Doctors who are working pitch-side week after week, have voted for introduction of a head injury assessment sub. In a Poll carried out, 29 (78%) out of 37 GAA Doctors who responded, want a head injury assessment sub introduced to Senior County Gaelic football games.
- Trained Doctors will have more time, in a calm environment, to perform a more detailed examination and be able to provide a more accurate diagnosis
- More players will be diagnosed correctly with concussion, will be prevented from returning to play the same day, will have their risk of a second concussion reduced and will avoid the risk of life threatening 2nd impact syndrome
- Research in Rugby 1 2 has shown that an accurate pitch-side assessment of players who sustain a head injury, reduces the number of players returning to play with concussion
- The American Medical Society of Sports Medicine Position Statement on Concussion3 and The Australian Institute of Sport and The Australian Medical Association Concussion in Sport Consensus Statement4 state that assessment of concussion should include a side-line assessment of symptoms, cognition, balance and further neurological examination. This is not possible on the field of play.
So what did I do with our player?
I allowed him to play on as I could not justify taking him off. He had taken a heavy impact, in a contact sport where there are frequent heavy impacts but his on-field assessment was normal. I then watched him nervously for the rest of the match to try to determine if he had an evolving concussion. Was he moving well? Was he making correct decisions? Was that bad pass he just gave anything to do with his heavy impact or was it just a bad pass?
Was I correct to allow him to play on?
Only hindsight can tell and often only if the player is honest. I have made many decisions like this over the years. Most of the time I have been correct but on some occasions I have got it wrong. I have had to remove some players from the field 10-15mins later when it had become obvious they had an evolving concussion as they became dazed/dizzy/developed a headache/playing behaviour was abnormal. On some other occasions, after the game has finished, players have admitted that they had symptoms of concussion during the game but lied so they could play on.
Concussion is a difficult condition to deal with. Despite medical advances there are many issues around concussion that we still do not fully understand.
“If in doubt, sit them out” is still the key message we need to get out there to players, coaches, teachers and parents all over the country.
It is also the message that pitch-side Doctors need to adhere to, no matter what assessments they have available to them.
Introduction of a head injury assessment sub is not perfect and will not answer all the questions around concussion. It will not detect all cases of concussion but it will allow experienced pitch-side Doctors to perform a more detailed assessment of our players. These Doctors will then be in a better position to make a more balanced call on how safe it is for the player to return to play in the game. Players risk of a second concussion and of life threatening second impact syndrome will be significantly reduced.
We stand pitch-side week after week as Team Doctors to look after our players. In my opinion, the GAA should introduce a head injury assessment sub and assist us in providing the best possible care for our players.
Dr Martin McConaghy
Sports Medicine Specialist
The Ulster Sports Medicine Clinic
(All of the views expressed above are my own and are not representative of any organisation)
- The International Rugby Board (IRB) Pitch Side Concussion Assessment trial: a pilot test accuracy study
Gordon Ward Fuller, Simon P T Kemp, Phillipe Decq
Br J Sports Med 2015;49:529-535 doi:10.1136/bjsports-2014-093498
- Evaluation of World Rugby’s concussion management process: results from Rugby World Cup 2015
Colin W Fuller1, Gordon W Fuller2, Simon P T Kemp3, Martin Raftery4 Br J Sports Med doi:10.1136/bjsports-2016-096461
- American Medical Society for Sports Medicine position statement: concussion in sport
Harmon KG1, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA, Kutcher JS, Pana A, Putukian M, Roberts WO.
Br J Sports Med. 2013 Jan;47(1):15-26. doi: 10.1136/bjsports-2012-091941.
- Australian Institute of Sport and Australian Medical Association Concussion in Sport Position Statement
Dr Lisa Elkington and Dr David Hughes Australian Institute of Sport