G. Yagnik, who is the team doc for the Fuller Panthers NHL team and the Miami Dolphins NFL team. And just, I want your perspective on this. And I'm going to ask you a question, and then we'll have some questions for these guys. But as a orthopedic doc, sports trained, don't have a spine background, you don't have a heart background, abdominal background, a head heat background, as you look at these type of things, how do you view this? And you've got different environments. You're not going to have a heat injury in the ice arena with the Panthers. But how do you approach somebody that's down on the ice versus on the football field? Can we get the mics? Yeah, there we go. So I think Dr. West and Brockmeyer kind of wanted me to be on this panel here to represent pretty much everyone else here in this room who doesn't typically take care of abdominal injuries or chest injuries or any of those types of things. But most of us are on the sidelines. And I think just hearing the experts talk about it, I think in answering your question, a lot of it depends on your resources and your level. And we kind of touched on that. So on the pro level, resources, help is seconds away. And then when you're taking care of high school, sometimes, as Drew mentioned, you may be the only person out there. And so I get a lot more nervous when I go cover high school games than when I'm covering hockey or football, just because of the resource issue that we talked about. I think one of the other things to be aware of, and you brought it up, is playing surface. So it can be a lot different outside versus inside. Hockey, you're not on the sidelines. Sometimes you're in the back and you're in the locker room. You don't have access to see all parts of the ice. Transporting patients on different surfaces can be different. If it's wet outside, if it's ice, your spine boarding technique is different. So I think the biggest take-home message for me is what everyone mentioned here is have a plan and rehearse and practice that plan for us. And myself, personally, when I first started doing this, we used to do that as more kind of going through the motions. I think we all take this a lot more seriously now. It takes a few events in your career to make sure that you practice and do these drills over and over. It's excellent. I really appreciate the message. Now, you guys heard it. The EAP, critical. Doesn't matter if you're at a high school or a professional. You get to the stadium at a high school, first thing you should know is where's the AED, where are the emergency personnel, is there going to be an ambulance there? You should do that first thing. Find out what those things are. So as my old football coach used to say, Bill McCartney by failing to prepare, you're preparing to fail. We don't want to fail. We want to take care of these kids. Now, how many here take care of teams on the sidelines? So great majority, that's probably why you're here. I'm sure there's a question. Come on up to the mic and ask a question. I'm going to ask a question of these guys, but come on up, we got time. So here's a question, Dr. O'Connor. Hyperthermia, there's a doc out in Stamper that has developed these cooling mitts. Is there anything to that in terms of helping with hyperthermia? Yeah, yeah, so a cooling mitt is a device we use in the military as well. They help mitigate the heat load, but they have no role in the treatment of heat stroke. So it's not a treatment, it's something to mitigate and prevent progression. Okay, thank you. Dr. Johnson, go ahead. For somebody that, so say a football player is standing on the sideline next to you talking, but has bilateral neuro complaints, numbness in both hands, something like that, but they're not down on the field. What steps would you take in that case to stabilize them and appropriately transfer if necessary? So at that point, if he's having bilateral symptoms, you have to assume that it's a spinal cord, okay? And so what you do is you slowly take his helmet off and you put a cervical collar on him and then you ease him over to the spine board and then you transport him, okay? Can you get away with doing something else? Yeah, you can. That's the safest thing to do. Common sense would tell you he walked off the field, okay? Is his spine really tender? No, it's not tender. So you got pretty good range of motion, yeah. So he might've had just a concussive event, a neuropraxia. So is it mandatory you do it? If something goes bad, it's mandatory. And so that's what you're planning for. Have I done it before where I've sent him home like that just in a cervical collar? Yeah, I've done it. When they're walking around, I can palpate their neck and they don't hurt. But your point is well made is that is a bilateral event which dictates it's a spinal cord. And so the safest thing you can do, the safest thing you can do is transport. And then you hope someone like me is there that says, no, I don't need to transport that. And that's why when I point out that you have to identify who you're gonna transport because it's a drill. I mean, it's a total drill to do this. And so be clear on who you wanna transport and why you wanna transport them. And if you don't know, then transport them. That's just that simple. Thank you. Yeah, the practice is critical. Like you're doing the practice on the ice before the season begins, right? Because you wanna know how to get that person on a spine board who's crumpled against the boards, which is different than the field when you're practicing for the cowboys or the dolphins, right? And so different scenarios. Jason, I got a question for you. Is there a role for ultrasound in some of these abdominal injuries? Like, do you have a ultrasound on the sidelines to look at some of these things, right? I do. There's various systems that are portable nowadays. A few of them actually connect to your phone or even iPad. But you also have to kind of know what you're looking at. And so there is a pretty steep learning curve when it comes to MSK ultrasound. Specifically, at least what I'm able to look at or what I feel comfortable looking at or anything within muscular erector sheath sort of area. But in terms of like fast scans or deeper injuries, personally, I don't even feel comfortable enough doing that. It's just not part of what I do. But there is a role if you have the skills and tools to use it, though. Because, you know, that's getting more prominent, you know, sideline ultrasounds. And, you know, many of our primary care sports docs are really getting very facile at it. And, you know, as orthopedics, most of us are, you know, we need to get better at it, too. But that's why I ask. Well, it's nice. The price is coming down, too. So, I mean, you know, five, 10 years ago, it's forget it. But over the last few years, thankfully, there's probes coming out that are $1,500, $2,000, while not cheap, much, much cheaper than what the big units are. So at least you can see something with them. Let's put it that way. Question. Hi there, I'm Darius. I'm one of the residents from Toronto. A lot of these discussions were on very severe injuries, very obvious, clear, you need to do something. What are your management strategies for those that are a little bit more combative or don't disagree with your management plan, like the patients or the athletes? Anybody want to take that? Fran, you want to take that? Well, you know, with heat stroke in particular, patients can be very, very combative. So you have one strategy. We have Marine Corps Marathon. You can surround yourself with Marines, which makes it pretty easy, you know, because you're going to have to intervene with the team to control someone who's combative so that you can properly cool. But it's a real problem, you know, especially if you've got a big guy. It might be 6'4", 6'5", who's going to be difficult. So you've got to have that in your emergency action plan. How are you going to deal with that combative individual? And it's really going to take a team. I think the whole lesson I've heard today, it's all about organizing the team. Drew, you've been on a lot of games, a lot of sidelines, different environments. Yeah, same question. You know, like you've seen this, right? Maybe, and what's your take? Well, when they have a spine injury, they're not that combative. When they're concussed, they can be very combative. And so that aids in the diagnosis, of course. But you just, you know, frequently you just have to use brute force on them, and that's it. And like you said, I mean, you have a bunch of Marines around you. Well, we have a bunch of large football players, and they know this guy's not right, and so they'll help you. And so you just have to, you know, look at your resources. What are my resources? Well, there's 10 guys just as big as them right here. So, you know, all of them know he's not right, so engage them to help you. I would add one thing, too, is that you really have to secure the environment. You know, you're treating someone who's combative, and you may have a spouse who's looking and screaming. You know, what are you doing to my husband or my wife? We had actually, I was at the Hawaii Ironman this year, we had a cardiac arrest. And all of a sudden we're doing CPR, and you had a spouse screaming. You know, you have to have control of that environment. So security is another thing to think about as well, and where are you gonna be performing these things? That's a good point. It makes me think. We had a player last year, the year before, at the University of Colorado, went down. Somehow mom got on the field. The mom is hysterical, and somehow she got on the field, like right around all of us, and the coach, one of the coaches was trying to help her out, but that doesn't help, right? None of these things help. So, one last question, and then we'll go. It's for Dr. Flanagan. Oh, you wanna say something first? I just wanna add one thing here. I've seen two residents who've said, I think you were resident bitten by heat stroke victims. Bitten, so be careful. Keep your tetanus status up to date, too. Good point. Dr. Flanagan, last question, and then we'll break. This was a question from the audience. I just wanna get to it. Are there any studies you're aware of that compare outcomes in situations where the EAP have been routinely practiced versus those where scenarios are not practiced? No, not in a head-to-head basis like that. I think that particularly procedures like yourself all can agree that the more you do something, the better you are at doing it. So, from a common sense perspective, it would make sense that outcomes are better with a well-rehearsed and well-educated EAP, but I don't think anybody's done a head-to-head trial. So, do your EAP, know where your AED is. Practice, practice, practice, be prepared. This is great. Thank you all for taking the time, especially to the sports medicine meeting that this is not your specialty. It is yours, Drew, but your spine. And you guys, thank you very much. Thank you to the audience. Thank you. Have a great day.

treating injuries

different sports environments

resources and preparedness

playing surface

transportation techniques