By Nick Verderame
“No two concussions we look at are even remotely the same, [and] this is the most complicated thing we’ll ever have to deal with.”[60] This explanation, by Randall Cohen, the University of Arizona’s Associate Director of Medical Services, makes a clear case for why today’s most studied athletic injury, the concussion, is so hard to diagnose and treat. The concussion is a moving target.
Concussions are not comparable to the average athletic injury. For example, there are only so many knee and arm injuries, but since experts do not know how many possible brain injuries exist, it is nearly impossible to pinpoint defining symptoms, perfect diagnosis or a blanket treatment. Instead, each concussion must be treated on a case-by-case basis and left to the judgment of physicians and team trainers.
Moreover, concussions are atypical because a doctor is expected to decide what the patient will do, as opposed to advising the patient. Plus, the athlete is generally lying to the trainer about the injury. If the player always has his way, schools would frequently be held liable for “second impact syndrome.”[61]
Thus, it is important for institutions to set forth minimal guidelines, requiring medical staff to take certain steps to identify a possible head injury, but also giving the staff, athletes and coaches sufficient education and leeway to make case-by-case evaluations.
Concussion Symptoms
While few are absolute, certain generic symptoms suggest someone is concussed. Examples are headaches, nausea, sensitivity to light and noise, dizziness, and loss of consciousness. However, each symptom has player-specific variables. What if an athlete easily gets nauseous — did he throw up from the dizziness after a fast fall or from a concussion?
Each concussion need be addressed individually. As such, it is currently impossible to expect a “one-size-fits-all” answer for concussions. This lack of specificity opens the doors for mistakes, and thus, university liability.
Liability Issues within Athletic Treatment
Because concussions are a moving target, treatment is very difficult to defend. There is no defense equivalent to “the ACL was not torn at the time of examination” or “90% of patients with these symptoms can play through the pain without further injury.” That clarity simply does not exist. Every concussion is different and must be identified individually.
Moreover, diagnosis is much more difficult because the patient is generally lying about his symptoms. This is hard to imagine, because a patient objective is generally to get better. In sport, however, the athlete’s priority is often to quickly return to play.
What should the standard be? Should a player’s word be carte blanche protection for a trainer, or should the trainer need to use personal judgment as well? The answer is likely the latter, and rightly so. That said, it begs the question — how much of a factor should an athlete’s claim be in the decision?
There is, obviously, a strong argument that the answer is easy. Caution is the guiding principle. The trainer’s responsibility is to the athlete, and any sign of a concussion should trigger treatment and removal from activities. While it is a good point, it is easier made in a vacuum than on a sideline. The sideline involves winning, losing, and coaches’ job security. So, to whom is the trainer really answering?
Thus, it is advisable for every institution to be out in front of these questions. General requirement standards, as opposed to specified details, are easier to execute and defend. Addressing them at the outset can protect the university, and more importantly, the athlete’s health.
NCAA Approach
The NCAA does not have a formal policy on concussion treatment, but rather leaves it to the member institutions.[62] Instead it has basic guidelines pertaining to removal and evaluation upon suspicion of a concussion.[63] Beyond that, “NCAA member institutions must have a concussion management plan for their student athletes on file with specific components as described in NCAA Bylaws.”[64] The plans must include education, removal with symptoms, and medical clearance requirements.[65] Perhaps to protect itself from liability, and perhaps to stay out of patient/physician health care decisions, the NCAA leaves the rest to member institutions.
The University of Arizona Athletic Department’s Concussion Guidelines[66]
Plan Description: The University of Arizona’s plan is not a protocol of management; instead it is a plan to educate. Coaches, players, and athletic medical staff must be annually trained in concussion symptoms, treatments and risks. Further, athletes and their roommates are re-educated after each injury, making it continual education.
Moreover, the guidelines require that athletes and coaches report symptoms, and injured athletes be evaluated by “a medical staff member experienced in the evaluation and management of concussion.”[67] According to the plan, “the medical provider’s return-to-play decision is final and may not be challenged.”[68] The athlete then must be tested the next day and eventually cleared before returning.
Plan Implementation: According to Mr. Cohen, intensive education has resulted in teammates and coaches being more honest with trainers, which is key. While injured athletes still claim they can play, the staff is frequently “tipped off” about likely concussions by concerned coaches and players. Since the implementation of this program, the number of reported concussions has gone up — showing that it is working.
Arizona trainers are also always on the lookout. Mr. Cohen explained, “We are assessing every player after every hit. Are they getting up slowly? Are they shaking their head . . . making eye contact? Do they do the right thing their next play? Is their balance okay? We ask them, ‘are you foggy?’” Any warning signs, and they pull the player for a full assessment.
Once trainers suspect a concussion, they use the Standard Assessment of Concussions (SAC) as general testing guidelines.[69] The plan also has language allowing trainers to use their own common-sense and experience, without being tied down to one test.[70] According to Cohen, if there is “any sign of a concussion we are going to pull the athlete out.”
For any plan to succeed, a trainer cannot work for a coach. Instead, trainers must be autonomous. Arizona takes this to heart. Trainers answer to the team physician, who reports to the Campus Health Director. That director answers to the Provost, who also hires and fires the Athletic Director. Thus, the training staff is protected.
“I have an order of responsibilities,” said Cohen. “First to protect the athlete, second to protect U of A, third to help the team succeed. And we are lucky here; I do not get push back from our coaches. They understand, they are really worried about the kids. They let us make the decisions.”
Conclusion
Despite some criticism,[71] U of A’s program is working, as displayed by the rise in number of treated concussions. This success is not from exponentially better treatment —the staff uses SAC. Instead, it is from better education and awareness. For a program to truly protect players from such an unexplored injury, there must be teamwork on all levels, from coaches to staff to teammates. Without that, too many concussions will go unnoticed. “Education is by far the most important part,” explained Cohen, “because the key is that players need to be honest.”
[60] Randall Cohen, Associate Athletic Director for Medical Services, University of Arizona
[61] http://www.sportsmd.com/articles/id/38.aspx
[62] According to Mr. Cohen, however, the NCAA is currently working on potential guidelines to set minimal standards for the member institutions.
[63]http://www.ncaa.org/wps/wcm/connect/public/NCAA/Health+and+Safety/Concussion+homepage/Concussion+Landing+Page
[64] 2012-2013 NCAA Sports Medicine Handbook, pg 7, available at http://www.ncaapublications.com/productdownloads/MD12.pdf. Specific guidelines are found in Guideline 2i.
[65] 2012-2013 NCAA Division I Manual, § 3.2.4.17 “Concussion Management Plan,” available at http://www.ncaapublications.com/productdownloads/D113.pdf.
[66] Officially titled: “University of Arizona Sports Medicine Mild Traumatic Brain Injury (MTBI) / Concussion Guidelines”
[67] University of Arizona Sports Medicine, “Mild Traumatic Brain Injury (MTBI) / Concussion Guidelines
[68] Id.
[69] All Arizona trainers are also licensed by the State of Arizona.
[70] The plan says “scope of [their] professional practice.”
[71] The school did get some public criticism for treatment of an injury to quarterback Matt Scott. However, the staff followed normal procedures and determined there was no concussion. As for Scott vomiting after he was hit, Mr. Cohen explained, “Matt has a history of nausea. We knew that. The announcers didn’t because the announcers aren’t his physicians.” Moreover, vomiting comes some time after the concussion, not immediately — as an example, look to boxing. Boxers are hit in the head and concussed repeatedly, but they do not throw up in the ring.
