Your Team Physician

Team Physicians are a valuable resource to us all. As athletic trainers we serve under the direction of a licensed MD within operational protocols. They are great allies in our professional dealings with athletes, parents coaches, administrators and others we come in contact with. I have been blessed through the years with some outstanding Team Physicians who have served as both mentors and friends. Dr. Richard Shaara at UF was one of my first along with orthopedic surgeon Dr. Bill Allen. Dr. Shaara was wise & visionary in his approach to sports medicine. He was Innovative in drug testing, general medicine, a mentor to many AT’s and MD’s. Dr. Paul Shirley was my first introduction into orthopedic residents and we have been working together frequently nearly 40 years. We were discussing ACL surgery which once required about 2 and a half hours, two 15 inch incisions, plaster cast immobilization, transforming to a less than a 30 minute procedure with 2-3 small incisions, grafts and decreased healing and rehab time. Dr. Peter Indelicato at UF taught me many valuable lessons through examination, research and his innovations in surgery. He was one of the first to use arthroscopy when it was a visualized process thru a single hand held lens. While in Boston, I experienced a new speciality, Physiatry or physical medicine with Dr. William Fishbaugh, a very experienced MD and former college team physician. Over the past years here in Jacksonville, there have been a number of Orthopedic Surgeons and Family Medicine physicians I’ve been very fortunate to work with. Probably too many to mention and if I left out a name I would probably hear about it. All are wonderful professionals, each with their own special pearls and qualities.

Regardless of your setting, learn all you can and appreciate your Team Physician as they are one of the most valuable participants on your sports medicine team.

Spring Musings

Just returned from the Alabama Athletic Trainers Assoc., always a great education opportunity as well as a time to meet and spend time with fellow athletic trainers. Engaging with other colleagues enhances our knowledge base and provides quality time with others of similar interests in keeping our athletes healthy and safe.  Congratulations are in order for Brad Montgomery for his induction into the Alabama Athletic Trainers Assn. Hall of Fame.
Volunteered recently at the State High School Track Championship and though I had a relatively safe time I was proud of my colleagues on the following day, who along with EMS responded to a coach suffering a sudden cardiac arrest.  The week following a de-briefing was held and provided all involved a very positive and professional learning experience.  Unfortunately, for the victim, it was not a successful outcome but reminds each of us to prepare and be alert to respond as life happens so quickly. I would add the benefit of having colleagues you can share your feelings and emotions with as you process any difficult situation.
As well, I along with others, mourn the passing of Don Bostic, a former UF basketball player I cared for as well as Jeff Daniels, an athletic training student with me while a Graduate Assistant while at EKU (Eastern Kentucky).  Both Don & Jeff were very positive individuals who made an impact in their own ways upon the lives of many.  Our prayers are with their family and friends.
As we begin to wrap up the spring season, congratulation to the Trinity Christian Academy Baseball team headed for the State Championship games in Ft. Myers.  Spring football games are next week for myself and many. Best wishes and keep them safe now and in the months ahead.

Yours in Good Health!

Never Quit

The final four is completed, a new college basketball champ is crowned, every team but one goes home with a loss but it’s not the end of the world, thankfully.  It’s an extreme journey as are many of life’s challenges experiences. Life is fleeting and the value of CPR & an AED is invaluable.  The Associated Press reported recently a rare case of survival, a 22-month-old Pennsylvania boy whose lifeless body was pulled from an icy creek and revived after an hour and 41 minutes of CPR, 101 minutes!!  It took a team of 50 people to revive him and he is now doing well at home.  To what extremes will you go to save life?
An encouragement witnessed this week was meeting a young man, changed by an experience during his Jacksonville Sports Medicine Program pre-season medical screening.  He checked the box “heart races during exercise” which caused a closer look, further cardiac testing and even a corrective procedure that literally saved his life.  He thanked the Dr. for saving his life, his mom for letting him participate and his coach for taking him to the screening.  It truly was a life changing event. It’s worth the time to closely scan your physicals and medical questionnaires regularly.
Take the time to learn CPR and the value of an AED, you may actually change a persons life.

Thoughts of Spring

The sports world is talking about Chris Borland, San Fransisco 49er’s linebacker who has retired following one year in the NFL due to his concerns about the long term effects of receptive head trauma and his future health.  With a history of concussions, both in high school or earlier and an episode in training camp he played through at the time caused him to reconsider. He sought the advice from family, as well as teammates and the medical profession.
Crumb rubber, synthetic turf and health concerns have been raised about these small specks of rubber picked up by athletes of all ages on todays synthetic fields. Critics are concerned about safety due to carcinogens and toxic chemicals (such as benzine and carbon tetrachloride) in tire manufactures which can be ingested, inhaled or absorbed through the infill. Research remains to be inconclusive and much of the early implementation was due to its cost effectiveness and safety.  The jury is still out but those little crumbs can still be annoying at times. Contributions from Jeff Roberts & The Record, Hackensack, NJ.
Spring football begins in Florida April 27th this year, an earlier start but still the same time appropriated.  The debate continues as to the value, risk of injury, player evaluation, etc..  More time should be spent on teaching, execution, technique, functional movement and less on contact. Kids & coaches both will benefit.
March is National Athletic Trainers Month: “We Prepare, You Perform”  How do you prepare? Thank your AT for helping you to perform your best.
Enjoy March Madness and congratulations to University of North Florida AT, Fred Burnett & his staff for their men’s basketball trip to the NCAA Tourney. Prepare & Perform!

 

National Signing Day

Just witnessed a special treat for 14 Trinity Christian Football Players and 10 other athletes signing their National Letters of Intent to continue their sports and academic careers.  It reminds you of how limited the opportunities are to continue at the next level.  One athlete was selected for Stanford University, a prestigious west coast university known for it’s academics and an interesting fact was shared.  47 thousand apply annually, 10 thousand have perfect SAT scores and only 1,400 are accepted.  Kind of like the NFL or professional sports which is even tougher and only a few make it there.  Interesting too was one choose to stay closer to home than a long time commitment far away, one to choose a school where a teammate attended, and one kept all in suspense until the last moment of his choice.
True there is more to life than sports and each athlete was grateful for their coaches and family.  Two things which are essential, good support and positive not toxic relationships.  Bottom line, do your best, stay in school and keep following your dreams.

School EpiPen Stocks Save Lives in First-Time Anaphylaxis

Sharing an article related to Epi-Pens.  Important to have access to in case of emergency.  Florida recently updated their law allowing schools to stock Epi-Pens.  Now is a good time to re-consider the availability of Asthma Inhalers.  It’s so very hard when a student says their inhaler is in their gym bag located somewhere in a locker room in a bag that looks like everyone else’s.

School EpiPen Stocks Save Lives in First-Time Anaphylaxis

Kate Johnson

November 18, 2014

ATLANTA — A policy of stocking spare epinephrine autoinjectors in Chicago Public Schools resulted in 38 emergency — and possibly life-saving — doses being administered during a 1-year period, a new study shows.

More than half of the doses were administered to children having a first-time reaction, with no documented allergy, said lead investigator Ruchi Gupta, MD, from the Northwestern University Feinberg School of Medicine in Chicago.

“That’s a lot more kids than we expected, having no history of any kind of anaphylaxis,” she said here at the American College of Allergy, Asthma & Immunology 2014, where she presented the findings.

First results were published online in the American Journal of Preventive Medicineas reported by Medscape Medical News.

“Making sure that schools have epinephrine autoinjectors, and that staff are trained to recognize anaphylaxis and know how and when to give epinephrine, is critical to the safety of kids with food allergy,” Dr Gupta said during an interview.

She pointed out that most states currently have a law in place, or in the works, that allows schools to stock epinephrine doses that are not prescribed to a specific person.

Physicians can prescribe the doses to the school, and nurses and other staff are authorized to administer the medication to anyone who they feel needs it.

“School districts all over the country are working on this right now,” she explained. “A lot of advocacy groups are pushing for it, and a lot of laws are being put in place.”

Emergency Epinephrine Initiative

Chicago Public is the third largest school district in the United States, with 670 schools and more than 400,000 students. Its Emergency Epinephrine Initiative to stock undesignated autoinjectors in all schools was the first of its kind in a large urban school district.

Because it serves a largely low-income area, only 4250 students (1.1%) had the proper documentation to be designated as allergic. Of those, only 51% had an emergency action plan on file, Dr Gupta reported.

Of the 38 emergency epinephrine doses administered during the 2012 school year, 35 (92.1%) were for students and 3 (7.9%) were for staff.

The school nurse administered 76.3% of the doses, other staff administered 18.4%, and 5.3% were self-administered.

Previous research has suggested that only 25% of reactions at school are first-time incidents, but in this study, 55% of the reactions were first-time incidents, said Dr Gupta.

Food, the most common trigger, led to 55.3% of the reactions, and the two most common foods were peanut (18.4%) and fish (13.2%). However, the trigger for a large proportion of reactions was unknown (34.2%).

Clear, simple instructions should go along with self-injectable devices — the way it is for defibrillators.

The number of first-time reactions is not a surprise, said Antonella Muraro, MD, from the Food Allergy Referral Centre at Padua General University Hospital in Italy, who is president-elect of the European Academy of Allergy and Clinical Immunology (EAACI).

“Many first-time reactions occur at school, and it is difficult to estimate the real figures and severity because of a lack of awareness and recognition of symptoms, as well as a lack of training,” she told Medscape Medical News.

Undesignated epinephrine in schools is a good idea as long as training of school staff is an essential component, said Dr Muraro, who is lead author of the new EACCI anaphylaxis guidelines (Allergy2014;69:1026-1045).

“There is a high unmet need to design such structured training programs. This program must include regular training of all school staff, establishment of adequate policies at school, and identification and empowerment of key people to administer the drug and manage the emergency,” she explained.

“Clear, simple instructions should go along with self-injectable devices — the way it is for defibrillators. The implementation of such programs would help limit the legal liability of the school staff. There are no potential risks with the drug itself, but a lack of adequate training could result in administration to the wrong patient,” Dr Muraro added.

Dr Gupta also emphasized the importance of training, but she acknowledged that it is not always easy to assess the appropriateness of an epinephrine administration after the fact. “We really need a detailed report for every time it’s used. We need to make sure it’s being used appropriately,” she said.

“It’s very difficult, even for physicians and parents, to recognize when anaphylaxis is occurring, so we want to make sure nurses and staff know how to recognize when to use epinephrine. You hope parents will be appreciative, and it’s not something that’s going to hurt the child most of the time, but it is an expensive medication and, for some parents, that’s an issue,” she explained.

American College of Allergy, Asthma & Immunology (ACAAI) 2014: Abstract 44. Presented November 10, 2014.

What’s new with concussions?

Concussions remain in the forefront of athlete safety concerns. Unfortunately, there have been eight recorded deaths in sports this fall season from heart conditions, head injury, heat related and other causes. Athletic Trainers, Physicians, and healthcare professionals are working to educate the public as well as promote safety. While football gets a lot of media attention, remember soccer, hockey, lacrosse, and other contact sports are now beginning their seasons and are a source of concussion. Know the signs and symptoms of a concussion and remember “When in doubt, sit them out”
Are there more concussions occurring? According to a leading researcher, Kevin Guskowitz, PhD, ATC; “concussion injuries have not increased, they are just better reported and the medic has continues to focus on this issue.”
Where are we at with helmet technology and sensors? Helmets prevent skull fractures, they do not necessarily prevent brain injury. While much has been done to improve helmet technology through padding, both inside and out as well as a controversial rating system concussions continue. There are new methods in use, especially at the collegiate level for monitoring the severity, location and number of impacts incurred. In the NFL, they also use a specific spotter to alert medical personnel when they see an unusually hard hit or player acting suspiciously. Helmets with sensors are valued at about $425.00 for which some parents are willing to pay for but are a cost consideration for schools.
Have some implemented reduced contact guidelines? Yes, the NFL has reduced the number of full contact practices significantly through their collective bargaining agreement. Some colleges have followed this pattern also as well as a few states at the high school level. Some coaches’ fear all contact will cease and the game evolves into flag football.
What is new in initial testing for a concussion? Research in visual testing has proved very useful to determine concussion symptoms. A new sideline test which includes a baseline being obtained first is called the King-Devick test which measures visual acuity on a timed based. If athletes do not reach their baseline they are automatically disqualified to return to play and undergo further testing.
What is Return to Learn? Sports are not the only thing that needs an adjustment when one incurs a concussion. Classroom activities, socialization, reading, test taking, concentration, comprehension can all be impacted. Academic accommodations may need to be made with a gradual return to learn process which includes an incremental process in the classroom. Part of a comprehensive concussion program includes this in the process. For more information check www.cdc.gov under their “heads up” Concussion program.
Do they still grade concussions? Concussions are no longer graded on a scale or classified as mild or severe. They are all considered brain injuries or as the Academy of Neurology defines concussion as “a trauma –induced alteration in mental status that may or may not involve loss of consciousness whose hallmark condition is confusion”
Prevention and recognition? While limited contact in sports helps, collisions will still occur resulting in concussions. This is a public health issue where parents and coaches should advocate for a Certified Athletic Trainer who has the resources to help to prevent and manage these concussive injuries. As Jim Thornton, President of the National Athletic Trainers Association says” would you ever drop your child at a swimming pool without a lifeguard?” yet parents drop their children off at hockey, lacrosse, football and other sports without an athletic trainer present – it doesn’t make sense”
Jim Mackie, M.Ed., ATC, LAT is a Licensed and Certified Athletic Trainer with the Jacksonville Sports Medicine Program and serves as the Athletic Trainer for Trinity Christian Academy through Athletic Training and Sports Medicine Services. For more information see www.jsmp.us or call 904-202-5320 or 904-477-9291.

A Lightning Dilemma

As many Athletic Trainers do, we work a variety of camps or events as providers. Hopefully we request a fair payment for our services, have proper liability insurance, dress professionally, practice professionally as well as prepare just like we would working with our own teams or employers. Recently, I worked a two day, half day camp here in Florida which leads the nation in lightning strikes. Day one was fine but cloudy and in conversation I asked what was our plan for In climate weather. I was told there was a “plan B”, that at most venues they’d go indoors but at this remote site they’d be moving to the picnic pavilion under the tall pine trees. Not necessarily the answer I wanted to hear and suggested they at least move to enclosed vehicles, a much safer alternative. The second day, while in the middle of treating a critical patient, lightning struck nearby and the camp was discontinued and moved to the picnic pavilion and under the trees for the camp awards close out session.

Fortunately, though the storm was in the surrounding area, there were no further strikes noticed. Regardless it, points out the seriousness of prior preparation and planning by all parties concerned. The 2013 NATA Position Statement (JAT 2013) regarding lightning is an excellent resource and should be shared with other groups as well as reviewed and implemented.

Protect yourself first as well as the lives of others. Promote National Weather Service slogans such as “When Thunder Roars, Go Indoors” or “Half and hour since thunder roars, now it’s safe to go outdoors.” It is certainly not something to be taken lightly

Concussions – Still in the front of our minds

Concussions article for GAME magazine
Nearly 30 million U.S. Children and youth participate in organized sports; the U.S. Centers for Disease Control reports that high school athlete’s account for an estimated 2 million injuries, 500,000 doctor visits and 30,000 hospitalizations each year. Sports-related concussions are a part of those figures and a leading cause of concern. Of the estimated 300,000 sports-related concussions, approximately 250,000 occurred in football players alone according to an article from the National Institute of Health. In 2013, several U.S. student athletes’ died as a result of untreated severe head injuries. Unfortunately, many go unreported due to peer pressure, personal desire to continue to play, or a belief that it’s not that serious to report.
According to a leading researcher, Kevin Gustkiewitz, PhD, ATC; concussions have not increased, they are just better reported and the media has continued to focus on this issue. The Academy of Neurology defines concussion as “a trauma-induced alteration in mental status that may or may not involve loss of consciousness and whose hallmark symptom is confusion”
The sports-concussion topic has even attracted the attention of the White House; which, recently hosted a summit to focus on prevention, diagnosis, treatment, and increased funding for research on this injury. As a parent or coach you may ask yourself, does my school or sports association have a licensed medical provider, such as a Certified Athletic Trainer educated in prevention, recognition and management of sports-related concussion supervising the functions of the organization in regard to player safety? Is there a written concussion management program that includes a return-to-learn component? If not, why not?
Concussion symptoms include; but are not limited to, headache (pressure in the head), nausea vomiting, confusion, dizziness, balance issues, increased irritability, personality change, feeling in a fog, sleep disturbances, light or noise sensitivity, sadness, feeling more emotional, difficulty concentrating, and visual problems. Symptoms may resolve with rest, which is actually “brain rest” and the limitation of visual and audio stimulation. (text messaging, video games, loud music, TV, etc.) A good rule of thumb in most cases, “rest your brain, aids the healing process.”
Florida law requires anyone suspected of a head injury be immediately removed from play and evaluated by a licensed physician (MD/DO). The physician should be someone who has been trained in the care and management of sports-related concussion. To assist the physician in making a return to play decision, the Florida High School Athletic Association provides two forms (AT18) which must be completed prior to any return-to-activity. The first is used at the physician evaluation, when all parameters are met to complete the form, the physician may authorize a progressive return-to-play protocol outlined on page one (AT18). This is a daily program to gradually challenge the athlete and make sure no symptoms return. The physician will then review the completed AT18 form and then authorize the return-to-competition, page two (AT18). The FHSAA forms are available through the Jacksonville Sports Medicine Program at www.JSMP.us as well as the FHSAA, www.FHSAA.org website
Computerized neuro-psychological assessments, while helpful, provides a baseline reference; but, are just one part of the process and are only to be used in combination with other medical evaluations by the physician..
What about school work and other activities? Concussions involve our brains which receive a lot of stimulation. A comprehensive “return-to-learn” process must also be considered in our overall management of concussion. Parents should work hand-in-hand with their physician, school administrators, guidance, school nurse and teachers to create an individualized program to aid the student-athlete in their recovery. These accommodations may involve a day or two at home (limited stimulation) followed by a daily increase of time and work load. A student-athlete must be able to resume a normal school workload prior to return to sports.
When it comes to safety, what can we as parents and coaches advocate? All students participating in contact sports should have the necessary resources to prevent and manage these concussive injuries. This includes: Access to an Athletic Trainer (AT) on and off the field. As President of the National Athletic Trainers Association, Jim Thornton says “would you ever drop your child at a swimming pool without a lifeguard?”; “yet, parents drop their children off at hockey, lacrosse, and football practices/games without an athletic trainer present – it doesn’t make any sense. This is a public health issue.”
Remember, there is no “one size fits all” in regard to brain injuries and concussion; especially, in their management and outcomes. Each athlete/injury needs to be treated individually. With any suspected head injury this requires immediate removal from the practice or contest immediately and NO return to play the same day as this can lead to significant consequences.

It’s Getting Hot out side! Cool it off inside out.

With the dawning heat of summer on the way it’s important our kids and all of us are properly hydrated to prevent heat illness. “Heat illness is the most preventable cause of sudden death in athletes” according to Douglas Casa, PhD, ATC, of the Kory Stringer Institute which does extensive research on heat and hydration in athletes at all levels of participation.
Children are more at risk as their thermo-regulatory systems are still developing. Often time kids and adults spend too much time sedentary or indoors that it takes them longer to acclimate to the heat. We recommend spending time outdoors daily involved in exercise, play, yard work, etc. to help one adjust to the heat.
Hydration affects our performance so we need be aware of the following signs & symptoms of heat illness: thirst, early fatigue, feeling hot, slower, difficulty with concentration, dizziness, cramping or muscle spasms may occur. The skin becomes red or flushed, clammy or hot or even dry which is a medical emergency. If you’re thirsty or exhibiting some of these symptoms you’ll need to catch up as you are already compromised. Cool fluids are recommended and do not cause cramping. Early treatment is cooling, best with immersion in a cool tub, ice towels, ice bags in a cool shaded area with removal of outer clothing and equipment.
Some tips:
Check your urine color, light is good, dark like tea is not
Drink frequently before, during and after exercise. One gulp equals about an ounce of fluid.
20 oz. an hour before and after activity and about 6 -8 oz. every 15-20 minutes. 16-24 oz. of fluid for every pound you lose in sweat.
Total consumption should be about 50% water and 50% sports electrolyte drink if exercising for an hour or longer
Avoid excessive caffeine and soft drinks as they can accelerate dehydration. Avoid energy drinks too as they may dangerously elevate the heart rate.
The Florida High School Athletic Association has policies and procedure in place regarding heat & hydrations at www.fhsaa.org and the Jacksonville Sports Medicine Program www.jsmp.us also has information on their web site that you will find helpful.

Jim Mackie, MEd, ATC, LAT is a Certified Athletic Trainer; 904-477-9291 jimmackie@atsjax.com