Monthly Archives: May 2015

Pro sports and in-game concussions: Blurring an already blurred line

Everything is magnified in the playoffs. Controversial calls. Player gaffes. Clutch moments. And I think we can safely add the controversy of in-game concussion management to this list.

Last night provided us yet another example of this murkiness in professional sports’ biggest stages. Stephen Curry of the Golden State Warriors jumped over Trevor Ariza of the Houston Rockets, and Curry landed directly on the back of his head on the court. He laid prone on the court for several minutes, speaking to team medical staff, and able to move all extremities. There has been no report that he lost consciousness at any point following the injury. According to the mandate of the NBA Concussion Policy (which I will delve into later), he walked with team staff back to the training room for evaluation by the team physician. Following evaluation which included neurological testing as well as seeing whether riding an exercise bike exacerbated his symptoms, the team staff deemed that he was fit to return to play.

Cue the second-guessing of the medical staff. “Was he diagnosed with a concussion?” “What symptoms was he experiencing?” “Steph Curry just air-balled a shot, clearly there is something wrong with his brain”. “Are they putting him at risk for persistent symptoms unnecessarily?”

Let’s back up for one second and address why we all seem to have such a passion for concussion management. We’ve all read “League of Denial” by Mark Fainaru-Wada and Steve Fainaru (or we all should have by now). Many of us have patients with long-standing debilitating symptoms as a result of concussion. We’re finally at a point in our society where the overwhelming majority of us recognize concussion as a serious condition that cannot simply be ignored. Sports leagues have slowly come to the same realization, mainly over liability concerns. They can no longer minimize the potential consequences of concussion, and the leagues have each developed their own policies for concussion prevention, education and management. These policies have been developed by medical consultants in the field who have reached consensus between the leagues, its players, and its medical staffs.

I think for the most part we can commend sports leagues for their recent management of concussion-related issues. They are providing adequate baseline testing, adequate education to players, and return to play is generally done methodically according to the accepted standards of advancing activity only if the player is symptom-free. Whether we’re talking about a pro athlete or an 8 year-old, these same principles apply.

Even in-game concussion decisions in a typical pro game are usually clear. The definition of concussion from the American Association of Neurological Surgeons is “a clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma”. The diagnosis is a clinical one based on the nature of the injury and presence of symptoms which may include confusion, headache, vision disturbances, dizziness, nausea or vomiting, impaired balance, confusion, memory loss, ringing ears, difficulty concentrating, sensitivity to light, or loss of smell or taste. The rule of thumb most primary care physicians and neurologists use is that if there has been head trauma, and even one symptom consistent with concussion is present, then you treat them as having a concussion (provided you have no concern about fracture, bleed, or other emergent symptoms). Is it possible that we will be removing athletes from competition that may not have gone on to experience debilitating symptoms? Certainly. But although there have been many interesting trials recently looking at blood biomarkers to distinguish concussed athletes at risk for severe symptoms and those at low risk, those biomarkers are far from being ready for widespread clinical use. Imaging doesn’t help either. So we’re left with our clinical acumen.

Bottom line, if you suspect a concussion, it’s a concussion until proven benign (or anything more severe). In the regular season, we don’t hear many stories of athletes being rushed back prematurely. Teams don’t want a hasty decision to limit their athlete for an unnecessarily long portion of the season.

But in a big game? Suddenly the ethics become a bit murky.

In the past calendar year, we’ve had three high-profile examples of players in big matches likely playing with concussion. Julian Edelman in the Super Bowl, Christoph Kramer in the 2014 World Cup Final, and Stephen Curry last night. Edelman continued in multiple plays despite being visibly unsteady and disoriented. In response, The NFL introduced a medical-spotter rule in the offseason to ensure players with concussion would be identified quicker. Kramer collided with Argentina’s Ezequiel Garay, and continued to walk aimlessly around the pitch for a number of minutes. Only after he asked the referee whether he was playing in the World Cup final did the referee signal to the sideline for a substitution. 

In both of those incidents, as well as the Curry incident last night, TV viewers could identify that a head trauma had occurred, and that the player’s behaviour was abnormal. Even with Curry, laying on the court for several minutes after a head injury cannot be considered benign behaviour. It signals a likely concussion. We can debate the accuracy of early symptoms being indicative of severity of concussion, but he quite clearly met the criteria for concussion.

Why do we experience that visceral discomfort when viewing a player playing through an apparent concussion? We know that concussion often carries long-lasting, debilitating symptoms, and our reaction is often an expression of empathy. Part of our reaction is the general unease we have with seeing people in pain or suffering. Players play through musculoskeletal pain frequently, but seeing a player continue to persevere, despite the possibility of lingering cognitive, emotional and somatic symptoms, is a troubling sight to witness.

Should we care though? If a player makes a capable decision to continue playing despite being able to understand and appreciate the consequences, should they be allowed the autonomy to continue? The best analogy may be boxing and MMA, where the combatants are suffering mild traumatic brain injuries every second. The ringside medical personnel are essentially for decorative purposes, only stepping in when the risk of catastrophic injury is considered to be high. The fighters are willingly accepting the liability associated with concussion.

Could there be a sort of Advance Concussion Directives outlined for each player in advance of an important game? “Player A agrees to continue to be allowed to play in clinical situations X, Y and Z. He agrees that he will be removed from the game in clinical situation W.” Would this be too confusing and onerous? Perhaps. Another option would be a substitute decision maker (SDM) designated for each player in advance of the game. Should a concussion occur, the SDM would make a decision on return to play based on the player’s previously stated intentions. (Yes, a great deal of my practice involves care of the elderly, so I’m a little biased here.)

The simplest solution to all of this is for the team medical staff to make the appropriate diagnosis of concussion, rather than looking for excuses to declare a patient fit for play. From the NBA Concussion Policy, here are the points under the heading Evaluation and Management:

  • If a player is suspected of having a concussion, or exhibits the signs or symptoms of concussion, they will be removed from participation and undergo evaluation by the medical staff in a quiet, distraction-free environment conducive to conducting a neurological evaluation.
  • If a player is diagnosed with concussion, he will not return to participation on that same day.

This system is flawed from the outset. You are taking a player who has suffered a suspected head injury in a noisy environment, evaluating them in a quiet environment, and if the examination is pristine, you are sending them back to the noisy environment full of distractions. An environment which will likely exacerbate their symptoms, which the athlete will rarely disclose. They have their approval from the medical staff, and won’t come out of the game willingly. The other flaw in this system is that a “normal” neurological exam does not rule out concussion. Neither does a normal IMPACT test, or whatever metric the team decides to use. The player will understandably understate any subjective symptoms, which is a major part of the clinical picture. I think we’re naive to believe that Stephen Curry didn’t have any symptoms when he returned to the court. According to the second point, he should not have played again last night.

Here’s the question we need to answer. Are we comfortable with players attempting to play through concussion? If a player accepts the risks of longer-term symptoms with continuing to play, should they be allowed? As long as they can competently defend themselves against injury? (Edelman was vulnerable to a major collision at the Super Bowl and should have been removed regardless). It’s certainly not otherwise terribly life-threatening to play through a concussion after a proper neurologic examination (1.5 deaths/yr in the US according to the CDC), and if the player has been sufficiently educated, it may be reasonable to give them that option. This is where the concept of the SDM and advance directives are important, as a concussed player in an important game may make a decision that they would otherwise regret.

This entire topic is much more complex than simply watching TV and deciding from our couch whether or not we think a player has suffered a concussion. Medical staffs across the leagues always have players’ interests as a top priority, but unfortunately league policies on in-game concussion management has left them too vulnerable to subjectivity with respect to the initial diagnosis and return to play. There is a discussion to be had about how much autonomy we want to give players to play through concussion, but I’m not sure our knowledge of concussion is sufficient to allow the leagues to feel comfortable with the potential of liability.

My prediction? It will be mere months until we have this discussion yet again in another big game, and these controversies will continue until we have more accurate diagnostic tools. The simplest path will be for leagues to be even more stringent in terms of removing any suspected concussed athlete from play for the remainder of that game. But money talks. And when someone like Steph Curry may or may not have a concussion, the lines get very blurred.

The Sens and Melnyk got their liver. Now their real work begins.

After a public plea for a living transplant donor, Ottawa Senators owner Eugene Melnyk successfully underwent a liver transplant May 19th at a Toronto Hospital. This case took the already enormously complicated ethics of organ donation and turned the volume up to eleven.

Let’s get this out of the way first: I’m thrilled for Melnyk and his family that he found a donor, and that the surgery went successfully.

When news initially broke that the University Health Network and Melnyk were asking the public for a living liver donor, the reaction from the majority of the public and the medical community was that of unease. Few of us are under the illusion that we live in a completely equitable system, but rarely are we confronted with this blatant of a disparity. A billionaire sports owner asking a living Canadian to donate an organ…it just doesn’t look good. That’s not to say most of us would not have taken the exact same action had we been either the patient or the physician involved. Melnyk was reportedly quite hesitant to make this type of public plea, likely aware of the optics of the situation. From a transplant physician’s perspective, given how organ donation is still pitifully undersupplied despite large-scale awareness efforts, they would be foolish to ignore the lure of a high-profile celebrity attracting new donors and awareness. Details regarding Melnyk’s exact condition have yet to be released to the public, but reports indicated that time was of the essence. They were advocating for their patient, and I can’t fault them for that.

Hundreds of prospective donors came forward, and one was selected to be Melnyk’s donor. Happy ending, right?

Here’s where my frustration starts to build. Of the hundreds that came forward to offer a sizeable part of their liver to Melnyk, only 26 elected to remain on the living donor list after they were told that they would not be Melnyk’s donor. While some would argue that we should be thrilled that 26 individuals are new living organ donor candidates and will save lives (and yes, those individuals are true heroes), I can’t help but wonder about the hundreds who were prepared to be a donor for Melnyk, but not for the next patient in need. Was it a hope of secondary gain in donating to a billionaire? Was it that they felt a personal link to a celebrity figure that they wouldn’t feel towards a stranger? Whatever the reason, this needs to be addressed urgently. There is potentially a large segment of the population that may be willing to be a living donor if they were made more intimately aware of the personal stories of those on the transplant list.

Despite the fact that I bleed blue and white, I can attest that the Ottawa Senators are a classy organization that have done great charitable work. Over the past few months, they have brought tremendous awareness to colon cancer screening following the cancer diagnosis of GM Bryan Murray. Many of my patients who previously refused colonoscopies are now agreeing to them after hearing Murray’s story.

But the Senators’ new obligations in the field of organ donation cannot be understated. Their owner received a liver because of his money and fame. That is not up for debate. The Ottawa Senators and Eugene Melynk are now indebted to the citizens of Ontario in perpetuity. They have been active on social media promoting , and next hockey season they will likely show advertisements during games promoting organ donation. As far as I’m concerned, that is only the tip of the iceberg of their new responsibilities. Unlike other “awareness” campaigns, this needs to be an active campaign rather than simply educational. Booths at every gate with the ability to register in real-time with Service Ontario as either a living or deceased donor. Hand-held devices to pass along rows at games to register. Similar technology used at every Senators promotional event and media scrum. The Senators using their clout throughout the league to have similar technology used at other arenas, and other sports leagues. Lastly, they need to work with provincial transplant groups to spread the stories of transplant patients, and coordinate it with their efforts to attract more living donors. The next patient in urgent need of a liver will come soon enough, and deserves the exact same public response that Melnyk received. Transplant networks should be overwhelmed with living donor offers, and until that happens, the Senators cannot rest.

There are 1,500 people on the transplant list in Ontario waiting for a heart, liver or kidney. The Ottawa Senators and Eugene Melnyk have an obligation to contribute their money and organizational resources to a system that should treat all of the patients like billionaires.

Ontario MDs: More of us need to engage

I have spent this weekend at the OMA Annual General Meeting and have had the pleasure of interacting with physicians and leaders from across the province, discussing matters of remuneration, health policy and governance.

One of themes that has come up repeatedly has been the seeming disconnect between physician leaders and the actions of the general populace of physicians in our community. A prime example of this has been the physician response to the recent draconian government cuts. A recent poll showed that while over 70% of Ontario physicians support posting educational materials and writing letters to our patients about the clawbacks, only 20-30% said they would actually participate in these actions.

Why the disconnect between their beliefs and their actions? Certainly part of this is governed by human behaviour. It’s easy to have beliefs, more difficult to take action. Another aspect may be the feeling from physicians that they are only one voice, and will be merely a drop in the dissenting bucket of physicians.

But let me tell you this, one thing I’ve learned over the past few months is the power of every voice. People have commended the work I do on this blog, and I appreciate the compliments, but why don’t more share their ideas through this ridiculously easy medium? Physicians have so many great ideas, and rather than keep them private, why not get them out there to see the response? Some may be popular, some not, but at least get the discussion going.

What about Facebook and Twitter? Realistically every physician with a computer should have an account for their practice. It helps to disseminate relevant clinical information as well as aiding in the general promotion of our profession. Our brand as physicians is being slowly eroded, and we need to leverage social media to strengthen our presence. I realize the irony of asking physicians who are reading this blog to be more active online. The majority of you will already have a strong online presence, but we need to step outside of our existing online community and engage those who have been hesitant to take the plunge.

Any benefit from speaking to MPPs about our concerns? I met personally with my MPP Jeff Yurek, and I’m pleased to say he has been one of the few MPPs to stand up in the legislature and challenge Minister Hoskins on his policies. There is no reason you can’t have the same effect with your own MPP, whether they are a member of a majority or minority party.

Don’t like the materials the OMA has sent out? Don’t feel that they are relevant to your practice? Create your own! I have crafted a letter that I have distributed to all of my patients, detailing to them how the cuts will affect them in my practice (lack of access to after-hours clinic since I can’t join a FHO, specialists leaving the province or retiring leading to longer wait times, no new physicians coming to region which may affect family members, etc). All of our practices have different issues, so craft your own message.

A quick message to those of you who aren’t concerned about the cuts. Yes, we’re well compensated. Yes, we can probably all survive a 2.5% cut to all of our fees. But unless you are prepared to be paid zero dollars for a number of months in late 2015 and early 2016 because of the global cap, government cuts should be a concern to all of us. The government has refused to have any further negotiations with the OMA, preferring to simply impose the cuts indefinitely. In these most recent negotiations, no agreement could be found through conciliation and mediation, and in the absence of binding arbitration, the government brazenly felt empowered to enforce their own cuts. Before we can begin to fix the system we have (optimizing utilization, enforcing accountability to MDs who are inflating utilization, etc.), we need an agreement from the government for binding arbitration, so that improvements can be made to our system through mutual respect. The OMA council has approved a motion this weekend demanding that government agree to binding arbitration. This is simply a logical way to resolve our dispute. Should the government refuse the call for binding arbitration, they will show the public how truly un-democratic the government’s approach is in their dealings with physicians.

So here are my challenges to you physicians for the month of May:

1) Start a Twitter and Facebook account for your practice and begin to engage with other physicians, if you haven’t already done so..

2) Make a specific point to encourage colleagues in your practice group to join Twitter and Facebook. Set a goal of approaching at least 5 physicians about this.

3) If you are one of the 70% of physicians who support posting OMA promotional materials in your office or writing a PERSONALIZED letter to your patients, be one of the 70% of physicians who actually do it. Don’t be a spectator.

4) Contact your local MPP and demand a meeting to discuss the ongoing physician-MOH dispute.

5) When issues arise with patients around wait times or frustration with access to tests or specialists, immediately encourage them to write a letter to their MPP. Those patients need to know they have the ability to strongly advocate for themselves.

Oh, it’s my birthday this coming Thursday, so in lieu of gifts, follow my advice 🙂