In the first of a series of posts about concussion, Dr Sam Barke – Medical Director of Return2Play and tournament Chief Medical Officer since 2018 – discusses how to make the right call with concussions and how coaches can deal with some common situations. Return2Play is the Official Medical Partner of the 2020 Rosslyn Park HSBC National Schools 7s.
Understandably, concussion raises a number of concerns for those providing sport, particularly those who are working with children, and it’s always interesting hearing from coaches what they are most worried about. It has been clear to me that over the last couple of years awareness of the injury has rocketed (significant thanks have to go to the RFU and their Headcase campaign for that) but there remains a consistent issue that causes nervousness among coaching – making a “diagnosis”.
Making the right decision pitch-side
“I’m not a doctor; how can I possibly decide if a player has had a concussion?”
The answer is simple – no one is asking you to. But what you do need to do is have a suspicion. In education sessions, I tell coaches to ask themselves two questions:
1. Have you seen an event that could have caused a concussion? (or has someone told you about an incident of concern – you can’t see everything)
A direct blow to the head or a hard hit causing a whiplash of the head.
2. Is the player showing ANY signs or symptoms that are not normal for them?
Talk to them. How do they feel? Any headache? Saw stars after the hit? Feel a bit dizzy? Maybe they stumbled as they got up.
If you answer “yes” to both of those questions then your suspicions should have been raised and we follow the mantra “If in doubt, sit them out”. We remove them from the pitch. Job done. The benefits of letting a player carry on never outweigh the risks. They follow the return to play pathway.
“But they felt better pretty quickly – surely they’re ok?”
A player has been correctly removed but then over the next 15 minutes they recover and feel much better. This is where things commonly go wrong. It is very common for symptoms to settle quickly after the initial injury but this does NOT mean a concussion has not occurred. Putting the player back to play at that point puts them at risk. Concussion should be presumed and the correct protocols followed.
Empowerment to make the right call
This raises a serious point for the senior staff within schools and committees at clubs. You will have parents complain. “Little Johnny is absolutely fine. I’m his parent, I want him to be allowed to play”. Don’t back down, support your coaches’ decisions, empower them to continue making those calls and protect the welfare of their players.
“The doctor said it was just a mild concussion and I only need a few days off sport”
I hear this sort of thing a lot. A coach has removed a player with a suspected concussion, but then a doctor gives advice that isn’t consistent with guidelines. What to do?
We’re at a fascinating point where the educated general public – the coaches, teachers, sports providers who have undergone training – have more knowledge than a lot of doctors on the issue. Concussion isn’t a vast topic covered at medical school, it doesn’t really fit into any medical speciality training (apart from perhaps sports medicine) and our knowledge about the injury has changed rapidly in the last few years. That means the advice given by doctors is often poor and out-of-date. It is good practise to seek medical attention after a concussion, mainly to make sure there is nothing else worrying going on, but accept that the wrong advice may be given which may put you in a difficult situation.
So, how should we deal with this situation? Unfortunately, there is the possibility of upset but you have to stay strong. The guidelines are extremely clear – there are no “grades” of concussion, all concussions are treated exactly the same, the player needs to follow the pathway. If the child is playing sport while under your care it is your responsibility to be satisfied they have followed the correct recovery guidelines.
Keeping it simple
The benefits of allowing someone to play on who may have sustained a concussion will never outweigh the risks. Once we have accepted this, it really is as simple as “if in doubt, sit them out”.