Listed As Probable

Injury of the Week: Post-Game Punch

Risk factor for sustaining a concussion = running your mouth off at a loose cannon

How are college athletes like medical residents?

Consider the sanctimonious uproar over a recent claim that the University of Michigan* football team allegedly devoted more time to football than is allowed by the NCAA - 8 hours per week in the offseason, 20 hours per week in-season.

 

"I am shocked, shocked to find that there are student athletes working long hours

on their sport at this establishment!"

Then take a look at this article from the Denver Post about the offseason activities of the Colorado and Colorado State football teams which for some reason didn't make even a blip on the national radar when it was published earlier this summer:

"They call it non-mandatory, but it's mandatory, really," CSU wide receiver Rashaun Greer said of conditioning coaches who keep tabs on attendance. "They will call (no-shows) or text, 'What's going on?' " CU strength-and-conditioning coach Jeff Pittman and his staff are keeping tabs on upward of 100 Buffs this summer. Pittman said participation is pretty much across the board, in every class."You can assume across the country everyone is working in the summer," he said.

Or note this USA today story headlined 'College Athletes are Full Time Workers" which discusses the results of a study that was presented at the annual NCAA convention!:

Football players in the NCAA's Division I Bowl Subdivision (formerly known as Division I-A) said they spent an average of 44.8 hours a week on their sport — playing games, practicing, training and in the training room — compared with a little less than 40 hours on academics.

— Division I baseball players said they spent 40 hours on their sport, 32 on academics. In men's basketball, it was 36.8 hours on their sport vs. 33.9 hours on academics.

— Women's basketball was little less time-intensive, players saying they spent a little more than 36 hours on their game vs. a little more than 37 on classwork.

— Other sports exceeding or approaching a 37 1/2-hour work week were men's golf (40.8) and hockey (37.6) and women's softball (37.1).

Nearly one in four baseball and men's basketball players and one in five football players said they'd put in more time if they could, the findings show.

So why all the consternation over the Michigan allegations? The original newspaper report did not address the difference between what the NCAA considers 'countable' and 'non-countable hours' towards the weekly limit (nor is there any indication the reporters explained this nebulous rule to their player sources). It basically comes down to what is truly voluntary? Wolverine coach Rich Rodriguez has openly said that some workouts are voluntary but playing time isn't. A coach is going to choose the player who is best prepared. Even the idea of ordering extra sprints at the next practice for someone who missed a 'voluntary' conditioning drill could be explained as being necessary to get that person's fitness level up to the needed standard. Basically, anything short of threatening to pull a scholarship seems like it would be defendable.

Throughout history some pretty big brains, like philospher Thomas Hobbes, have struggled with the notion that any action is truly voluntary and yet the NCAA writes and enforces rules based upon the concept. So if limiting athlete work-load is truly a priority valued more highly by the NCAA than say putting a high quality product on the field for television networks to bid on then a more straightforward standard needs to be set.

Consider the ACGME duty hour restrictions for resident physicians - a maximum 80 hour work week, continuous duty limited to 24-28 hrs at a time, in-hospital call no more frequent than every third night, and 1 day in 7 free from program responsibilities**. No matter which side of the duty hours debate you support I think we can all agree that these rules do a better job of avoiding the gigantic loopholes that the NCAA regulations leave open. There are no 'voluntary' clauses to muddy the waters. The onus is therefore on the program to chase the resident away from the hospital no matter how much he or she wants to stay. Faculty don't have room to tell post-call interns at lunch "you can go if you want, but those who work 36 hours straight get the best evaluations".

The trouble with these stricter criteria is that if college athletes want to put in extra work - and they would just as residents put in extra studying in order to pass their board exams - they would truly be on their own without the safety support and guidance that professionals like athletic trainers and conditioning coaches can provide. And so the argument comes full circle. Which leads me to believe that the NCAA understands this quandry, lives with the vague rules in order to keep at least a semblance of balance in the lives of athletes, and hopes it never has to actually try and enforce them.

* Full disclosure: My undergrad degree is from U of M

** Late last year the Institute of Medicine recommended further limits including no more than 16 hours of continuous work without a 5 hour period of uninterrupted sleep between 10 PM and 8 AM. If my residents and fellows thought they heard alot of stories from me now about how it was tougher in my day they will never here the end of it if these 'nap-time' rules come to pass.

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90% of an injury is physical, the other half is mental

Oakland A's pitcher Justin Duchsherer announced that he will sit out the rest of the season in order to focus on getting treatment for depression. It is not clear if Duchsherer has dealt with clinical depression in the past but the fact that the former all-star has missed a large portion of the last 3 seasons due to injury probably hasn't helped matters at all. The risk for mood change in an athlete after an injury can be significant.

How common is it? One study of 343 male college athletes found that 51 percent had some symptoms of depression after being injured, and 12 percent became moderately to severely depressed. I find that college underclassmen are particularly vulnerable. Their self-esteem is already under attack as they adjust from being the high school star to just another player on the team fighting for playing time - all while dealing with new academic and social pressures not to mention living away from home for the first time. Not a good time to have a health problem put one's very identity - the role of athlete - at risk.

A New York Times article about skier Picabo Street's mental struggles after blowing out her knee provides a glimpse into the mind of an athlete during the post-injury period:

What sent her hurtling into a depression was the realization of how long and difficult her recovery would be. In the end, it took 20 months.

''I think it was a combination of the atrophying of my legs, the new scars, and feeling like a caged animal,'' Ms. Street said. ''I went from being a very physical person, a very powerful athlete, to barely having any strength to get from my room to the kitchen. You're stuck and you can't do what you normally do and it makes you crazy.''

Because suicide is the third leading cause of death in teens (and college aged persons too) the USPSTF recommended this year that all teens should be screened for depression. Athletes are no different. As mentioned in a previous post, the sports pre-participation exam presents an opportunity to ask about mood problems. We also need to stay particularly vigilant while athletes recover from injury. 1994 article in the Journal of Athletic Training described 5 common factors among 5 athletes who had attempted suicide:

1) considerable success before sustaining injury; 2) a serious injury requiring surgery; 3) a long, arduous rehabilitation with restriction from their preferred sport; 4) a lack of pre-injury competence on return to sport; and 5) being replaced in their positions by teammates. Also, all were in the high-risk age group (15-24) for suicide.

This is why athletic trainers and those practicing sports medicine should be well-versed in the psychology of athletic injury. It can be quite challenging to get young people to share their feelings with someone who is outside of their peer group. This task can be even more difficult in athletes who as a group have been trained to hide anything that could be perceived as a weakness. Athletic trainers are best positioned to monitor for post-injury depression as they usually have a pre-existing relationship with the athlete and are with them regularly through the recovery process allowing them to pick up on subtle changes in mood and behavior.

Here at Wake Forest we have had success with an injured athlete support group that allows these students to share their frustrations and fears with and learn coping skills from others who are going through the same challenges. Another strategy is to make sure to focus on achievable short term goals during the rehabilitation process - e.g. regain full motion in the knee after an ACL reconstruction - because, as mentioned in the Picabo Street article above, it can be quite daunting to consider the long road to full recovery. Finally, medical staff, coaches, and peers can work to make sure that the sidelined athlete still feels included as a part of the team.

These steps can help insure that the mental rehabilitation goes as well as the physical side.

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Quick Hitters: TN high school football death, H1N1 gets tougher

A couple of news items that relate to recent posts: 

1. High school football death in East Tennessee. Sullivan South High School football player Jack Logue collapsed during a game due to an apparent cardiac arrest and was pronounced dead later that evening. This is yet another tragic reminder that medical emergencies do occur in youth sports and schools have to make sure their personnel are prepared to respond to them. Sounds like fire department and school first responders on site began CPR and at some point a defibrillator was used but unclear from various reports I've read whether the AED was present on the sidelines or arrived with the EMS vehicle that answered the call. Hopefully all of these decisions, communications, and interventions happened as quickly and optimally as was possible.

The topics of AED availabilty and screening efforts to prevent sudden cardiac death in athletes will be addressed in future posts.

2. Documented resistant H1N1. Our infectious disease experts here at WFUBMC released the following communication (with underlines added by me for emphasis):

On August 14 and 19, 2009, the Centers for Disease Control (CDC) identified oseltamivir resistance in pandemic influenza A (H1N1) isolates from two epidemiologically linked patients in North Carolina. Both developed illness in July while receiving oseltamivir chemoprophylaxis for presumed exposure to an ill person. Their illnesses were mild and resolved without complications. To date, there is no evidence of ongoing transmission of oseltamivir-resistant pandemic influenza A (H1N1) virus. Most circulating virus remains susceptible to oseltamivir and zanamivir, but resistant to amantidine and rimantidine.

In light of these events, the North Carolina Division of Public Health reminds clinicians of the following: 

• Antiviral chemoprophylaxis should be used judiciously to decrease opportunities for development of antiviral resistance.
  • Chemoprophylaxis for prevention of illness in healthy children or adults following exposure to ill persons is not indicated.
  • Antiviral chemoprophylaxis may be considered for persons at higher risk from complications due to influenza or for some health care workers with an exposure to influenza secondary to inadequate personal protective equipment.
  • Careful observation for symptoms following an exposure combined with early treatment if symptoms develop could be an appropriate alternative to chemoprophylaxis in some settings, and could reduce the potential for oseltamivir resistance.
  • Development of symptoms while receiving prophylaxis does not necessarily indicate antiviral resistance. 
• Healthy patients with uncomplicated illness need not be treated with antivirals.

This new resistance is a not so gentle reminder that all of us, even those involved in athletics, need to be good stewards when it comes to anti-viral medication use so that these remedies will remain effective when they are really needed by the sickest/most vulnerable of people.

The Silent Killer in Sports

The death of Philadelphia Eagles defensive coordinator Jim Johnson from a recurrence of melanoma was an unfortunate reminder that while athletes, coaches, and athletic trainers may direct almost all focus to their sport, they need to remember that those long hours outdoors can put them at risk for skin cancer.

This is not a disease only of older indivduals. I was surprised to learn that melanoma is the second most common cancer diagnosed in women aged 20-29. The potential impact of this disease on young people hits very close to home here at Wake Forest as former Demon Deacon field hockey player Maria Whitehead died from the disease at the age of 25. In her memory, USA Field Hockey has partnered with the Melanoma International Foundation to create the Foundation for Sun-Safe Play and Skin Cancer Education. Mental and physical mistakes are one thing, but it is when one of her players or campers neglects to wear sunscreen that you'll really see WFU coach Jennifer Averill really go ballistic. Now if we could just get field hockey to buy into the idea of eye protection.

In an article from the American Academy of Dermatology Brian B. Adams, MD, MPH says:

 “Perspiration on the skin lowers what's called the minimal erythema dose, the lowest ultraviolet (UV) light exposure needed to turn the skin barely pink.”

I'm guessing that this is from some sort of refraction or magnification of the sunlight as I am not sure how sweat alone would disrupt the skin's outermost barrier, the epithelial layer.

The article also describes 2004 Olympic marathon bronze medalist Deena Kastor's battle with basal cell carcinoma and early stage melanoma.

Distance runners may be a class of athlete that is at even higher risk:

When comparing the runners with the non-runners, researchers found that the runners had more atypical moles, age spots, and other lesions that increase the risk of developing skin cancer.
The reason seems to be the significant exposure during training and competition to ultraviolet (UV) rays emitted by the sun. The researchers also believe that endurance exercise such as distance running suppresses the immune system. A suppressed immune system increases the risk of developing skin cancer.

Only 56.2% of the runners in this study reported that they regularly use sunscreen.

This number towers over the 6% consistent use rate found in a 2005 study of college athletes. And I would bet the number of athletes who bother to reapply after sweating is a tiny fraction of that 6%. "Waterproof" sunscreens can hang in there for up to 30 minutes in water before losing effectiveness...athletes are usually sweating for quite a bit longer than that.

So sweat is part of the problem but could also be part of the solution - hippo sweat that is. Researchers are trying to develop products that mimic the light scattering properties of the rotund mammal's oily secretions. But wait, there's more:

"It would be nice to also try and replicate the antiseptic and insect-repellent characteristics of the sweat, to obtain a four-in-one product: sunscreen, sunblock, antiseptic, insect repellent," co-author Christopher Viney told Discovery News.

And remember, athletes and coaches need to be reminded that a tan - which itself is a result of enough UV energy to damage skin DNA - does not necessarily offer protection. For example, in one small study three Ironman Triathalon participants suffered sunburn during a race despite being tan and applying SPF 35 waterproof sunscreen at the start.

And if preventing llong term health problems like cancer isn't enough, remind your athletes that they don't want to end up like former Oriole Mary Cordova who was forced by the team doctor to sit out a couple of day games because of the severe sunburns he suffered after falling asleep in a tanning bed.

Gender Identity Issues at Track and Field World Championships

18 year old South African runner Caster Semenya, a favorite in the women's 800m and 1500m events at the world track and field championships in Berlin, is having to undergo a 'gender test' by order of IAAF, the sport's world governing body.

Even if you didn't go to med school that test should only take about 5 seconds right? Well, it isn't actually as simple as having the athlete drop his or her pants.

The Androgen Insensitivity Support Group website has a comprehensive explanation of the conditions that could make gender identification less than straight-forward. If allowed to simplify, you could say that sometimes the message from the chromosomes doesn't always get translated into the corresponding gonads (testes or ovaries) and the message from the gonads does not always make it to the external sex organs.

So why not just pick a definition - go by the external sex organs - and use it? Well, as with the rest of life there is quite a bit of gray area between even the mixed message scenarios I presented above - i.e. the genitalia themselves can be incomplete or indeterminate. The ESPN article describes the IAAF gender 'test' as involving "a physical medical evaluation, and includes reports from a gynecologist, endocrinologist, psychologist, an internal medicine specialist and an expert on gender", reflecting that gender determination can be a complex issue.

So what criteria does the IAAF use to render a final verdict? A vote of these specialists? That isn't clear, but I did find this helpful chapter in the book Women in Sport by Barbara Drinkwater. It describes how the medical community actually uses eight criteria when determining gender: 1) Sex chromosomes 2) Sex hormone pattern 3) Gonadal sex 4) Internal sex organs 5) External sex organs 6) Secondary sex characteristics (breasts, facial hair, etc) 7) Apparent sex (as presumed by others) 8) psychological sex (as person identifies him/herself - this is the one legal courts usually rule in favor of).

The problem, the author goes on to say, is that the initial screening tests used by sport organizations are usually only based on one of these criteria. The IAAF screening method apparently is/has been chromosome testing. She also brings up the fact that the main reason gender determination testing was adopted is to simply keep men from attempting to compete as women, not to make a decision in ambiguous cases. This is why, at least as of 2000, only 5 of the 34 Olympic sport governing bodies bothered testing for gender at their world championships. Female athletes themselves have not been clamoring for this type of testing and it has been shown that the more athletes are educated about the potentially complex nature of gender and testing for it the less likely they are to be in favor of screening.

The Science of Sport blog has a nice post about how most of the global scrutiny of this poor young woman could have been avoided if her country's federation had planned ahead. Such a situation indeed is unfair for both Semenya and her competitors.

The story of Erik Schinegger is probably the most famous case of gender identity in sport. Raised as Erika, Schinegger won the world championships in the women's downhill in 1966 only to have the title taken away when chromosomal tests said she was a he. The fact that he then decided to live as a male after 'medical treatments' goes to show the fluid nature of gender in certain cases and the absurdity of trying to break it down into a black and white issue.

I also recommend reading this excellent article from the Washington Post about 1932 Olympic champion sprinter Stella Walsh and the rumors that swirled upon her death in 1980 that she was really a man. Probably the most logical approach to this complicated issue is captured by this excerpt:

The best way to determine such children's sexual identity, says (William G.) Reiner, who directs the University of Oklahoma's psychosexual development clinic, is simply to ask them.

In The News: Sports Medicine Crisis Management Workshop

Local print and television media here in Winston-Salem produced nice stories about the "Sports Medicine Crisis Management Workshop" we've developed here at the the WFU School of Medicine. The program brings together teams of folks - including team physicians, athletic trainer/first responders, and coaches/administrators - from local high schools who are responsible for managing medical emergencies for their athletic departments. 

There are two main principles we focus on during this seminar:

1. Teamwork

The aviation industry has been a leader in recognizing that while individual knowledge and abilities are important, it is usually the ability of the aircraft crew to work together effectively that determines the safety of a flight. The Tenerife Airport Disaster in 1977, still the deadliest aviation accident in history, was the ultimate example of teamwork failure that lead to industry wide changes.

The medical field has been catching up in this regard over the last 10 years or so. One of many examples of the importance team concepts in medicine was a study by Risser and colleagues which showed that a majority of malpractice awards from emergency room cases could have been avoided with proper teamwork behaviors. 

The sports medicine setting - like an airplane or an emergency room if not more so - demands teamwork due to the time stress, the uncontrolled environment, the scattered information, and high stakes that are a part of responding to an emergency out on the football field or in the middle of a crowded gym. Then consider that the sports medicine "team", especially for high schools, is often a loose association of people with varying training, experience, and even familiarity with each other who are expected to instantly work together as a well oiled machine during a crisis situation.

I think if nothing else, just bringing together the team doc, athletic trainer, coach, administrator, and local EMS providers into the same room so the end up getting to know each other and talking about these issues is the biggest benefit of the course. To facilitate matters I provide a couple of presentations and exercises on teamwork concepts like role assignment, communication, situation assessment, and back-up behavior.

2. Practice in a realistic environment

It is one thing for a team to study their playbook, it is another to actually run those plays against a live defense in a scrimmage. The same holds true for emergency preparedness - it's great to have a plan and understand teamwork principles but you have to practice. Fortunately, emergencies don't occur that often in the athletic setting. The downside is that when a crisis occurs - and they do, as the deaths of 5 high school athletes in NC last year will attest - it is usually the first for those responding. You can't rely on learning on the job.

For our workshop, we use a high fidelity simulation mannequin - he talks, opens and closes his eyes, breathes, has a pulse, even sweats - in full athletic equipment as the "victim". Around this patient we use a referee, PA announcements, crowd noise, camera crews, real sideline medical equipment, ambulance crews, and other surprises to make the setting seem as real as possible. The teams then have to deal with changing information and distractions in order to stabilize the patient, all in front of a group of onlookers. While the setting is still artificial, the idea is to get the participants used to doing their job at "game speed" with the adrenaline pumping. Then we break down their performance just as coaches would look at game film so the group can learn from the experience.

So far feedback has been very good. We hope to publish the results of particpant confidence surveys and teamwork performance during the emergency simulations as part of a paper on the topic of how to improve emergency preparedness in the athletic setting.

Injury of the Week, Part 2: Another pitcher hit in the head

Right on cue after my recent post that touched on pitchers and their risk of head injuries from batted balls. This one was traveling with such velocity that after it carommed off the head of Dodger hurler Hiroki Kuroda it landed in the first row of the stands. The batter was awarded a ground rule double on a ball that never made it past first base.

Fortunately initial imaging tests for discreet injuries like skull fractures or bleeding around the brain were negative and Kuroda has been diagnosed with a concussion.