The Rugby Doctor and
Immediate Trauma
Care in Sport
© BBC
John Morgan
GP Partner (Wigan)
Clinical Director Bucket and Sponge Medical Services
GPSI Sports Medicine (North West)
Member of Joint Consultative Forum for Exercise
Referral
GP Tutor Manchester University Medical School
Field Placement Supervisor Salford University Sports
Rehab & Physiotherapy
Chief Medical Officer Ireland Rugby League
Key Note Lecture BASRaT 2012
Duties of Team Doctor
• coordinating pre-participation screening, examination, and evaluation
• field-side assessment and triage
• managing injuries on the field
• providing for medical management of injury and illness
• coordinating rehabilitation and return to participation
• integrate medical expertise with other health care providers
• provide appropriate education and counselling regarding nutrition, strength
and conditioning, ergonomic aids, substance abuse, and other medical
problems that could affect the player
• develop and maintain a current , appropriate knowledge base of the sport,
understanding current techniques for managing sport injuries
Code of Ethics For The Team Doctor
The Team Doctor must:
• Be primarily responsible for the safety and well-being of the athlete
• Abide by the guiding regulations of the medical profession
• Abide by the rules of the sport governing body
• Must seek other medical opinions when in doubt, and then integrate this
expertise as provided
• Preserve confidentiality in all circumstances
• Must not seek secondary gain from commercial interests that in any way
would alter that which is in the best interest of the athlete
Immediate Medical Management on the Field of
Play (IMMOFP)
• Mandatory qualification required by RFL for medical personnel entering the
field of play
• Must be a currently registered medical practitioner or a Chartered and
State registered Physiotherapist with a degree in Physiotherapy
• Qualification is valid for two years
• Renewal of qualification must be achieved within two months of expiry or
you are prohibited from entering the field of play
Medical Personnel
Super League Requirements
For home and away matches:
• Physiotherapist – CSP and HPC registered with a degree in physiotherapy
and current IMMOFP qualification
• Doctor – Qualified, registered with GMC and practicing with current
IMMOFP qualification
Source: Medical Standards – 2011 provided by RFL
Medical Personnel
Championship Requirements
For home matches:• Physiotherapist – CSP and HPC registered with a degree in physiotherapy
and current IMMOFP qualification
• Doctor – Qualified, registered with GMC and practicing with current
IMMOFP qualification
The Doctor is to remain for at least 15 minutes following the end of the match and to
check with the away team physio (if they do not have a Doctor present) to confirm
his/her services are not required before leaving the dressing room area.
For away matches:• Physiotherapist – CSP and HPC registered with a degree in
physiotherapy and current IMMOFP qualification
Source: Medical Standards – 2011 provided by RFL
Medical Personnel
Academy,U20s, U23s and Scholarship Requirements
For home matches:• Physiotherapist – CSP and HPC registered with a degree in physiotherapy
and current IMMOFP qualification
• Doctor – Qualified, registered with GMC and practicing with current
IMMOFP qualification
Where a qualified medical practitioner is unavailable, as a last resort the club may hire a qualified paramedic, operating
through a private paramedic company who is on duty and fully equipt by that company. For the avoidance of doubt it is
still the responsibility of the home club to provide the Mandatory Medical Equipment. If a paramedic is being used then
the visiting club should be informed in advance. The RFL Operations Department must be informed of the name of the
company concerned.
For away matches:• Physiotherapist – CSP and HPC registered with a degree in
physiotherapy and current IMMOFP qualification
Source: Medical Standards – 2011 provided by RFL
Mandatory Medical Equipment
The following equipment must be in the dressing room at least 1 hour
before kick-off:• Spinal Board and Trained Stretcher Bearers
• Cervical Stiff neck Collar(s)
• Splints
• Airways including a selection of ALL of the following: Oropharyngeal airway (assorted sizes)
 Nasopharyngeal airway (assorted sizes)
 Pocket Mask (1 way valve)
• Automated External Defibrillator
• Portable Suction
• Oxygen
Mandatory Medical Equipment
• Emergency Drug Box containing: Adrenaline 1:1000 1ml vial
 2 vials Hydrocortisone 100mg for IV administration (200mg dose)
 Chlorpheniramine (Piriton) 10mg in 1ml vial for IV/IM use
 10mls water for injection
 Diazepam IV IM injection 10mg in 2ml vial
 Salbutamol UDV 5mg per 2 mls
 300mg Aspirin
 IV fluids 500ml Sodium chloride 0.9%
 IV giving set
 Venflon – one of each
 Green/Blue/Orange needles (3 of each)
 1ml, 2ml, 5ml, 10ml syringes (2 of each)
Mandatory Medical Equipment
• Foil blanket and Ambulance blanket
• Sharps Bin and Clinical Waste Bag
• Bleach Solution and Disposable Gloves
Highly Recommended but not Mandatory
Equipment
• Entonox
• Emergency Cricothyotomy Device and/or needle Cricothyotomy
Equipment
• Crutches
• Penlight Torch
Additonal Recommended Equipment
• Various ET tubes
• Laryngoscope
• Stethoscope
• Sphygmomanometer
• Various needles, syringes – in addition to those in drug box
• Adrenalin 1:10,000 plus additional 1,000 or epipen
• Suture Kit
• Eye irrigation materials
• Emergency cricothyroidotomy kit
• Anti-inflammatories (tablets/IM)
• Painkillers (check WADA Prohibited List) (Tablets/IM)
Additonal Recommended Equipment
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Anti-emetics
Anti-fungals
Antibiotics (various)
Medipreps
Gauze Swabs
Scissors
Inhalers - Salbutomol
Jelly Babies/Lucozade Tablets
Other drugs you personally feel necessary to carry out your duties
Additionally all medics should have:• Effective means of communication with emergency services
• Sound knowledge of additional medical persons at ground
• Detailed knowledge of treatment room facilities
The Preparticipation Examination: Preventing injury
• Recent development in sports medicine
• Completed at start of Pre-Season training
• Used to: Assess overall health
 Detect conditions that may cause injury
 Detect conditions that may disqualify the player from
participating
 Assess fitness
 Make recommendations for the exercise program
Components of the Pre-participation Examination
• Medical history
• Musculoskeletal examination
• Family/Social History
• General medical health evaluation
• 100% ME talk
• Cardiac Screening
 ECG
 Echocardiography Report – if required
• Consent
 Medical Treatment
 Information
• COGSPORT
Rugby League is an ‘international collision sport‘
with an elevated risk of injury, compared with many
other popular international sports. Some
investigations have indicated that injury rates in
rugby-league play are as high as 1.4 serious
injuries per game, and the frequency of injury in the
sport seems to be increasing rather than
decreasing
‘A Prospective Study of Injuries to Élite Australian Rugby Union Players,‘ British
Journal of Sports Medicine, Vol. 36, pp. 265-269, 2002
Basic Life Support
Three elements:
Airway – establishment of an airway
Head Tilt / Chin Lift or Jaw Thrust
Jaw thrust should be used to open the airway if an injury to the Cspine is suspected
Adjuncts should be used if required
Breathing – artificial ventilation of the lungs
Circulation – artificial circulation of blood through the body
Alex Thompson
Scene Safety
• Most Important Person is YOU
• Is Area safe and game stopped?
• No matter how well equipped you are hospital may be the most
appropriate place for treatment
• Don’t forget to request an ambulance as early as possible
• Collapse Witnessed?
• If not – consider more unusual causes
Aims of Treatment
• Preserve Life
• Maintain an Airway
• Perform CPR
• Stop Bleeding
• Prevent the Situation Deteriorating
• Summon Help
• Use First-Aiders or Bystanders
• Promote Recovery
• Reassure Patient
• Wrap in a Blanket
Priorities of Treatment
• In all patients involved in trauma it is important to immobilise the head
and neck until a C-spine injury is ruled out
• Treatment of a player and their injuries should be dealt with in the
following order:
• If any life threatening problem is found it should be dealt with
immediately before moving on to the next stage
• Breathing
• Airway – ensure the airway is patent
• Breathing – patient is breathing and respirations are adequate
• Circulation – the patient has a palpable carotid pulse
• Bleeding – ensure there is no major bleeding
• Bones – Examine the patient for any fractures
Sudden Cardiac Death
7 deaths in Rugby League 19962011
Unconsciousness
Causes:
• Head injury
• Asphyxia
• Skull fracture
• Fainting
• Concussion
• Extremes of body temperature
• Compression
• Cardiac arrest
• Cerebrovascular accident
• Hypoglycaemia
• Epileptic fits
• Hyperglycaemia
• Infantile convulsion
• Hypothermia
• Hysteria
• Blood loss
• Poisonous substances and fumes
• Drug overdose
Management of an unconscious patient
• AcBCDE – airway must always take priority
• If in doubt treat as a C-spine injury!
• If YES to any of following, continue with Full Spinal Immobilisation
1. Decreased conscious levels?
2. Any loss of consciousness post incident?
3. Under the influence of drink/drugs (including prescription medication)?
4. SIGNIFICANT neck or back pain?
5. Deformity, tenderness, swelling over the spinal process?
6. Neurological signs and symptoms?
7. Other painful injuries?
8. Significant pain on moving the neck or back?
Levels of Response – AVPU Scale
Alert
The casualty is fully alert
They are responsive and fully orientated (a casualty in this category
will usually know what month it is)`
Voice
Confused
The casualty is not fully orientated but asks and answers your questions
Inappropriate words
The patient is able to speak words, but cannot put them together
into logical sentences
Utter Sounds
The casualty is not able to speak words but makes noises often in
response to painful stimuli
No verbal response
The casualty makes no noise
Pain
Localises pain
The patient is able to localise where painful stimuli is being applied
Responds to (but does not note localise) pain
The patient responds to painful stimuli, but is unable to localise it
Unresponsive
Unresponsive
Spinal and Cervical Injuries
Mechanism of Injury
Caused by direct or indirect violence and should always be
suspected in all cases where:
• There is a history of accident or injury to the vertebral column
• The patient complains of pain in the back or neck
• There has been hyper-flexion or whiplash injuries of the neck
• A heavy weight has fallen on the casualty’s shoulders
• A fall from a height and landing on the heels has occurred
• There is acceleration or deceleration strains of the neck
• An unconscious patient has been involved in a road traffic accident
Spinal and Cervical Injuries
Signs and Symptoms of a Spinal Injury
As well as normal signs and symptoms of fracture, there may be
other clinical features which are specific to a spinal injury
• Loss of feeling or sensation in the body below the site of the injury
• A hot feeling, or ‘pins and needles’ sensation above the site of the injury
• Paralysis or generalised weakness below the injury site, which may lead
to incontinence
• Displacement of the spinal vertebrae felt as an unnatural lump, or
depression, from the normal continuity of the spinal column
• Fixation of the spinal column at the site of injury
Spinal and Cervical Injuries
Management of Spinal Injuries
•
Ensure an open airway using jaw thrust technique
•
Do not move the patient unless there is immediate danger
•
Avoid rotation or extension/flexion of the neck
•
Manual immobilisation of the patient is paramount. Once applied it should not be
released until the patient is firmly strapped to the spinal board and head blocks are
applied
•
Apply a correctly sized collar, remembering that this will only provide 30% support
and manual immobilisation must continue to be applied
•
Spinal injuries can be masked particularly in a patient with multiple injuries. A thorough
secondary survey is important to establish the site of the injury
•
If in doubt as to the presence of a spinal injury, you must immobilise the patient,
prevention is better than cure!
•
Immobilise the patient to a spinal board using as much help as possible
•
The person who is controlling the head must give all the movement commands in a
clear and precise way to eliminate the risk of jerky uncoordinated movements
Waiting for the ambulance service to assist in the movement of this type of patient is
usually the best idea
•
Spinal and Cervical Injuries
Specific to the Cervical Spine on the field of play
Stinger or Burner
•
A soft tissue injury to the cervical spine which is quite common in rugby
league
• It is a traction injury occurring with cervical side flexion and simultaneous
shoulder depression
• Usually caused by nerve root compression in the upper root of the Brachial
plexus (C5/6)
• Symptoms are burning/tingling in the lateral arm, thumb and index finger
• Usually transient and often player can be seen to ‘shake off’ symptoms in his
arm and does not require him to be removed from the field of play
• Muscles involved are deltoid, biceps and infraspinatus
• A weakness in any of these muscles on assessment means that the player
should be removed and not return to the field of play during that game
Cervical Spine Injuries
Classification of injuries
Harris usefully classified cervical spine injuries according to the
mechanism of injury and the subsequently expected pattern of fractures
into the following groups:• Axial loading
• Flexion injury
• Hyperextension injury
• Flexion + Rotation
• Extension + Rotation
• Odontoid peg fractures
all of which may occur in a rugby match
It is important to know when and why these injuries must be suspected as well
as how to manage them in the field of play
Cervical Spine Injuries
Clinical Suspicion
Following ATLS guidelines, CSI must be suspected in any of the
following circumstances:• Unconscious victim
• Significant impact above clavicles
• Immediate neck pain after an injury
• Presence of step deformity in posterior midline of the neck
• Presence of abnormal neurology
• Significant distracting injuries
• Significant MOI
• Multiple trauma
• Increased risk due to predisposing factors (general abnormalities, old
age, neck injuries)
Cervical Spine Injuries
Clinical Exclusion
Before a CSI can be clinically excluded, the patient must satisfy the
following criteria:• GCS 15/15 on assessment
and all of these
• Not under effects of alcohol or drugs
• No pain on palpation
• No pain on movement (see Canadian Cervical Spine Rule)
• No abnormal neurology
• No significant distracting injury
Cervical Spine Injuries
Canadian Cervical Spine Rule
Canadian researchers devised an algorithm for selective cervical spine radiology
The algorithm classifies the patients as having a low probability of injury
(sensitivity 99.6%) if the patient meets the next 5 criteria:• No mid-line cervical tenderness on direct palpation
• No focal neurological deficit
• Normal alertness
• No intoxication
• No painful distracting injuries
This helps to eliminate any unnecessary investigations and, therefore reducing
cost and wasteful overuse of medical resources at the same time as minimising
exposure to unnecessary radiation
PRACTICAL!