Safe Sport – Protecting the Players and the Game

Rugby and contact sport has always been a part of my life; from the junior rugby fields where organizing young children is like herding cats, to university rugby with post game beers and weekly rejection from the blondes of the ladies hockey team. I’ve always been passionate about sport but now as I’m aging and no longer finding difficulty putting on weight, I’m noticing a different aspect to it; in particular, a large change in the way we prepare and our awareness of participant safety.

Many of us will be able to name some disasters in sport. One of the most high profile in the last few years would have to be Phillip Hughes, the Australian cricketer who was struck by a cricket ball in a domestic match causing a vertebral artery dissection. A freak accident, leading to a young athlete’s life being cut short and a nation mourning for a sporting talent in the prime of his career. I regret to say that his case is not isolated. All types of sports all over the world have their stories, and not just of death, but serious life changing injury. Brain bleeds, spinal cord injuries, career ending fractures; the list is endless. People are noticing these cases and they realize the potential for serious harm by taking part. The argument coming out from some campaigners is for banning of sports deemed to be dangerous. Is the answer to wrap people in cotton wool, forcing them to get their exercise and have fun by playing games with no more contact than lawn bowls? Maybe, I certainly don’t think so.

People passionate about their sports don’t want to see them lost. What is excellent to see is that those involved in sport acknowledge the potential for serious injury and are preparing for it now better than ever seen before. Pitch-side medics are no longer limited to the magic sponge and a large tub of Vaseline. Today, clubs and organizations want to offer their players an appropriate level of care promoting the safety and welfare of its participants. To do this they expect their healthcare staff to be prepared and trained to be able to give the very best of care.

For the last 3 years I’ve been fortunate enough to be part of the medical staff of a professional rugby team in Australia. Gaining first hand experience of how to manage the acutely injured athlete safely. However even as an Emergency Registrar there are myriad things to learn on the field when you don’t have the luxury of a fully stocked and staffed resuscitation bay. It is so different when you have an athlete face down in a puddle and a suspected neck injury, or a downed jockey knocked unconscious with horses still passing over the fence. It still requires training to extricate and treat appropriately.

Last month I took part in the Word Rugby ‘Immediate Care in Rugby’ Level 3 Course, a course designed to teach gold standard identification, removal and treatment of injured athletes. I didn’t know what to expect from the course, in fact I thought it would come easy with my Emergency Training. The reality was quite different, it highlighted to me that even with my background there were concepts and skills to learn with training specific for the sports field, proven to save lives and prevent adverse outcomes. Being in healthcare I am a huge advocate for health promotion and in particular safe practice of sport. I believe these courses are going be a huge part of our preparation for sport and that it will be essential that games not only have access to the ‘first aider’, but also the staff who can step up to the next level of care when needed to. This will make our sports not only safer, but will reassure the athlete that help is available should they ever require it.

No doubt the improvements in pitch-side care are fundamental in regards to making our games safer. The real debate however is not within medical care present at the game, I believe that is a given. What I am not sure is a step in the right direction is the changes to the games themselves.

Where this comes from is the highly topical area of concussion. Head injury is a hot topic currently in the Sports Medicine world and now thanks to Will Smith it is even the plot of a Hollywood movie. The concern over the long term effects of concussion is now leading those involved in healthcare, particularly those in sport, to recognize and remove our players, allowing them appropriate recovery time. For me this has been a positive development. Having been concussed 3 times in my life during sport, but thankfully not displaying any long term effects, I realize the danger and am not blind to the suggested links with chronic traumatic encephalopathy (CTE). Although research is still in its relative infancy, it’s reassuring that organizations are not brushing this problem under the carpet. It is now common practice to remove concussed players and rehab them appropriately. In the professional Super Rugby league we now have dedicated Concussion Doctors watching the match by video link who can spot players with suspected or confirmed concussion with the aid of video technology and request them to come off for testing, a move which I believe is hugely progressive for professional sport. Now I understand this isn’t going to be an accessible tool in the amateur game, what is good is that referees and coaches are now being trained to identify and remove those concussed. Similarly, medical staff are also very aware of symptoms and can utilize pitch-side cognitive tests to identify concussed players and keep them as safe as possible thanks to courses such as ‘Immediate Care in Rugby’.

Is this enough however? The argument from those who say ‘no’ is that we should be changing the nature of our sports to make them safer. American Football banned spear tackles, or charging head first into an opponent in 1976. This move saw a huge reduction in serious head and neck injuries, without doubt preventing many American Footballers from serious harm. There have been many successful changes to a wide variety of sports to reduce risk, however, have we stopped to think of much adjusting we actually are doing?

In November 2015 the United States Soccer Federation banned all players under the age of 10 from heading the ball over safety concerns and potential for class lawsuit. For me this seems like it may be a bit excessive. I won’t lie, I was in no way a talented football player, nor an avid fan. However my basic knowledge of football suggests heading the ball is quite an important part of the game (I believe Argentina might have even won a world cup semi-final against England with a header in 1986). Should we be changing the dynamics of the game now as a result? Particularly when the search for evidence that heading a football leads to CTE is still questionable. There is also talk of banning lineouts in Rugby Union, where player are lifted into the air to compete for the ball after a restart in play from the sideline in fear of a fall from height. For me, having become accustomed to this as part of the game I couldn’t really imagine it without lineouts. This is even becoming an issue in non-contact sports. There have been some very vocal calls to ban the ‘bouncer’ in cricket, where a bowled ball arrives at speed to the batsman at head height in order to intimidate them. It was this type of tactic that unfortunately led to Phillip Hughes’ death. Argued as an integral part of the game, many don’t want to see it banned, but it faces the very real possibility of no longer being part of cricket.

Many of our sports are facing these discussions and there is real concern that we risk changing the very core of the contest. Some would say it’s the element of risk that attracts them to their sporting passion. I suppose I’m very conscious that if we remove all that is dangerous about our sports, it may change them too much to make them interesting for participants and fans alike. Lets consider a sport I have no interest in. Boxing without doubt in its nature of repeated trauma to the head with only a mouth guard for protection is dangerous. Would I personally partake in boxing? No, I’ve the limb to eye co-ordination similar to that of a giraffe without the height, but I am also concerned about the potential for long term neurological effects due to its nature, that’s just my opinion. However there are those who don’t agree and practice. They know the risks and accept them. Like I know the risks of rugby and accept them and play on. This, I feel is the key to the argument. We all know what we sign up for when we play these sports but by forcing change upon them to order to try and make them safer, it may in fact drive people away and change the fabric of the games we love. As long as people know what they risk and they wish to play on, should we force the adjustments? I reckon there is a fine line for this and although some new rules are logical for safety, we run the danger of taking it too far.

For me the most important thing is to be prepared for potential issues. In a strange co-incidence I’m actually finishing this article whilst waiting for a Sheffield Shield match to start where I’m the Match-Day doctor. It’s the very competition in which a little over a year ago Phillip Hughes died, in fact many of the players who played against him that day are playing this afternoon. Even for a simple game of cricket I’ve had meetings already with the home and away teams support staff, the ambulance service for the ground, confirmed extraction plans in event of serious injury and checked equipment and looked through the boot of my car for in-date Paracetamol. I like to think I am prepared. For Fabrice Muamba, the English Premiership Footballer who had a cardiac arrest on the pitch for Tottenham Hotspur, it was having prepared medical staff at the ground which led to his survival. The same as the Scottish and Welsh Rugby Medical Staff who saved Tom Evans from a serious spinal injury thanks to their precision extraction from the pitch with safe spinal precautions following an awkward tackle. These two cases were very different to that of Petr Čech, the Chelsea goalkeeper who crawled off the pitch himself after fracturing his skull.

Things have changed, and for the better. I consider it a huge honour to look after the health and wellbeing of elite athletes and indeed the ‘casual weekender’. My one hope is that others feel the need to learn and practice excellent pitch-side care and Sports Triage. With the drive to safely and appropriately manage the acutely injured, and perhaps not changing too much of the core of our sports, I reckon we will maintain thrill of the games we all follow and create a safer playing environment. The push for safety doesn’t have to mean losing the magic of sport.